Health

Summary

C complained about the care and treatment provided to their parent (A). A had been admitted to hospital before being transferred to a mental health facility. A then developed abdominal symptoms, which required them to be transferred to an acute hospital for treatment. A had been considered for surgery, but this was changed to treatment with medication. A was transferred back to the mental health facility but became unwell again and was taken to A&E. A died from a pulmonary embolism (a blood clot that blocks and stops blood flow to an artery in the lung).

C said that A’s medical and nursing care fell below an acceptable standard which resulted in A’s dignity being compromised, their personal care neglected and A not receiving the medication that they required. C believed that A’s death was caused by a failure to examine A properly or ensure that A received anti-clotting medication. C felt that this resulted in A developing deep vein thrombosis (DVT, a blood clot in a vein) which led directly to their death. C was also unhappy with the board’s response to their complaint. C felt that the board had not represented meetings with the family accurately, and failed to follow up on the actions that they had told the family were being taken, despite acknowledging that there was significant learning to be gained from the family’s experience.

We took independent advice from a registered nurse and a consultant geriatrician (specialist in medicine of the elderly). We found that A’s nursing and medical care had fallen below a reasonable standard. We also found that the board failed to communicate reasonably with C and their family and that they could not provide evidence that they had taken the actions promised to the family following the board’s complaint investigation. In addition, the board’s Significant Adverse Event Review had been delayed, reducing the utility of it to the board. We upheld all of C’s complaints.

Recommendations

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

• All nursing staff on the relevant ward should be compliant with the board’s medicine administration policy.
• An assessment by the medical team of the current rota and continuity of care based on the assurances given to A’s family that staff numbers would improve this.
• Patient documentation completed to an appropriate standard, without sections left blank, this should include admission documents, care rounding charts, person centred care plans and delirium screening.
• The board should develop clear guidance to ensure patients with mental health issues can have timely access to nursing staff trained in mental health care, to reduce the reliance on family members providing care.
• The case should be discussed at the next available morbidity and mortality meeting.
• The medical staff involved should include this case for discussion at their next appraisal.

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

C complained about the care and treatment that their spouse (A) received from Scottish Ambulance Service (SAS). C called for an ambulance after A fell from a height at home. A was assisted to their feet after an initial check and then walked to the ambulance for further checks. After returning to the house, A became pale and reported a brief loss of sight. It was decided A should be transferred to hospital where they were later diagnosed with a broken pelvis.

C said that one of the crew members was rude and dismissive when they had tried to describe the height A had fallen from. C complained that SAS had not fully assessed A, failed to consider the accounts given by eyewitnesses and unreasonably concluded that A could remain at home and take painkillers. A was clear that they did not want to go to hospital, however, C considered the crew failed to recognise A was in shock.

In responding to the complaint, SAS advised that a full assessment had been carried out. It was also noted A did not initially wish to be transferred to hospital and had declined to be immobilised on a spinal board. The response advised of actions for learning and improvement which would be taken with the crew in response to C’s complaint. This included actions in relation to the mechanism of injury (in this case a fall from height), moving and handling, consideration of silver trauma (the impact of trauma on older patients), and communication with patients and relatives.

C was unhappy with this response and brought their complaint to us. We took independent advice from a senior paramedic adviser. We found that SAS failed to undertake a reasonable assessment of A as they did not act in keeping with the Joint Royal College Ambulance Liaison Committee guidance on Spinal and Spinal cord injury. In particular, there was a failure to immobilise A at the scene given the mechanism of injury. We also considered that SAS failed to reasonably document the incident, consider A’s age and the effects of ‘silver trauma’ and to correctly calculate the National Early Warning Score. SAS did not document any discussion about the risks/benefits associated with immobilisation or fully record A’s reported initial refusal to comply with treatment or to be transferred to hospital. Finally, we noted a failure to document a pain score before and after analgesia had been given. Therefore, we upheld C’s complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to A for failing to provide a reasonable standard of care. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

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

• The patient record should be completed in full to reflect the presenting condition/mechanism of injury; the assessment and observations undertaken including NEWS, pain score, the accounts of eye witnesses and consideration of other relevant factors such as age; and the patient’s decision regarding treatment and the information shared to inform this decision.

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

C complained about the actions taken and treatment provided by the board in respect of their pregnancy. C reported reduced fetal movements and was admitted to hospital with vaginal bleeding. The hospital discharged C as the vaginal bleeding settled and all clinical assessments undertaken were within normal parameters. However, C returned to hospital with significant vaginal bleeding and was diagnosed with placental abruption (a condition in which the placenta starts to come away from the inside of the womb wall). C’s baby was stillborn shortly after.

In C’s view, the board failed to take into account warning signs or carry out an appropriate assessment when they were admitted to hospital. C feels the outcome would had been different if their baby had been delivered at an earlier opportunity. The board acknowledged some failings in respect of delays caused by the hospital triage process, IT issues and signage. However, they concluded that these delays were unlikely to have made a difference to the outcome. The board were also satisfied that the broader treatment provided to C in respect of their pregnancy was appropriate.

We took independent advice from an adviser with an extensive background in obstetrics and gynaecology (a specialist in pregnancy, childbirth and the female reproductive system). We found that the board’s management of C’s pregnancy was reasonable and in line with relevant national guidance. There was no evidence that the board unreasonably failed to take any actions that they should have. Nor did it indicate that they unreasonably missed any warning signs pointing to this outcome. We noted that guidance prioritises the aim of prolonging the pregnancy in the absence of any signs of maternal or fetal compromise. In addition, we considered the staff’s actions to be reasonable when C presented at hospital. We agreed with the board’s conclusion that it was unlikely that the outcome would have been different had C not encountered the delays at the hospital. Therefore, we did not uphold C’s complaints.

Summary

C complained that the board failed to provide hip replacement surgery within a reasonable period of time. C experienced back and buttock pain for several years due to an existing condition. C started to experience new pain in their right leg. Their GP referred them for an x-ray and made an urgent referral to the orthopaedic department (specialists in the treatment of diseases and injuries of the musculoskeletal system) as C had been off work due to debilitating pain in the hip and was concerned about losing their employment as a result.

C had a consultation with the orthopaedic surgeon and was told that the hip was badly damaged. C was listed as a priority 4 case (a lower priority) for a total hip replacement. C’s condition continued to deteriorate; they were in severe pain and it was affecting their day to day life. C contacted the board to explain the severity of the problems that they were experiencing and they were reviewed in clinic. Shortly afterwards, C underwent surgery privately.

We took independent advice from a trauma and orthopaedic consultant. We found that a number of failings occurred that were not simply as a result of the delays caused by an extensive waiting list. It was unreasonable that C was incorrectly categorised from the outset and that an outdated prioritisation tool was used by the board. It was also unreasonable that the radiological deterioration was not documented and that C’s surgical treatment was not expedited at the further clinic appointment. Therefore, we upheld C’s complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the specific failings identified in respect of the complaint. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.
• Calculate and reimburse C in relation to their private surgery on production of appropriate receipts. The calculation should be based on what the surgery would have cost the NHS (rather than what it cost C). The payment should be made by the date indicated; if payment is not made by that date, interest should be paid at the standard interest rate applied by the courts from the initial date to the date of payment.

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

• Patients should be given timely, clear and accurate information about their clinical prioritisation and potential waiting times for surgery.
• Patients should receive the appropriate clinical priority level based on assessment and the clinical evidence available.
• Patients who report clinical deterioration during their wait for surgery should be appropriately assessed and reprioritised where this is appropriate.

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.

This case was reviewed and closed in October 2024. This summary was published prior to review. No changes are required to this summary as the outcome of the review was unchanged from the initial decision from April 2024. 

Summary

C complained on behalf of their parent (A) that the board unreasonably failed to proceed with hip replacement surgery within a reasonable timeframe.

C said that A was referred for physiotherapy before being added to the waiting list for surgery. They complained that this was unreasonable as it was known that it would not help given the extent of deterioration in A’s hip joint. C also complained that several of A’s appointments had been cancelled or postponed, and that the board had failed to act on an urgent referral sent by A’s GP. As it was unclear when A would receive their surgery, they opted to have this carried out privately.

In responding to C’s complaint, the board confirmed that they must take all reasonably practicable steps to ensure that they comply with treatment time guarantees. This includes considering whether to send patients to another care provider if they cannot provide treatment by the patient’s treatment time guarantee. In A’s case, the board noted that A had elected to make their own arrangement for private surgery and, therefore, the NHS offer of treatment was no longer relevant to them.

We took independent medical advice from a consultant orthopaedic surgeon (a specialist in the treatment of diseases and injuries of the musculoskeletal system). At the point of referral to orthopaedics, we found that A was reasonably referred for physiotherapy and added to the waiting list as a routine category patient. At the pre-operative assessment clinic, we found that an x-ray was taken but it had not been reported or reviewed. At this point, A should have been re-prioritised to urgent in keeping with the physical changes that they had reported and the radiological deterioration evident on the x-ray. It was unreasonable not to re-prioritise A at this time. In reference to the urgent referral sent by A’s GP, A continued to be considered as a routine category patient. However, it was clear A’s case had been expedited as they were offered a place on a private sector list for surgery run by the board at the time. The board could not provide evidence to support their decision making. We also found that the board did not meet their legislative requirements when communicating with A about their treatment time guarantee date. On balance, we upheld C’s complaint.

During our investigation, we identified issues with the board’s handling of the complaint. We made a recommendation to the board to support improvement of their complaint handling.

Recommendations

What we asked the organisation to do in this case:

• Apologise to A for not reasonably communicating with A about the breach of their treatment time guarantee date, for not acting on the changes reported by A at the pre-assessment clinic, for not reviewing or reporting the x-ray, for not appropriately reviewing and reprioritising A following the urgent GP referral, and for not documenting the reason for the decision to add A to the private list for surgery. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

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

• Patients on waiting lists for surgery should be managed in keeping with the relevant policies and guidance, and they should be kept informed about delays particularly when a treatment time guarantee has been breached. The outcome of assessments and test results including x-rays taken at pre-assessment clinics should be timeously reviewed and documented in the medical record. Patients should be appropriately reviewed and reprioritised based on assessment and the clinical evidence available. Decisions made in respect of the patient should be documented by the relevant person in the medical record.

In relation to complaints handling, we recommended:

• The board’s complaint handling monitoring and governance system should ensure that complaints are appropriately investigated and that failings (and good practice) are identified and learning from complaints are used to drive service development and improvement The final complaint response should include information about the SPSO, including the timescale for making a complaint, in line with the Model Complaints Handling Procedure.

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

C, a support and advocacy worker, complained on behalf of their client (A) who suffered from thyroid eye disease (an autoimmune disease in which the eye muscles and fatty tissue behind the eye become inflamed). A complained that the treatment provided by the board had been ineffective and requested a second opinion and a review of the treatment that they had received to date.

We took independent initial advice from a consultant ophthalmologist (a specialist in the study and treatment of disorders and diseases of the eye). We found that while the board had obtained a second opinion on A’s condition and plan of care moving forward, they had promised to review A’s past care and treatment which had not been done. The board have now confirmed that a consultant has been found to review the relevant treatment and this has been agreed by all parties as a resolution to this complaint.

Summary

C complained about the care and treatment provided to their spouse (A). A stayed in critical care wards after surgery and acquired wounds to their back and shoulders. C complained that A’s wounds were not appropriately documented or treated.

In response to C’s complaint, the board acknowledged that documentation of A’s wounds was not started in critical care wards, and A’s wounds were not initially logged on the board’s system for reporting adverse events. The board told us that after C’s complaint, the tissue viability service developed online learning for staff, and developed and promoted a wound management policy. The board apologised that A sustained wounds after surgery.

We took independent advice from a nurse with a specialism in wound care. We agreed that the board did not reasonably document C’s wounds; however, we also found that they did not follow their guidelines in treating A’s wounds. We found that there was a delay in referral to a tissue viability specialist; a lack of skin inspection; inadequate repositioning to prevent pressure damage occurring or deteriorating; and inappropriate wound management. We also found that the board did not provide C with a full and informed complaint response. Therefore, we upheld C’s complaints.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C and A for the failings identified. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

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

• Patients should be regularly assessed for tissue damage in line with board procedures. Where tissue damage is found, appropriate treatment including timely escalation to a tissue viability specialist as required should be provided.

In relation to complaints handling, we recommended:

• The board’s complaint handling monitoring and governance system should ensure that complaints are properly investigated and responded to; are accurate; and that failings and good practice are identified.

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

C complained that the board failed to carry out a reasonable assessment of their late parent (A) when they were admitted to hospital. They were also unhappy with the decision to discharge A and said that the board failed to communicate adequately with them and their family during the time A spent in the hospital. C complained that the board’s complaint response was not consistent with A’s clinical records.

We took independent advice from a consultant in geriatric and general medicine. We found that while a reasonable assessment of A’s clinical condition was carried out, the assessment of A’s physical condition and the discussion with their family before discharge fell below a reasonable standard, particularly with respect to A’s mobility. We also found that communication with A’s family fell below a level that they could reasonably expect. Finally, we were critical of the board’s complaint response which appeared to be selective in terms of the information provided rather than being objective. Therefore, we upheld C’s complaints.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failings identified and provide an explanation to C about why the discharge document mentioned ‘urosepsis’. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

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

• The gap between a patient’s previous and current abilities should always be assessed and considered when making a decision about discharging the patient. Where a patient’s family is involved in their care at home, they should be involved in discussions about the patient’s discharge and any follow-up care and treatment.
• Complaint responses should be objective, clear, accurate and address the issues raised.

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

C’s spouse (A) was admitted to hospital following a stroke. A remained in hospital for several weeks before transferring to another hospital. A later died. C complained to the board about A’s hospital stay and raised concerns about wound management, fall pain management and the identification of hip and shoulder injuries.

The board’s response highlighted several areas for improvement. Firstly, there should have been a referral for A’s wounds, with more robust documentation. Staff training has been conducted to address these issues. Secondly, A fell twice in the ward, prompting a thorough medical review after each fall. Staff training regarding falls has been provided. Thirdly, although A was on regular pain medication, there should have been a pain recording chart in place. Staff will receive training on this aspect. Lastly, A’s hip dislocation likely stemmed from their stroke rather than a fall, with no evidence of shoulder dislocation occurring the ward.

C was dissatisfied with the board’s response and brought their complaint to us. We took independent advice from a nurse with a speciality in wound care and a consultant geriatrician (a specialist in medicine of the elderly). We found that staff failed to follow the board’s policy on wound management. We also found that whilst the medical care of A’s falls was reasonable, the nursing documentation about A’s falls was unreasonable, because documentation was incomplete and at times inaccurate. A’s care plan was also poor, making it difficult to manage A’s pain, and there was a delay in A receiving a medical review over the weekend. Therefore, we upheld these parts of C’s complaint. We found that the board’s explanation of A’s injuries was reasonable. We did not uphold this part of C’s complaint.

We also found that the board’s complaint response did not provide C with a timely, full and informed response to their complaints about the board’s management of A’s wounds and falls. Therefore, we made an additional recommendation to address this.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failures in A’s care. The apology should meet the standards set out in the SPSO guidelines on apology available at http://www.spso.org.uk/meaningful-apologies.

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

• Nursing staff should be competent in the accurate completion of falls documentation.
• Patients should receive appropriate pain management including regular structured assessment of their pain, e.g. through the use of a structured pain assessment tool or chart. This should be documented. Patients should receive appropriate medical review on escalation, and reviews should be carried out promptly.
• Patients should receive care as required and prescribed in care rounding bundles. Those requiring wound care should be appropriately managed in line with local and national guidance on wound management. This should be appropriately documented.

In relation to complaints handling, we recommended:

• The board’s complaint handling monitoring and governance system should ensure that complaints are properly investigated and responded to; are accurate; timely; and that failings and good practice are identified.

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

C contacted the Scottish Ambulance Service (SAS) when they began experiencing abdominal pain. An ambulance attended but did not take C to hospital. The crew provided advice to contact the service again if their symptoms worsened. C contacted the service again the following day. A telephone assessment was completed but no ambulance was sent. C later made their own way to hospital where they required surgery for a perforated bowel.

C complained that the SAS failed to recognise the seriousness of their symptoms and failed to provide appropriate care and treatment. C said that as a result, they required more extensive surgery than if they had been taken to hospital sooner.

We took independent advice from a paramedic. We found that the ambulance crew had unreasonably failed to carry out an adequate assessment of C. The crew assessed that C had withdrawn consent for further assessment, and did not provide adequate advice on the benefits of assessment or the risks of not completing the assessment. We also found that the telephone assessment the following day was inadequate and was poorly documented. Therefore, we upheld C's complaints.

Recommendations

• What we asked the organisation to do in this case
• Apologise to C for failing to conduct an adequate assessment, failing to recognise the potential seriousness of their symptoms, and failing to provide them with the care that they required. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

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

• Clinical staff are able to recognise symptoms of potentially serious abdominal conditions.
• Clinical staff ensure that benefits of assessment, treatment and transport to hospital, and the risks of declining care, are fully discussed with the patient and recorded.
• Clinical staff reflect on and learn from patient experience to improve future practice.

In relation to complaints handling, we recommended:

• Relevant staff and senior managers are familiar with the Adverse Events Policy, understand the criteria for a Significant Adverse Event Review, and apply it correctly.

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.

Amendment - 27/06/2024

When this complaint was originally published (19/03/2024) we made the following recommendation: "Clinical staff are aware of Kehr’s sign and are able to recognise symptoms of potentially serious abdominal conditions."  This has since been amended to "Clinical staff are able to recognise symptoms of potentially serious abdominal conditions." following receipt of new information.