Health

Summary

C complained about care and treatment provided to them by the board in relation to diagnosis and treatment of prostate cancer. C had concerns about medical treatment both prior to and after surgery, and about nursing care when they were in hospital following surgery.

We took independent advice from a urologist and a nurse. We found that overall, medical care and treatment had been reasonable and did not uphold these aspects of C’s complaint. However, in relation to nursing care, we found that C’s needs and risks were not properly assessed, resulting in a lack of person-centred care planning and implementation. We upheld the complaint about nursing care.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failings in nursing care. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/meaningful-apologies.

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

• Patients admitted to hospital should receive appropriate nursing care including complete assessments and development of person-centred care plans. These should be updated to reflect the patient’s presenting condition.

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, an advocate, complained on behalf of A. A had been detained by the board under mental health legislation. C complained as to whether the board had taken steps to address the acknowledged deficiencies in discharge planning experienced by A, and whether A's personal belongings were securely stored in a way which allowed patients to access them.

The board said that there was evidence of discharge planning, however they accepted that A’s need for district nursing care was omitted. The process had been reviewed, and the board were happy to provide a report to demonstrate progress had been made. The board said that patients’ rooms were lockable and while staff had the keys for rooms, patient access was not restricted, beyond the need for staff to open and close rooms for individuals. Restricted items were stored separately, and patients would be supported by staff in accessing these.

We took independent advice from a mental health clinical adviser. We found that the board’s response demonstrated that they were taking reasonable steps to review the discharge process. However, we found that A’s discharge planning did not include the district nursing team. We upheld this aspect of the complaint but made no recommendations. We found that the board’s approach to the storage of possessions was reasonable. We did not uphold this aspect of the complaint.

Summary

C gave birth involving a forceps delivery (where a medical instrument is used to assist birth) and suffered a fourth-degree perineal tear (significant injury to the area between the vaginal opening and anus). C had surgery to repair the perineal tear and again to have treatment for retained placenta (where some placenta remains in the womb after birth). C complained about the maternity care and treatment in hospital, the board’s communication with C in hospital and the board’s handling of C’s complaint.

The board apologised for poor communication during the birth and said that they were carrying out actions to improve management of obstetric and anal sphincter injury and obtaining consent for instrumental birth.

We took independent advice from a consultant obstetrician. We found that the maternity care and treatment provided to C during the time of the birth was reasonable. We did not uphold this aspect of the complaint.

We found that the board’s communication with C when C was in hospital was unreasonable. Though the birth situation was urgent, it was not an emergency, and a fuller discussion should have taken place with C regarding the forceps delivery. We upheld this aspect of C’s complaint.

We found the actions that the board said they were carrying out were reasonable in response to the failing in communication.

We found the board’s complaints handling was unreasonable, because C’s initial complaint was not reasonably progressed, the scope of the complaint investigation was not agreed with C, the board’s response to the complaint was not reasonably clear, and there were regular and significant delays in the board’s communication with C regarding the complaint. We upheld this aspect of the complaint.

Recommendations

What we asked the organisation to do in this case:

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

In relation to complaints handling, we recommended:

• All staff should be aware of how to identify and progress complaints about the board. The board should provide full, clear and timely complaint responses in line with the NHS Scotland 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 about the care and treatment of their late parent (A) following an admission to hospital with a hip fracture, and about the communication surrounding this. C raised concerns about A’s fitness for discharge, including a lack of rehabilitation in hospital and length of wait for community rehabilitation, as well as a lack of support with food and fluid intake, and a lack of adequate skin care. C also raised concerns about a lack of engagement with them as A’s next of kin and power of attorney.

We took independent advice from a consultant orthopaedic surgeon and a registered nurse. We found that A’s discharge was medically reasonable, and that the level of input from therapists was reasonable. The board acknowledged shortcomings in communication with C around their discharge, and a failure to document the nursing handover with the care home. The board also apologised that the target timescale for community rehabilitation was not met.

We found that there were unreasonable failings in the nursing documentation, person centred care, and pressure care that A received. A’s person centred care plan was not completed, and a documented instruction that A required full assistance with nutrition and hydration was not adhered to.

We identified frequent gaps in skin inspections and repositioning, and inconsistent completion of a pressure ulcer risk assessment. The relevant foot care did not take place in light of A’s diabetes, and there was no referral to podiatry when pressure damage to A’s heel was discovered. We were concerned to note that A’s nutritional needs were not met, and that there was a failure to protect A from pressure damage. We upheld this complaint.

We also identified inconsistencies in the board’s complaint responses and noted that important failings were overlooked. We made recommendations to the board to address these.

Recommendations

What we asked the organisation to do in this case:

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

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

• Food, fluid and nutrition standards should be met. Instructions set out in care plans to be adhered to, and patients to receive the appropriate level of assistance.
• Patients’ person centred needs should be fully considered. Documentation should meet the professional standards required by the NMC – The Code.
• Pressure ulcer prevention standards should be met, and patients protected from healthcare acquired pressure damage.

In relation to complaints handling, we recommended:

• Stage 2 complaint responses should meet the aims of the NHS Scotland Model Complaints Handling Procedure. They should aim to establish all the facts relevant to the points made in the complaint and to give the person making the complaint a full, objective and proportionate response that represents the organisation’s final position. We offer SPSO accredited Complaints Handling training. Details and registration forms for our online self-guided Good Complaints Handling course (Stage 1) and our online trainer-led Complaints Investigation Skills course (Stage 2) are available at https://www.spso.org.uk/training-courses.

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 the board provided to A, who had long-term mental health conditions. A was subject to a Community Compulsory Treatment order (CTO, a legal order that allows a person who has been detained in hospital for treatment to be discharged and receive supervised mental health care in the community). C was A’s Named Person in respect of the CTO. A experienced a deterioration in their mental health over a short period of time, which concluded with them attending A&E and requesting hospital admission. A was not admitted to hospital and died later that night. The post-mortem believed that A may have completed suicide.

The board carried out a Significant Adverse Event Review (SAER) and concluded that the outcome could not have been predicted. The SAER identified areas of good practice but also some learning points. These centred on missed opportunities to refer A to addiction services and paper notes from the Forensic Community Mental Health Team (FCMHT) not being accessible by other services.

C complained to the SPSO as they felt that there were failings in the care and treatment provided to A that contributed to their death. In addition to this, C complained that the board did not communicate with them reasonably, given that they were A’s Named Person.

We took independent advice from an adviser with a background in forensic psychiatric nursing. We found that the overall care and treatment provided to A in respect of their mental health was reasonable. We considered it clear that access to the FCMHT records across services would have been preferable. This would have assisted the clinical decision-making when A presented to A&E. However, we found that there are no standard guidelines or requirements for the sharing of records across NHS services in Scotland. Based on A's presentation and what was known to clinicians at the time, we found that the care and treatment provided by the board was reasonable. Therefore, we did not uphold this part of C's complaint.

In respect of C’s role as A’s Named Person, we found that it was unreasonable not to involve C in discussions regarding A’s circumstances. Relevant Scottish Government guidance indicates that it is necessary for the board to ensure that Named Persons are given information regarding compulsory measures. We found that the board’s actions and responses did not fully reflect the Scottish Government guidance regarding Named Persons. Particularly as there were discussions at the time about ending A’s CTO. Under the circumstances, we found that the board did not involve or communicate with C to a reasonable level. Therefore, we upheld this part of C's complaint.

During our investigation, we found failures in the board's handling of C's complaint and made recommendations to address these.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for not involving or communicated with C to a reasonable level. 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:

• Relevant staff and services should have a firm understanding of what the Named Person role involves. Services should engage and communicate with Named Persons in line with the relevant guidance issued by the Scottish Government: Mental Health Law in Scotland: A Guide to Named Persons

In relation to complaints handling, we recommended:

• Causation/conclusion codes on adverse event review reports should accurately reflect the findings of the review.
• Documentation that is relevant to the SAER should be available to and considered by the team carrying out the review.
• In response to SPSO enquiries, every effort should be made to provide any requested information at the earliest opportunity.

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 of their late spouse (A). The day before A’s first admission to hospital, the GP submitted an urgent suspicion of cancer (USOC) referral. A was experiencing abdominal pain with vomiting and diarrhoea. The initial diagnosis had been a suspected blocked bowel. After symptoms settled, A was discharged before returning to hospital a few days later with ongoing symptoms. A was discharged home with a plan to return for an outpatient colonoscopy. However, A returned to hospital with a diabetic foot infection resulting in surgery. During this final admission, A was diagnosed with bowel cancer. C considered A was inappropriately discharged from hospital following the first two admissions with no clear diagnosis or plan in place. C said that communication throughout A’s hospital admissions was poor and also complained about the nursing care provided to A, particularly in relation to the care given to their feet as a known diabetic.

We took independent advice from a clinical adviser and senior nurse adviser. We found that given A’s symptoms, and the USOC referral, the board unreasonably failed to consider A for an inpatient colonoscopy during their second admission to hospital and unreasonably failed to schedule an outpatient colonoscopy for A one to two weeks after discharge. We also found A’s second discharge from hospital was inappropriate because their presentation, along with other relevant information, should have alerted clinical staff to the possibility of cancer.

We found that basic nursing care could not be evidenced due to poor documentation and that appropriate assessments were not carried out. We found that the foot care provided to A was unreasonable with no evidence to show wound assessment or monitoring was done to a reasonable standard. We upheld all aspects of the complaint relating to the care and treatment of A.

C also complained that the boards handling of the complaint was poor. We found that steps were taken to agree the complaints issues that would be investigated, regular updates were provided and steps were taken to manage contact with C, Therefore, we did not uphold this aspect of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C 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 receive appropriate nursing care. In particular in relation to Food Fluid and Nutrition, Wound Assessment and Management and Pressure Ulcer Prevention, including CPR for feet.
• Nursing documentation should be completed to the required standard.
• Patients should receive appropriate investigations in relation to their presenting symptoms either during admission or as soon as possible on discharge.

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 the board provided to their parent (A). The complaint relates to several different primary and secondary care services, including A’s medical practice, which was managed directly by the board. A had a long history of peripheral arterial disease (a condition where a build-up of fatty deposits in the arteries restricts blood supply to leg muscles).

A experienced gradually worsening pain in both their legs and had contacts with the Out of Hours (OOH) service, their GP and the board’s vascular team. Ultimately, A was admitted to hospital due to worsening critical limb ischaemia (severely blocked flow to one or multiple hands, legs or feet). It was decided to amputate A’s leg but, following the surgery, A’s condition deteriorated. They were diagnosed with myocardial infraction (a heart attack) and died in hospital.

C complained about several aspects of A’s care and treatment which covers both the period up to, and the time during, A’s admission to hospital. Firstly, they complained that the OOH Advanced Nurse Practitioner (ANP) failed to provide reasonable care and treatment. The board’s position was that the care and treatment provided by the ANP was reasonable but they apologised that C and A had been given the expectation that an OOH GP would attend.

We took advice from an independent GP adviser. We found that the care and treatment provided was reasonable, and that the ANP had appropriately reviewed A’s medical history before attending. Therefore, we did not uphold this complaint.

C’s second complaint related to A's medical practice. C stated that a GP in the practice had unreasonably failed to diagnose A’s condition correctly and provide appropriate treatment. The board concluded there were missed opportunities to see A face to face. However, they considered the practice’s clinical decision-making to be reasonable.

We took advice from an independent GP adviser. We found that different GPs may have taken different courses of action based on the same set of circumstances. However, this did not mean that the course of action taken here was unreasonable. Overall, we found that the care and treatment the practice provided to A was reasonable. Therefore, we did not uphold this complaint.

C’s third complaint related to the outpatient vascular care and treatment that the board provided to A prior to their admission to hospital. In C’s view, the Vascular Consultant involved in A’s care unreasonably refused to admit A to hospital in conjunction with A’s GP. The board concluded that A’s care and treatment plan under the care of the vascular team was managed appropriately. While they regretted not admitting A earlier, this would have been unlikely to change the outcome.

We took independent advice from a vascular consultant. We found that the vascular input provided by the board prior to A’s admission to hospital was reasonable. We also found that given A’s circumstances, the decision not to insist that admission to hospital was urgent represented established good practice. Therefore, we did not uphold this complaint.

C’s fourth complaint related to the clinical treatment provided to A following their admission to hospital. We took independent vascular advice on this complaint. We found that the clinical decision-making of the vascular team was reasonable. This included the decision to proceed with amputation in the absence of any alternative treatment options. In respect of A’s myocardial infraction, we found that the care and treatment from a vascular perspective was reasonable. We also concluded that there was a record of appropriate discussions regarding DNACPR and the risks of amputation. Given this, we did not uphold this complaint.

C’s fifth complaint related to the nursing care provided to A during their admission to hospital. The board had acknowledged some failings in this respect, particularly around communication. We did not uphold this complaint.

C’s final complaint related to the end of life care provided to A. We took independent nursing advice. We found that the end of life care, as documented in the records, was reasonable. We did not doubt C’s account of how traumatic A’s death was. However, in the absence of additional evidence that indicated staff failed to carry out the kind of actions that they should have, we did not conclude that the care provided was unreasonable. Given this, we did not uphold this complaint.

Summary

C complained about the care and treatment of A, who had a background of complex medical conditions, including a history of diabetes, heart disease, chronic kidney disease and cardiorenal syndrome (a chronic disorder and imbalance of the heart and kidney function).

A was admitted to hospital three times over the course of approximately eight weeks. A had surgery for a fractured hip. After surgery, A developed bilateral non-arteritic anterior ischaemic optic neuropathy (NAION, a rare condition that causes sight loss). C complained about the medical and nursing care that A received.

We took independent advice from a consultant renal physician (a specialist in kidney conditions), a consultant ophthalmologist (a specialist in eye conditions) and a cardiac nurse (a nurse who specialises in heart conditions). We found that the board provided reasonable medical care to A over the course of their three admissions. Therefore, we did not uphold this part of the complaint.

We found that on one occasion, A was unreasonably recorded as being able to attend the toilet independently overnight, when A had an accident. In all other aspects, the board provided reasonable nursing care to A. Therefore, on balance, we did not uphold this part of the complaint.

Summary

C complained that there had been a lack of neurological (of the nervous system) support for their family member (A). A sustained a traumatic brain injury (TBI) that required emergency surgery, and was transferred to the board under the care of neurology. C said that staff dismissed their concerns about A’s worsening condition and that A was being managed for their epilepsy as opposed to someone with a TBI. They also complained that there had been an unreasonable delay in identifying the disconnected shunt (a thin tube implanted in the brain to direct excess cerebrospinal fluid (CSF) to another part of the body), despite A’s symptoms.

The board said that the neurology team had been managing A’s epilepsy but in the absence of a consultant in neurological rehabilitation they had been seeking to provide general support and make appropriate referrals. It was acknowledged that there was a lack of NHS services for TBI rehabilitation generally throughout Scotland. The board also said that the disconnected shunt was not necessarily the cause of A’s symptoms.

We took independent advice from consultant neurologist. We found that the management provided to A was appropriate with relevant referrals made. However, given the significant head injury suffered by A, we found that the consultant neurologist could have met with them at an earlier date. The information available indicates that the first meeting did not take place until some 14 months after A’s head injury. An earlier meeting would have assisted A in terms of general support and also in managing their expectations whilst providing confidence and reassurance that their condition was being managed in the best way possible. In relation to the time taken to identify the disconnected shunt, we considered that the evidence available indicated appropriate and timely steps were taken by clinical staff.

We did not uphold C's complaints. However, we did provide feedback to the board in relation to the timing of the first meeting between A and the consultant neurologist.