Health

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.

Summary

C complained about the care and treatment that they received from the board. C said that following gynaecological surgery, they were left with side effects including recurrent pain and the need for further treatment.

C complained that the board failed to provide them with adequate care and treatment in relation to the operation. The board did not identify any failings in C’s care, but did apologise for communication failings relating to the operation. They said that C had experienced a rare complication, but that this had been recognised and treated appropriately.

We took independent advice from a consultant gynaecologist. We found that C’s care and treatment during and after their operation was reasonable and noted that the complication that occurred was swiftly identified and managed. However, we also found that prior to their operation, C was not provided with adequate information about other possible treatment options, including a lack of discussion about the surgery. We also found that the surgical consent process was inadequate.

The board accepted that discussions relating to informed consent and counselling to support patient decisions should be fully documented, and that this had not occurred in C’s case. The board also acknowledged the importance of discussing and documenting all potential post-operative complications with the patient, so that the patient has informed choice when agreeing to a management plan.

We found that there were aspects of C’s care and treatment prior to their operation that fell below a reasonable standard. Therefore, we upheld C’s 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.

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 sibling (A) received whilst in hospital following a fall. C also raised complaints about communication issues with the board. The board accepted that there had been poor communication with A’s family but did not indicate any concern regarding the care and treatment of A. C and their family were dissatisfied with the board’s responses and brought their complaints to the SPSO.

We took independent advice from a nursing adviser. We found that A did not receive timely medical intervention due to documentation and assessment gaps, particularly in relation to A’s positioning, their need for increased oxygen support, falls prevention and support for hydration. We upheld this part of C's complaint.

In relation to communication and complaints handling, we found that the board did not respond within reasonable timescales. We also found that it was unreasonable that the board did not apologise for the time taken to provide their response, that they did not take action to prevent any recurrence, that they included an inaccurate statement and that they did not respond to all of the complaints that they had clarified with C. We upheld these parts of C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to A’s 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.
• Apologise to C that they did not respond reasonably to their complaints. 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:

• The board review the handling of C’s complaint to understand why there had been a delay in the drafting and approval of the response and devise an action plan to prevent any recurrence.

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 handle their telephone call reasonably. C called the practice while being discharged from hospital to speak to a GP about an urgent review of their GP prescribed medication. In particular, regarding the safe discontinuation of pregabalin (an anti-epileptic drug that can also be used to treat nerve pain and anxiety) following surgery.

We found that the call did not address C’s concern that C needed advice about how to safely discontinue GP prescribed medication. C was also not told that further fit notes could be accessed by requesting one through the practice website or that they needed to wait until they had received a discharge letter so that the pharmacy team and the GP had the correct information.

C was not informed that they could call for a same day triage appointment on their discharge from hospital. Although C was offered a routine appointment which is consistent with the practice’s policy on GP access, C was not given the chance to say whether they wanted to accept this before the call was terminated by the practice.

We found that no offer was made to send a message to a GP informing them of the problem, to be actioned by the GP as and when appropriate. No explanation was provided to C about why their request to speak to the Practice Manager was refused and no consideration was given to requesting someone else (such as the Team Leader) to call C back. Therefore, we upheld this part of C’s complaint.

C also complained that the practice failed to handle their complaint reasonably. We found that the complaint response did not address all the issues that C raised. The response also made statements about what C was told that were not supported by the recording of the telephone call to the reception team. We upheld this part of C’s complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for not addressing C's concern that they needed advice about how to safely discontinue GP prescribed medication, not informing C that further fit notes could be accessed by requesting one through the practice website, not informing C that they needed to wait until they had received a discharge letter so that the pharmacy team and the GP had the correct information, not informing C that they could call for a same day triage appointment on their discharge from hospital, not giving C the chance to say whether they wanted to accept the offer of a routine appointment before the call was terminated, not offering to send a message to a GP informing the GP of the problem, to be actioned by the GP as and when appropriate, not explaining why their request to speak to the Practice Manager was refused and not giving consideration to requesting someone else (such as the Team Leader) to call C back, not addressing all the issues they raised in the complaint response, and making statements in the complaint response that were not supported by the recording of the telephone call to the reception team. 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 should be provided with appropriate explanations and advice when they contact the reception team.

In relation to complaints handling, we recommended:

• Complaints should be investigated and responded to in accordance with the NHS Model Complaints Handling Procedure. Complaints investigators should fully investigate and address the key issues raised, ensure responses are supported by the relevant records, identify and action appropriate learning and apologise where issues have been identified. 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.