Not upheld, no recommendations

Summary

C complained on behalf of their late partner (A) about the care and treatment they received at the Royal Infirmary of Edinburgh for heart disease. A’s condition deteriorated and they were transferred to the intensive care unit and then ultimately referred to another health board for a heart transplant. A died five days later.

C said that the board did not treat the left side of A’s heart which resulted in a grave outcome for A. C also said that the board did not notice that A was deteriorating and that A should have been transferred to the other health board earlier.

The board said that when A was admitted they had a blocked right coronary artery and treatment was given for this. They explained that there was no viability in the left side of A’s heart (due to damage caused by a previous heart attack) and therefore, to treat that side would have subjected A to additional risk. The board said that A was very unwell, but reasonably stable until their sudden deterioration. They said that there was no indication that an earlier referral outwith the health board was warranted or would have altered the outcome.

We took independent clinical advice from a consultant cardiologist (a doctor that that deals with diseases and abnormalities of the heart). We found that it was reasonable for the board not to have a treatment plan for the left side of A’s heart as it would have exposed A to increased risk and there would have been no benefit to A (due to irreversible damage caused by a previous heart attack). The board reasonably monitored A’s condition and provided appropriate care and treatment in response to their deteriorating condition. We also found that the board’s decision to refer A to another heath board was reasonable and that there was no indication this should have been done earlier.

As such, we did not uphold this complaint. We did, however, provide feedback to the board regarding their communication with A.

Summary

C was referred to Raigmore Hospital by their midwife with high blood pressure. C was pregnant and there were concerns they had pre-eclampsia (a condition that causes high blood pressure during pregnancy and after labour). C said that on attending the hospital they did not receive reasonable treatment over a four-day period. C also considered the care provided to their newborn child (A) was unreasonable.

We took independent advice from a consultant obstetrician and gynaecologist (a doctor who specialises in pregnancy, childbirth and the female reproductive system) and a consultant neonatologist (a doctor who specialises in the medical care of newborn infants, especially ill or premature newborns). We found that the tests carried out when C attended the ward were reasonable and in line with relevant guidelines. We considered it was reasonable that C was initially discharged prior to their later admission and when C’s condition worsened, appropriate action was taken. As such, we did not uphold this complaint.

In relation to C's concerns about A's health, we considered that the actions taken after concerns were raised about A’s condition were reasonable. While we considered that the communication and documentation was below a reasonable standard, the clinical care provided to A was reasonable. As such, we did not uphold this complaint. However, feedback was provided to the board.

C complained that the board failed to reasonably respond to their complaint. We found that while the response to the complaint was accurate in relation to the medical records, it would have been good practice to provide more detail as to the board's position on certain points. A consultant spoke with C after events and arranged for further details to be provided regarding A’s care, which was good practice, particularly considering the board had identified communication issues. While further detail could have been given, and we provided feedback to the board on this point, on balance, we found the response to be reasonable. As such, we did not uphold the complaint.

Summary

C complained about the treatment their spouse (A) received for their pressure sores from district nurses. When A died, one of the main causes of death was noted to be multiple pressure sores. C said that there was no examination by a GP at any point. They believed the pressure sores had become infected, causing sepsis and leading to A’s death.

The board outlined the steps district nurses had taken when they identified that A’s sacral and heel pressure areas were starting to break down. They told us that over a four-month period, district nursing staff carried out more than 80 visits as well as providing support over the phone. They said the district nursing team involved A’s GP and the tissue viability service, who agreed with the care and advice that was being provided.

We took independent advice from a nursing adviser. We found that A’s clinical records showed risk factors which increased their risk of developing skin damage: weight loss, poor mobility and double incontinence. We noted that the advice to patients with pressure sores is to move and regularly change position and to use a pressure relieving mattress, cushions and boots. District nurses ordered appropriate equipment for A and monitored A’s pressure areas closely. We found that there was evidence in the notes of appropriate advice being given to A and C regarding sitting in a chair for a long period of time and the detrimental effect this could have on the skin, especially the heels and sacrum. The boots provided to A were returned to the equipment store despite documented advice that these should be worn.

We considered that there was clear evidence of partnership working between the carers, district nurses, and the wider multi-disciplinary team. Noting the complications associated with A’s incontinence, we found that the documented evidence demonstrated the appropriate treatment being delivered.

Therefore, we did not uphold this complaint.

Summary

C operated a bed and breakfast business from their home (the premises) and a number of years ago was identified as a gap site (a property where commercial activity is being conducted and should, therefore, be liable for commercial water charges, but that has not yet been registered for commercial water services). Scottish Water installed a water meter on pipework outside the premises so that C’s water consumption could be measured for commercial water charges. As they had not chosen one, a licensed provider was appointed to manage C’s water account.

Following installation of the meter, C began to receive water bills that were disproportionately high for the number of residents and guests in the premises. Investigations by their licensed provider established that there was likely a leak between the meter and the premises. The location of the presumed leak meant that it was C’s responsibility to locate and repair it. C appointed a contractor to undertake this work. The contractor ultimately decided to lay a new supply pipe from the premises to the meter at a cost to C of more than £10,000.00. In doing so, they did not encounter the original supply pipe and no leaks were identified. However, following the work, C’s water consumption fell to a normal level.

C subsequently learned that a lot of the work carried out by the contractor had been unnecessary. Scottish Water had previously replaced their communication pipe with a narrower pipe, which was connected to C’s original larger supply pipe. C contended that the work carried out by Scottish Water had caused the leak. C also considered that, had Scottish Water informed them that they had installed a narrower pipe, the contractor would have been able to slide a similarly sized pipe through the original larger pipe, negating the need to excavate the ground and saving a substantial amount of money.

C complained that they had incurred substantial financial losses as a result of Scottish Water’s work and lack of communication. They considered that Scottish Water should, therefore, make a significant contribution towards the costs they incurred.

We found that Scottish Water communicated reasonably with C regarding the gap site process and the installation of the meter. We did not consider there to be a particular need for Scottish Water to advise C that they had used a narrower pipe when they changed the communication pipe some years previously. We were also satisfied that Scottish Water reasonably investigated C’s concerns regarding the leak. We found that their conclusions and decision not to cover C’s costs were demonstrably based on information gathered during their investigation. A full leak allowance was paid and we found this to be reasonable in the circumstances. We did not uphold C's complaints.

Summary

C complained about matters relating to their mail. A letter sent to C was retained by the Scottish Prison Service (SPS) for the purpose of testing because the item of mail was thought to be suspicious. The mail was tested using the rapiscan itemiser (a machine used by the SPS to trace and detect a broad range of illicit substances). C’s mail indicated a positive result for an illicit substance.

C considered the testing procedure was not carried out properly. In particular, they believed that the mail item was cross-contaminated due to inappropriate handling. C also considered the SPS failed to provide an appropriate explanation as to why their item had been identified as being suspicious.

The SPS explained that testing of suspicious incoming mail was in place across the prison estate and was an important process ensuring the safety of both prisoners and staff. The equipment used was the same in all establishments and was calibrated to detect significant amounts of illicit substances. The scan of C’s letter had indicated for a specific illicit substance. It was also noted unlikely the letter would have been cross-contaminated.

We looked at the SPS’s standard operating procedure and we considered the prison rules. We were satisfied that the SPS handled C’s mail appropriately, in line with the relevant standard operating procedure. Whilst recognising C’s concerns about cross-contamination, we considered the SPS’s response on this point reasonable. In relation to C’s complaint that the SPS failed to properly explain why their mail had been retained for testing, they were particularly concerned that the SPS had not given detail as to why the mail was deemed as suspicious. We were satisfied that there were reasonable grounds for the SPS to deem C’s mail as suspicious. Whilst it would have been good practice for the SPS to have explained to C at the time that specific details of their suspicions could not be shared, we accepted that providing C with a detailed explanation could have potentially compromised the security of the process. Therefore, we felt it reasonable the SPS did not fully explain to C why their mail was deemed suspicious. As such, we did not uphold C’s complaints.

Summary

C held Power of Attorney (POA, a legal document appointing someone to act or make decisions for another person) for their parent (A) who moved to a care home. Due to their level of capital, it was determined that A would be self-funding their accommodation. C requested a reassessment for funding towards care home fees as A’s savings had reduced to the required threshold.

C provided the evidence required to show A’s income and expenditure to social work and was informed that A had been overspending on items other than care costs. The council determined that there had been deprivation of capital (where someone has spent or otherwise reduced their capital at least in part to avoid paying that money towards care home fees). This meant they would not contribute towards A’s care costs. By the time C was informed of this, A’s finances reduced significantly and had accrued debt.

C complained to us that the council’s view that A had deprived themselves of capital was unreasonable and also that the council had failed to provide adequate information about reasonable spending and deprivation of capital.

We took independent advice from an appropriately qualified social worker. On reviewing the council’s records, we considered a reasonable approach had been taken to the financial assessment and that the conclusion reached was reasonable, as there was clear evidence that A’s spending had not been consistent with their spending in previous years. We also considered that reasonable information had been provided about deprivation of capital and made clear that it was the responsibility of a POA to understand A’s financial obligations and that the council did not have responsibility to provide financial advice.

As such, we did not uphold C’s complaints.

Summary

C’s sibling (A) was being treated in hospital after being diagnosed with a brain tumour. C complained about social work involvement in planning for A’s discharge from hospital. C believed the home environment was unsafe for A, and thought the council should have made alternative arrangements for A’s accommodation on discharge. C also complained about the communication with C and C’s sibling (B) regarding discharge arrangements for A. C was dissatisfied with the council’s complaint response, and brought their complaint to us.

The council said that they had acted in accordance with the relevant legislation. They noted A consistently expressed a wish to be discharged home to their family, and the council undertook a number of tasks to improve the home condition prior to A’s discharge.

We took independent advice from a social work adviser. We found that the council had provided an appropriate care and support plan for A. We noted C’s concerns about A’s home environment, but considered that the council had worked to minimise the risks to A of returning home. We considered that the council had met their obligations in respect of A and we, therefore, did not uphold this aspect of C's complaint.

With regard to the complaint about communication, the council acknowledged some of their communication with the family could have been better, and apologised for this. We noted that although C said they had Power of Attorney (a legal document appointing someone to act or make decisions for another person), this had not been registered with the Office of the Public Guardian and therefore gave them no authority to act on behalf of A. Although C and B had no legal authority to be involved in decision-making regarding A, we noted that the council had worked to involve them. We recognised this was a complex and difficult situation but we did not uphold this complaint.

Summary

C complained about the care and treatment their parent (A) had received from the board. A had a terminal cancer diagnosis and severe arthritis. C complained about a series of admissions A had to hospital. C said A had been discharged without C being consulted, even though they were A’s main carer. This meant A was discharged to a potentially unsafe environment, and did not receive the necessary levels of care.

C said A was readmitted to hospital. A was then discharged to a care home, but was not provided with oxygen. C said that A had required oxygen in hospital and the failure to accept that A required long term oxygen support or to provide A with oxygen meant that A required a further hospital admission.

C said that when A was readmitted to hospital, they received substandard care. A was put on a busy ward, that did not specialise in palliative care or geriatric medicine (medicine of the elderly) and that this type of care was only provided once C intervened.

We took independent advice from a consultant geriatrician. We found that A’s discharge planning was carried out to a reasonable standard. A had capacity and the board’s actions took into account their wishes and included a reasonable assessment of A’s home environment.

We found A was very ill during their final admission and that at times A was dehydrated and eating very little and that this would have been very distressing for C and other family members to have witnessed. We noted that dehydration and low food intake were a common feature of this stage of A’s illness and were not evidence of neglect on the part of staff. We found, based on the advice we received, that communication with A was of a reasonable standard and that their pain and condition was monitored and acted on appropriately.

In terms of A’s discharge without oxygen support, we found that staff gave appropriate consideration how best to manage A’s low oxygen saturation levels and that on discharge A’s own preference was a factor in the decision to discharge A without an oxygen supply.

We did not uphold C's complaints.

Summary

C complained on behalf of their child (A). A attended their GP practice and A&E at University Hospital Hairmyres on a number of occasions before examination by a physiotherapist led to a referral back to hospital, further x-ray and diagnosis of slipped upper femoral epiphysis of the hip (SUFE, where the growing part of the bone in the hip joint moves). C complained that A was advised to continue walking unaided despite being in severe pain. C believes failings in care contributed to A’s condition worsening to the point where significant surgery was required. C was dissatisfied with the board’s response to their complaint and asked this office to investigate.

In their response to our enquiry, the board confirmed that A’s case had been discussed at a Morbidity and Mortality review, with learning identified. They said that the initial referral letter from the GP to orthopaedics (specialists in the treatment of diseases and injuries of the musculoskeletal system) prompted no red flags from the orthopaedic team and they suggested musculoskeletal physiotherapy in the first instance. A was given an appointment but they attended A&E in the interim.

We took independent clinical advice from a consultant in emergency medicine and a consultant orthopaedic surgeon. We found that SUFE was a difficult condition to diagnose and we did not consider the delay in diagnosis to be unreasonable. We were, however, critical of the decision to discharge A without further investigation, when they were unable to weight-bear. We noted that the board had identified learning but considered they also ought to develop a multidisciplinary pathway for the limping child. We also found that the referral from the GP was assessed appropriately in view of the information it contained. On balance, we did not uphold this complaint but provided the board with feedback in relation to the issues mentioned above.

Summary

C was suffering from swelling and pain in their right knee. C attended an appointment with a consultant vascular surgeon (a specialist in the treatment of diseases affecting the vascular system including diseases of the arteries, veins and lymphatic vessels). The consultant noted that C had varicose veins (swollen and enlarged veins that usually occur on the legs and feet) but believed them to be uncomplicated. The consultant felt the swelling in the right leg was not caused by a problem with the veins and that there were no other symptoms of venous disease. C was not referred for vascular surgery. C had an ultrasound scan which confirmed the lump on the leg and the symptoms were likely caused by a trapped nerve.

C complained that the care and treatment provided were not reasonable and that it was unreasonable not to refer them for varicose vein surgery.

We took independent advice from a consultant adviser. We found that the examination and conclusions of the board were reasonable on the basis of C’s condition at the time. We noted that there were no indications that further vascular investigations/treatments needed to be offered. Additionally, we were satisfied the board had appropriately applied the National Policy NHS Protocol for access to Varicose Vein surgery.

We did not uphold the complaints.