Health

Summary

Mr C complained on behalf of his wife (Mrs A). Mrs A was referred to the board by her dentist for a wisdom tooth extraction. After the procedure Mrs A experienced significant pain and other adverse symptoms. She was re-referred to the board by her dentist for further review, however, they did not identify any post-operative issues such as nerve damage, other than that the surgical site was healing slowly. Mr C complained that the dentist failed to provide thorough information about the risks associated with the wisdom tooth extraction, and that the procedure was not performed correctly.

We took independent dental advice. We found that the information and advice provided to Mrs A was clear and in line with national guidance. We also found there was no evidence to suggest the procedure was not performed correctly. We did not uphold Mr C's complaints.

Summary

Mr C complained about the care and treatment he received from the board's mental health services. In particular, he raised concerns about the board only offering appointments outwith his home when he had difficulty leaving his home and that they did not discuss his care plan with him. Mr C also complained about the board's handling of his complaint.

We took independent advice from a mental health nurse. We found that there was evidence that a thorough assessment had been carried out in which Mr C was meaningfully involved. We acknowledged that it was clear that leaving the house was anxiety-provoking for Mr C. However, it appeared that Mr C was resorting to managing his anxiety by displaying avoidant behaviour which generally serves to increase anxiety in the long term. We considered that the types of support offered to Mr C, including group and one-to-one sessions aimed at confidence building, were reasonable under the circumstances. We also found evidence that confirmed Mr C's participation in discussions about his care plan. Therefore, we did not uphold this aspect of Mr C's complaint.

In relation to complaints handling, the board accepted that there had been unacceptable delays caused by confusion around who was investigating the complaint. We found that the board had unreasonably classified Mr C's original complaint as a 'concern', when it should have been treated as a complaint. Even after it was classified correctly, the board took almost three months to respond to the complaint. We were also critical of the board's failure to send Mr C an application to access his medical records, despite him twice providing the information they had requested. Therefore, we upheld this aspect of Mr C's complaint.

Recommendations

In relation to complaints handling, we recommended:

• The board should have a system for keeping track of commitments made during a complaint investigation.
• An expression of dissatisfaction with the standard of service provided should be treated as a complaint.

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 medical care and treatment he received when he attended Queen Margaret Hospital to have biopsies (a procedure to remove tissue or cells for analysis) carried out. In particular, Mr C complained that, despite telling the operating surgeon that he was in extreme pain the biopsy procedure was continued. He also said that during the consent process for the biopsy procedure, he was not advised there was a risk of major bleeding.

We took independent advice from a consultant urological surgeon (a specialist in diseases of the urinary organs in females and the urinary tract and sex organs in males). We found that the operating surgeon should have stopped or acted to address Mr C's discomfort during the biopsy procedure. We were also concerned that, although uncommon, the risk of major bleeding was not explained to Mr C. While we found that the care and treatment Mr C received following the biopsy procedure was reasonable, we were concerned that the level of communication in relation to the discharge letter was unreasonable. Therefore, we upheld Mr  C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for the failings in relation to the decision to continue the biopsy, the consent process and communication. 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:

• Patients who display signs of distress during a procedure should have this acted on in line with guidance and standards.
• Patients should be appropriately informed of the risks following prostrate biopsies in line with national guidance on consent.

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

Mrs C complained about the care and treatment provided to her late husband (Mr  A). Mr A was admitted to Victoria Hospital day surgery for an operation. Mrs  C called the hospital the next morning to advise that Mr A was unwell, and was told to call his GP. Following GP review, Mr A was admitted to hospital, where he was subsequently diagnosed with necrotising fasciitis (a very aggressive bacterial infection). He died in hospital less than two weeks later.

The board carried out an investigation into the source of Mr A's infection, but concluded that they could not say whether the infection was acquired in hospital or in the community. Mrs C complained about the infection, and that the nurse she spoke to on the phone the day after the surgery was not more supportive. In response to Mrs C's complaint, the board met with her family and explained their findings. The board apologised for the poor communication by the nurse, and shared Mrs C's concerns with the ward for reflection and learning. The board also put in place new procedures for responding to calls from patients or family. Mrs C remained dissatisfied with the board's response, and she brought her complaint to us.

Mrs C complained to us that the board unreasonably failed to prevent infection during Mr A's operation. We took independent advice from a general and colorectal surgeon, and from a nurse. We found that, whilst some aspects of the surgical care could have been improved, staff had taken reasonable steps to reduce the risk of infection during the operation, although it was not possible to eliminate the risk entirely. We also found that, once Mr A was re-admitted, staff identified his infection and began antibiotics promptly. We found that the board had carried out a reasonable and timely investigation into the source of the infection, and we agreed with their finding that it was not possible to know with certainty where this was acquired. We did not uphold this aspect of Mrs C's complaint.

Mrs C also complained that the board failed to provide adequate support when she called the hospital the morning after Mr A's surgery. We found that it was appropriate for the nurse to refer Mrs C to the GP because Mr A required an assessment of his medical condition, which the nurse was not qualified to give. Whilst we were not able to comment on the tone or tenor of this conversation, we noted that the board had taken appropriate steps by sharing Mrs C's concerns with nursing staff for reflection. We did not uphold this aspect of the complaint.

Summary

Ms C complained about the nursing care provided to her father (Mr A) at Dumfries and Galloway Royal Infirmary. Ms C raised a number of concerns including:

• Mr A having suffered a fall that resulted in a wound to his arm;

• the suitability of his diet;

• his developing of a pressure ulcer;

• him not seeing a dietician and;

• poor record-keeping, specifically the failure to record her father's fall.

We took independent advice from a nurse. We found that risk assessments about the risk of developing a pressure ulcer and being nutritionally compromised had not been completed correctly. This resulted in Mr A not receiving adequate pressure ulcer prevention interventions and being assessed at a lower risk of being nutritionally compromised than he should have been. We also found that important records relating to fluid intake and weight were not kept up to date and that the board failed to follow their policy when they became aware of Mr A's fall. We considered the care and treatment Mr A received was unreasonable and upheld this complaint.

Ms C also complained about the board's responses to her complaints. Ms C was concerned about the tone of the board's response, whether the response reasonably addressed the complaints she raised, the time taken to respond and the efforts to communicate the response when it was clear Mr A was in the final days of his life. We found that the tone of the response had been reasonable but not all of the issues raised had been responded to and that some of those that were, were unreasonable. We found that the response had been provided within a reasonable timescale but the board had not acknowledged Ms C's complaints as they should have. We found that it was unreasonable for the board to have refused to read their decision letter, which was awaiting a final signature, to Ms  C over the telephone so she could communicate it to Mr A before he died. Therefore, we upheld this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms C for failing to provide reasonable care to Mr A during his admission to hospital. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/leaflets-and-guidance.
• Apologise to Ms C for not responding reasonably to her complaints about Mr A's time in hospital. 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:

• The board should ensure they are following the Healthcare Improvement Scotland Standards for Prevention and Management of Pressure Ulcers (2016). The standards clearly lay out what is expected in terms of leadership and governance; education, training and information; assessment of risk for pressure ulcer development; reassessment of risk; care planning for prevention and treatment and; assessment, grading and care planning for identified pressure ulcers.
• The board should ensure that they are following the Healthcare Improvement Scotland Standards for Food, Fluid and Nutritional Care.
• The board should ensure that all staff follow their Falls Risk Assessment policy.

In relation to complaints handling, we recommended:

• The board should appropriately respond to the points of concern within complaints. The board should ensure that each aspect of the correspondence is addressed.
• Complaints should be dealt with in accordance with the model Complaints Handling Procedure (CHP).

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

Mrs C complained about the care and treatment that her mother (Mrs A) received at Dumfries and Galloway Royal Infirmary. She was admitted to hospital with a large haematoma (a localised collection of blood outside the blood vessels) on her right leg. Mrs A received treatment and was later discharged. After a visit from the district nurse, Mrs A was readmitted to hospital and her leg was operated on the following day. Mrs A was eventually discharged to a hospital outwith the board. Mrs C complained that the board failed to provide appropriate treatment for Mrs A's haematoma following her admission to hospital. She also complained that the board unreasonably discharged Mrs A from hospital.

We took independent advice from a registered general nurse and a consultant in general medicine. We found that there was a lack of wound assessment, inappropriate wound assessment and a failure to debride the wound (to remove the damaged tissue from the wound) before discharge. We were also concerned about the use of dressings which stuck to Mrs A's leg and considered Mrs A should have been referred to a wound care specialist. We considered that these failings would have contributed to the time taken for Mrs A's wound to heal and her pain during that period. Initially Mrs A received appropriate medical care, with appropriate investigations carried out on admission and clear attention to detail. However, we found that Mrs A should have received a greater level of medical review prior to discharge, and her care therefore fell below a reasonable standard. We upheld this part of Mrs C's complaint.

In relation to Mrs A's discharge, we found that Mrs A should have received a debridement before discharge. We were also concerned about the level of medical review Mrs A received in the days before her discharge. Given the severity of Mrs A's wound a few days later, and the lack of detail in the records at the time of discharge, we were not confident that Mrs A's wound had improved significantly and enough for Mrs A to return home safely. Therefore, we considered Mrs A's discharge to be unreasonable and upheld this part of Mrs C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise for the failing to appropriately assess and document the wound on admission, correctly assess the wound, apply appropriate dressings, debride the wound and, refer Mrs A to a wound care specialist. 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:

• Patients in a similar situation should have a wound chart completed on admission and updated at every dressing change.
• From admission, a wound should be measured using a measuring scale to ensure accuracy of size. Staff should be knowledgeable on the type of tissue that is present on the wound bed and be competent in this prior to completing a wound assessment chart.
• A non-adherent contact layer or non-adherent dressing should be applied to the wound bed. Gauze swabs should not be used as a wound dressing.
• Where appropriate, a wound bed should be debrided without surgical intervention prior to the patient being discharged home.
• Patients should typically be seen by a doctor at least once a week.

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.