Health

Summary

C complained about the nursing care and treatment provided to their parent (A) who was admitted to hospital after a fall.

We took independent advice from a registered nurse. We found that there were unreasonable time gaps between care and comfort checks, making it impossible for the board to provide assurance that appropriate checks were completed. We found that the necessary risk assessments and care documentation were not completed to the required standards, with no person-centred care plan in place for A. We also found that the standard of record-keeping was unreasonable. Therefore, we upheld this part of C’s complaint.

C complained that the board had failed to provide them with timely updates on A’s care and treatment. The board accepted that C was not provided with appropriate updates regarding changes to A’s health. We upheld this part of C’s complaint.

C also complained about the board’s communication in response to their complaint. C said that the board had not investigated their concerns about A’s dementia diagnosis and reduced capacity, and had referred in the complaint response to allegations by nursing staff about C’s behaviour which detracted from the complaint. We found that the board had shared the issues for investigation with C, inviting correction. We also found that it was reasonable for the board to take into account the experiences of the relevant nursing staff when responding to concerns C had raised. Therefore, we did not uphold this part of C’s complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the specific communication and process 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 appropriately assessed by nursing staff, in particular in relation to continence and cognition issues, and nursing care provided in line with the assessments carried out and in a timely manner. Records about a patient’s care and treatment and decisions made should be clearly and accurately documented, in accord with the relevant professional standards and guidelines, and reflect a person-centred approach. Patient records should include clear details explaining why a decision about care and treatment has been made.
• Family members should be communicated with in a timely and appropriate manner.

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 nursing care provided to their late parent (A) in hospital. A had been transferred from another health board for rehabilitation having suffered a stroke. C said that there was infrequent care rounding and that the provision of and monitoring of A’s diet, nutrition and fluid intake was poor. C also complained about communication, catheter care and pain management.

We took independent advice from a nurse. We found that record keeping was not to the standard required in areas such as care rounding, fluid balance and food charts, and pain assessment documentation. The lack of accurate records of A’s nutritional assessment and needs suggested that A’s nutritional intake was not delivered to a reasonable standard and that they were at risk of malnutrition. Additionally, the absence of pain assessments on A’s observation and care rounding charts indicated a failure to properly evaluate A’s pain levels, making it difficult to determine if the pain medication provided was effectively relieving their pain. We determined that there had been a lack of assessment, evaluation, and implementation of A’s care needs and lengthy gaps between care interventions. Therefore, we upheld C’s complaint.

Recommendations

What we asked the organisation to do in this case:

• 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:

• Nursing staff should be aware of and achieve the required standards of the Nursing and Midwifery Council: The Code in relation to record keeping. A patient’s pain should be appropriately assessed and documented in their patient records.

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 medical and nursing care and treatment provided to their late parent (A). A was admitted to hospital after repeated falls at home. A’s behaviour changed significantly during their admission which suggested that their mental state was deteriorating. C said that they were not directly informed of this, and that A was not referred to the mental health team. A had also been refusing to eat and began to vomit blood. C was not contacted at this point, and was not informed of A’s deterioration until later that day.

We took independent advice from a registered nurse and a consultant geriatrician (specialist in medicine of the elderly). We found that A had been prescribed medication, which combined with existing health conditions, should have required additional medication to protect their stomach. This was exacerbated by A’s refusal to eat. We found that nursing records of A’s nutritional intake were not completed. Additionally, A’s mental state was not properly assessed. We also found that the board had told C that they would make a change to improve the electronic prescription system. However, this change was not possible and the board had not informed C of this. We considered that A’s nursing and medical care fell below a reasonable standard and upheld these parts of C’s complaints.

C also complained about the board’s complaint handling. We found that the board’s response to C was inaccurate. Therefore, we upheld this part of C’s complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failure in medical and nursing care, as well as the complaint handling failures identified in this report. 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 receive the relevant assessments and care planning that reflects their needs. All relevant patient documentation should be completed and recorded in the nursing records in accordance with the NMC Code.
• Patients receiving corticosteroid medication at risk of gastritis or other gastric injury, should receive proton-pump inhibitor (PPI) medication as well.
• Patients should be appropriately assessed when there are changes in their behaviour.
• Person centred care plans should be followed for each patient and weight loss should be recognised and responded to.
• Staff are aware of the importance of prescribing and monitoring a patient’s medication appropriately.
• 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.

In relation to complaints handling, we recommended:

• Complaints should be investigated in line with the Model Complaints Handling Procedure. Actions and improvements should only be included in complaint responses when the board is able to carry them out.

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 practice failed to reasonably respond to their complaint. C had made a complaint to the practice about communication and the service provided by them, particularly in relation to their appointment services, phone lines, and frontline staff. C was concerned by the content and tone of the practice’s complaint response.

We found that the practice’s handling of C’s complaint was unreasonable, including the tone and language of their response and a failure to signpost to the SPSO. We considered some of the language used in their response came across as overly defensive and failed to maintain an appropriately conciliatory tone. The practice also failed to have an appropriate two-stage complaint procedure in place that follows the NHS Scotland Model Complaints Handling Procedure, as they were unaware this applied to them. Therefore, we upheld C’s complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to respond to the complaint reasonably. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

In relation to complaints handling, we recommended:

• Complaint responses should acknowledge the complainant’s experience and, in presenting the facts, should use appropriate conciliatory language and tone with the intention of maintaining positive relationships wherever possible.
• The practice should have a complaint procedure that is in line with the NHS Scotland 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 complained on behalf of their parent (A). A had a long history of contact with mental health services at the board. They had a diagnosis of paranoid and antisocial personality disorder for several years before it was changed to paranoid schizophrenia. A later received an occupational therapy assessment but did not receive support and was referred to social work. A few months later, A was referred to mental health services by their GP due to confusion. A failed to attend two appointments and was discharged. The following year, A was admitted to hospital with confusion and left side weakness. A CT head scan showed an established infarct (an area of necrosis (tissue death) due to blood vessel blockage, often caused by a stroke). A was discharged from hospital and mental health services two months later. A did not receive a psychiatric assessment prior to, or following, discharge and did not receive any community support. C complained that A had not received appropriate support, had not received a psychiatric assessment for several years, and was unsure of their diagnosis. C requested a second opinion but this was refused.

The board said that A had received consultant psychiatric assessments, including two prior to their discharge. They advised that the diagnosis was paranoid and antisocial personality disorder and refused to offer a second opinion.

We took independent advice from a consultant psychiatrist. We found that the board’s response could not be verified by the records and seemed to contradict the diagnosis of paranoid schizophrenia that was given previously. The records did not offer a clear clinical rationale for changing the diagnosis to paranoid schizophrenia and it was not clear that the A had been informed. Given the confusion around A’s diagnosis and lack of psychiatric assessment, we considered that it was unreasonable not to offer a second opinion. Therefore, we upheld C’s complaints.

Recommendations

What we asked the organisation to do in this case:

• Apologise to A for the inconsistencies and contradictions in the complaint response. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.
• Apologise to A for the lack of clear diagnosis, the lack of psychiatric assessment, the lack of rationale in not offering mental health input following A’s stroke and the refusal to offer a second opinion. 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:

• Assurance that diagnostic rationale and patient symptoms including clearly documented Mental State Examination are clearly and consistently recorded.
• Assurance that all staff are aware of and follow the policy “Mental Health and Learning Disability Services Standard operating Procedure – Managing Second Opinions”.

In relation to complaints handling, we recommended:

• The board’s complaint responses and responses to SPSO enquiries should be consistent and supported by the medical records available.

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 provided to their spouse (A). A had been diagnosed with lung cancer and were due to start treatment. A had become unwell overnight and attended the A&E twice in 24 hours. At the first attendance A had been examined but sent home. A’s condition had worsened, and they had been taken back to the A&E by paramedics. A had been examined and then admitted to hospital but died shortly after.

C believed that A’s first assessment was inadequate, and that their concerns about pneumonia were dismissed unreasonably. They felt strongly that had A been given antibiotics and admitted, they might have had a better outcome. C believed that on A’s second attendance, A’s cancer specialists should have been contacted sooner.

We took independent advice from an emergency medicine adviser. We found that A’s assessments were reasonable and that it was unlikely that the outcome would have been different had A been prescribed antibiotics or admitted sooner. We did not uphold the complaint.

Summary

C complained that the dentist failed to provide them with a reasonable standard of dental care and treatment, resulting in significant deterioration. C had concerns about x-rays and the dentist's complaint response. Following contact from our office, the dentist offered a resolution which C accepted. Therefore, we closed the complaint as resolved.

Summary

C complained on behalf of a relative (B), about the care and treatment provided by the board to B's late spouse (A).

When A first felt unwell, they visited their GP on three occasions where they were prescribed antibiotics and told they had a chest infection. Following an x-ray, A was prescribed medication to increase the amount of urine produced, with a plan to carry out a follow up x-ray. A visited the GP again with breathlessness and was referred to the hospital where they were admitted and diagnosed with COVID-19. Blood tests showed that A had an infection and a chest x-ray reported fluid on the right side of A’s chest. A was initially treated for infection with COVID-19 and a suspected bacterial infection. A was discharged from hospital with a plan to repeat the x-ray as an outpatient. A few days later, A was readmitted and diagnosed with lung cancer and was showing signs of spinal cancer.

A was further told that there was a cancerous tumour pressing on their lungs. A’s breathing worsened, they had severe weight loss and they were not eating. Only one family member at a time was permitted to visit A. Staff said that more of A's family would be able to visit if their condition deteriorated. A remained in hospital until their death a week later.

In considering C’s complaint, we took independent advice from a consultant in general and respiratory medicine and a senior nurse. We found that the decision to discharge A from hospital was reasonable and did not uphold this aspect of C's complaint. However, we found that it was unreasonable that A's pleural effusion (fluid build up) was not treated on or shortly after admission. Therefore we upheld the complaint that the board unreasonably failed to carry out further investigations whilst A was on the ward.

We also found that A was unreasonably left sitting and sleeping in a chair during their admission, that A’s family were not given any additional time to visit when A was at end of life and that there was a failure by the board to notify A’s family that their condition was rapidly deteriorating. We upheld these aspects of 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 these complaints. 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:

• Further investigations should be carried out in line with the expected standards for management of pleural effusions in the context of acute admissions.
• In such circumstances, staff should contact the family promptly to inform them of a patient’s deterioration.
• Relevant staff should be aware of changes to guidance.
• The person-centred care plan should be fully completed for each patient and updated with a changing deteriorating picture. When a patient is nursed in a chair it should be clearly documented that this is an informed choice to ensure person centred decision making and regular skin checks completed. Recliner chairs should be obtained promptly where required.

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

The complainant (C) had a right top hip replacement. Some years later, C began to experience back pain and left ankle pain for which they attended physiotherapists and podiatrists. C told us that two years after their hip replacement, a podiatrist identified that C had a leg length discrepancy. C complained that they now have a leg length discrepancy of approximately 17 mm which they considered to be unacceptable.

The board said that leg length discrepancy is a recognised risk following hip replacement surgery. This was confirmed on a form signed by C prior to the procedure.

We took independent advice from a consultant orthopaedic surgeon. We found that the risk of leg length discrepancy was reasonably discussed before the procedure and that the true discrepancy was 5mm which was reasonable. We noted that the operation was carried out to a reasonable standard.

As such, we found that the care and treatment provided by the board was reasonable and we did not uphold the complaint.

Summary

C complained about the care and treatment provided to their late parent (A) by the board. A was living independently but fell and injured their knee. A was admitted to hospital and underwent surgery. C believed that A did not receive adequate food or drink and that A was not provided with antibiotics timeously. A died in hospital and C complained about the way that A’s end of life care was managed, as well as a delay in providing C with a death certificate.

We took independent advice from a consultant physician and a registered senior nurse. We found that A’s medical and nursing care fell below a reasonable standard. During the end-of-life period, we also found that A’s nursing care fell below a reasonable standard, although their medical care was reasonable. We also found that there was an unreasonable delay in providing C with A’s death certificate. We upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C and their family 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:

• Care for patients receiving end of life care should be planned and their care plan updated to reflect their specific needs. Appropriate end of life care should be provided in particular in relation to repositioning and comfort care and this should be documented.
• Patients admitted to hospital should receive appropriate nursing care including appropriate nutritional and fluid intake monitoring, as well as appropriate and regular monitoring of their weight when requested as part of their care plan.
• Patients admitted to hospital should receive reasonable medical care including appropriate and timely medical assessments for feeding and nutrition and delirium and appropriate antibiotic treatment.
• Staff caring for a patient with diabetes should be competent in the monitoring and appropriate recording of blood sugar results and any action taken to address low or high blood sugar.
• Staff involved in wound care should be knowledgeable and competent in wound assessment; wound care and treatment.
• Reporting of deaths and issuing of a death certificate should not be delayed unnecessarily by staff absence.

In relation to complaints handling, we recommended:

• Complaints should be investigated and responded to in accordance with the board’s complaint handling procedure and the NHS Model Complaints Handling Procedure. Complaints investigators should fully investigate and address the key issues raised, identify and action appropriate learning.

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.