Health

Summary

Mrs C complained to us about the nursing care and treatment her mother (Mrs A) had received at the Western General Hospital after she had fallen and injured her head. Mrs C, who had power of attorney for Mrs A, was concerned about the nursing care she received. Mrs C had particular concerns about her falls care and monitoring; pain relief; personal care and hygiene; and the communication with Mrs A. Mrs C also had concerns about a lack of response to Mrs A's weight loss and to her swollen leg.

We took independent advice from a nurse. We found that there was a failure to prepare timely and comprehensive care plans in relation to Mrs C's care needs, and to review the ongoing effectiveness of those care plans. We found that this should have been carried out with the appropriate involvement of Mrs C and her powers of attorney but there was no evidence that this had been done. We also found that there were failings in the board's records-keeping, as there were gaps in completing care round checklists which were sometimes not completed fully. We upheld Mrs C's complaint.

We noted that the board did not identify the failings we found in the nursing care provided to Mrs C. In addition, the board did not provide us with all relevant documentation at the appropriate point in our investigation. Therefore, we made recommendations in relation to their complaints handling.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C for the failings identified in the nursing care Mrs A received.

What we said should change to put things right in future:

• Patients should have comprehensive nursing assessments and clear care plans in place, which are regularly reviewed, to facilitate consistent and person-centred care, with the appropriate involvement of patients and their powers of attorney.
• Care round checklists should be completed consistently and fully.

In relation to complaints handling, we recommended:

• The board's complaints handling system should ensure that failings (and good practice) are identified, and enable learning from complaints to inform service development and improvement.
• The board should ensure that clinical evidence demonstrating the treatment and care provided is provided at the appropriate point in an SPSO investigation.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

Summary

Ms C complained about matters related to the care and treatment of her son (Mr  A), who had been an in-patient at the Royal Edinburgh Hospital. Mr A had a diagnosis of schizophrenia (a long term mental health condition that causes a range of different psychological symptoms) and had been subject to a Compulsory Treatment Order (an order that allows professionals to treat a person's mental illness). During the in-patient admission, the local authority's social work staff were working towards finding a suitable supported accommodation vacancy for Mr A, with input from clinicians. Ms C firstly raised concerns that board staff had contributed to delays in progressing Mr A towards discharge. We received independent advice from a consultant psychiatrist. We found that the clinical team reasonably fulfilled their responsibilities to identify a suitable accommodation placement for Mr A. We did not uphold this complaint.

On a particular occasion during the admission, Mr A did not return to the hospital following an agreed one hour period of leave. The hospital notified the police the next morning and informed Ms C later that day. Ms C raised concerns that the board failed to apply the correct risk level to Mr A's absence. We did not find evidence that the board had acted in accordance with the procedure for missing persons that was in use at the time. We upheld this complaint, however, we noted that the board had since revised and improved this procedure.

We also noted that the board's complaint investigation referred to the relevant procedure but did not identify that staff had not complied with this. We were critical of the complaint investigation and made a recommendation in relation to this.

Ms C was also unhappy with the level of communication with her during the time Mr A was absent from the hospital. In response to her complaint, the board acknowledged that there had been a delay in contacting Ms C to notify her. We found limited documentation of communication with Ms C and we concluded that communication was not in line with the procedure in place at the time. We upheld this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms C and Mr A for the failure to follow their Standard Operating Procedure for Missing Persons. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/leaflets-and-guidance.

What we said should change to put things right in future:

• Staff should be familiar with the procedures to follow when a patient goes missing, and confident in applying these correctly.
• When a detained patient is missing, factual details such as dates/times of significant events and information discussed with next of kin and police should be recorded.

In relation to complaints handling, we recommended:

• A complaint investigation should identify any applicable policies or procedures and assess whether these have been followed (and if not, why).

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

Summary

Ms C complained about a number of aspects of the mental health care and treatment provided to her by the board over a number of years. In particular, Ms  C felt that the board failed to provide her with appropriate crisis support and appropriate psychiatric treatment. Ms C also complained that their communication around these matters was unreasonable and that their handling of her complaint was poor.

We took independent advice from a mental health nurse and a psychiatrist. We found that some of the crisis care provided to Ms C was reasonable, however, there were a number of areas where care could have been improved. We were not satisfied that the board had taken appropriate action, following an upheld complaint about staff attitude, to ensure that this issue did not impact on Ms C's access to the service in future. The mental health adviser noted that an out-of-hours care plan was not reviewed within the appropriate scheduled timescale and that the board held conflicting information in relation to Ms C's ability to access other services. Therefore, we upheld this aspect of Ms C's complaint.

In relation to Ms C's psychiatric treatment, we found that the care provided by a psychiatrist and a psychologist was reasonable. The psychiatric adviser noted that both the psychological treatment that Ms C received, and the administration of medication, was appropriate. Therefore, we did not uphold this aspect of Ms  C's complaint.

Additionally, Ms C felt that the board's communication around these matters had been poor as she had been unreasonably excluded from meetings where her care was being discussed. The psychiatric adviser considered that the board followed their usual and appropriate practice in relation to meetings held about a patient. We did not find evidence to suggest that Ms C had been unreasonably excluded from these meetings and that the boards communication with her was unreasonable. Therefore, we did not uphold this aspect of Ms C's complaint.

Finally, we found that the board had not consistently handled Ms C's complaints in line with their complaint handling guidance in place at the time. Therefore, we upheld this aspect of Ms C's complaint. However, we noted that since Ms C first made a complaint, a new complaints handling procedure has been introduced by the board and therefore, we made no recommendations for improvement on this point.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms C for failing to review her out-of-hours care plan as had been scheduled, failing to communicate with her consistently and accurately about her ability to access a crisis support service and failing to handle her complaints appropriately. The apology should meet the standards set out in the SPSO guidelines on apology available at https://www.spso.org.uk/leaflets-and-guidance.

What we said should change to put things right in future:

• Staff should treat patients with courtesy and respect at all times. Staff should have access to appropriate focused clinical support and supervision.
• Care plans should be reviewed within the scheduled timescale. Where this is not possible, a reason for this should be documented. Care plans should accurately reflect a patient's ability or inability to access other support services, and communication about this matter should be consistent.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

Summary

Mr C complained about the care provided to his late mother (Mrs A) by staff at Wishaw General Hospital. Mrs A had attended the emergency department following a fall at home. She was observed for a few hours and discharged home. Mrs A fell again at home that evening and had to be readmitted to hospital where it was established that she had problems with the blood supply to her left leg. Mrs A was told that no further treatment could be given and she was commenced on palliative care. Mr C believed that the seriousness of his mother's condition should have been identified on the first attendance to hospital.

We took independent advice from a consultant in emergency medicine. We found that on the first attendance the staff carried out a thorough assessment, made appropriate investigations and reasonably concluded that Mrs A could be discharged home with follow-up by the hospital at home team. When Mrs A re- attended hospital, her observations were mostly normal and it was only after a further period of review that issues were identified which revealed a lack of blood supply to her left leg. We found that the staff could not reasonably have predicted that Mrs A would go on to have subsequent problems. We did not uphold the complaint.

Summary

Miss C complained about the treatment which her late child (Child A) received at Wishaw General Hospital. Child A had recently had a vaccination and had developed a temperature and a rash. Miss C asked the staff if Child A could have Kawasaki Disease (heart disease) and was told that they did not meet the criteria. Instead Child A was treated for a viral infection and then discharged home after a period of observation. Although Child A showed some signs of improvement, over two weeks later they were admitted to hospital where they died. The post mortem report showed findings in keeping with Kawasaki Disease. Miss C felt that staff should have carried out additional investigations when Child A was originally at the hospital and the disease would have been identified sooner.

We took independent advice from a consultant paediatrician. We found that the staff carried out appropriate assessments when Child A attended the hospital and that it was reasonable to have arrived at a working diagnosis of viral infection based on their reported symptoms. Child A did not meet the criteria for Kawasaki Disease at that time and there was no clinical indication that a hospital admission or referral to other hospital specialist was required. We did not uphold Miss C's complaint.

Summary

Mr C complained about the decision to transfer his wife (Mrs A) from Wishaw General Hospital to a care home and the manner in which this was done. Mr C was concerned that he was not advised in advance about the transfer or that the decision was discussed with him. Mr C was also concerned about the lack of information given to him about the facilities available at the home and the handover provided by the hospital to the home.

During our investigation the board issued an apology to Mr C for the errors made. They confirmed that the transfer took place during a time when there was an extreme pressure on beds and the information provided to Mr C was not adequate. They also accepted that staff on the ward were not aware of the type of services available at the home. They confirmed that there should have been a more adequate handover note. As the board apologised for the errors and confirmed steps they would take to improve the service, the complaint was resolved and we took no further action.

Summary

Mr C complained about the care and treatment his late father (Mr A) received when he attended the emergency department at Monklands Hospital, after having been involved in a minor road traffic accident. The board concluded that Mr A had a soft tissue injury and he was prescribed paracetamol and ibuprofen. Mr A returned to the emergency department one week later reporting worsening symptoms. A further assessment was carried out and it was noted his international normalised ratio (INR - a measurement of how long it takes blood to form a clot) levels were high and fractures to his vertebrae and ribs were identified. Mr A's condition deteriorated significantly and he developed sepsis (a  blood infection) and discitis (inflammation between the discs of the spine). Mr  A died as a result of these complications. Mr C complained that the board failed to note that his father was taking warfarin (a drug used to prevent blood clots) and he should not have been prescribed ibuprofen. Mr C also complained that the fractured vertebrae and ribs were not identified during the first assessment.

We took independent advice from a consultant in emergency medicine. We found that the assessment of Mr A's symptoms was reasonable and an x-ray to inspect for fractures was not warranted. However, we considered that the prescribing of ibuprofen was not reasonable and other forms of pain relief could have been considered. Therefore, we upheld the complaint. We did not make any recommendations as the board had already taken steps to address this failing.

Summary

Mrs C complained about the care which she received from the practice. She said that the practice unreasonably refused to prescribe her pethidine (painkiller) medication and removed it from her list of repeat medications. Mrs C said that she had been on the medication for a number of years and that no alternative painkillers were prescribed and she was at risk of withdrawal symptoms.

We took independent advice from a GP. We found that the clinical records indicated that Mrs C had agreed to stop pethidine, she had also said it was her intention to try ibuprofen (anti-inflammatory pain relief medication) and that she still had a stock of pethidine at home. We found that the GP correctly did not prescribe additional painkilling medication in the meantime and also that Mrs C had not been taking pethidine on a regular basis and as such it was unlikely she would have suffered from withdrawal symptoms. Therefore, we did not uphold Mrs C's complaint.

Summary

Miss C complained about the antenatal care she received from the community midwifery team when she was pregnant. Miss C was informed she was on the "red pathway care" for her pregnancy which meant her antenatal care would be led by a consultant obstetrician (a doctor who specialises in pregnancy and childbirth) and supported by the community midwifery team.

Miss C complained that she was told by her midwife at her first appointment that she would not need to have future appointments with her midwife and would only see her consultant. Miss C also complained that she missed out on vital check ups and she did not receive her relevant maternity forms on time. The board apologised that the consultant did not provide Miss C with the appropriate forms.

We took independent advice from a midwife. We found that when Miss C contacted the community midwifery team, the midwife acted appropriately and offered to meet with Miss C to provide her with the necessary forms and information, however, Miss C refused this offer and did not engage in the service. We found at this point, Miss C was still within the required timescale for submitting her forms, therefore, she did not suffer any significant injustice as a result. We did not find any evidence that Miss C was advised at her first appointment that she was not required to see her midwife again. We did not uphold Miss C's complaint.

Summary

Ms C has complex Post-Traumatic Stress Disorder (a psychological disorder that can develop in response to prolonged, repeated experience of interpersonal trauma) and had been receiving Comprehensive Resource Model (CRM - a holistic therapeutic approach to help people re-process and release the effects of traumatic events) treatment under the care of her psychiatrist. Ms C heard that her psychiatrist had left the practice and that she was to be offered a six week course of Cognitive Behavioural Therapy (CBT - a talking therapy aiming to help manage problems by changing the way people think and behave) in place of CRM treatment. Ms C had tried this before and found it of little benefit. Ms C complained that the board had failed to consult her on the decision to withdraw CRM treatment, and had failed to put in place an appropriate support plan for her.

The board explained that the removal of this treatment was a result of a review of all adult psychiatry services, stating that there was no evidence base for CRM and it did not appear on the Matrix for Psychotherapy Treatments (a guide to planning and delivering evidence-based psychological therapies within NHS boards in Scotland).

We took independent advice from a consultant psychiatrist. We found that Ms C had been discharged from the service on clinical grounds and would only have been informed of the decision to withdraw the treatment when she requested a new appointment. We were satisfied that the board did not have a specific duty to consult with Ms C before deciding to withdraw from providing CRM treatment and we, therefore, did not uphold this complaint.

In relation to the support plan put in place following the board's decision to withdraw CRM treatment, the board said that the psychiatrist had wanted to find out the wishes of their patients in care provision. They had discussed the future care of all their patients and had agreed to refer them to their Community Health Team for an assessment of their needs. We found that the board's approach in offering individual appointments to assess ongoing needs for future treatment was reasonable. Therefore, we did not uphold this complaint. However, we did find shortcomings in the board's communication with Ms C in relation to the matters she complained about and fed this back to the board.