Some upheld, recommendations

Summary

C’s elderly spouse (A) spent approximately ten weeks in hospital. While in hospital, A fell on two occasions. C complained about the medical, nursing and physiotherapy care and treatment provided by the board.

We took independent advice from a consultant geriatrician (specialist in medicine of the elderly). We found that the medical care after A’s falls was reasonable. We found that the board had taken reasonable and proportionate actions to acknowledge, apologise for and support learning and improvement regarding the provision of pain relief and a delay in reviewing an x-ray after A’s first fall. We found that the board did not reasonably handle A’s prescriptions for haloperidol (a sedating medication) or codeine (a type of painkiller). On balance, we upheld this part of C’s complaint.

We took independent advice from a registered nurse. We found that the care and treatment regarding A’s falls was unreasonable, as a mechanical aid should have been used to assist A from the floor, and risk assessments and care plans should have been updated. We found that A should have been more closely supervised prior to their second fall. We also found that the board’s post-fall protocol was not reasonable in its current form. Finally, we found that A’s hygiene needs were not reasonably met in hospital. The board had taken some action to support learning and improvement regarding the management of falls. On balance, we upheld this part of C’s complaint.

We took independent advice from a physiotherapist. We found that the care and treatment provided to A was reasonable, and physiotherapy sessions were appropriate, timely and sufficient, considering A’s clinical presentation. We did not uphold this part of C’s complaint.

Additionally, we found that some points of the board’s complaint response were incomplete and made a recommendation to address this.

Recommendations

What we asked the organisation to do in this case:

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

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

• Patients with dementia should receive regular assessments of the benefits of medication, with consideration given to stopping or reducing medication when possible, and patients' families/carers should be informed appropriately.
• Nursing staff should handle falls using safe handling techniques in order to reduce risk to patients and staff. Nursing staff should have access to a reasonable and up-to-date post-falls protocol.
• Nursing staff should ensure patients' physical needs are appropriately assessed and responded to.

In relation to complaints handling, we recommended:

• The quality of the complaint response is very important and should address all the issues raised and demonstrate that each element has been fully and fairly investigated.

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 adult child (A). A had addiction issues and was admitted to intensive care with a head injury after a fall. They were later transferred to a different hospital and onto a ward after their condition improved. A received treatment from the addiction team while in hospital and following further scans and reviews, was deemed fit for discharge. A died at home shortly after discharge.

C complained that the board failed to provide A with a reasonable standard of medical or nursing care. They also said that the board failed to communicate appropriately with social services or community addiction services prior to A’s discharge.

We took independent advice from a consultant neurosurgeon (specialist in surgery of the nervous system, especially the brain and spinal cord) and a nurse. We found that both the medical and nursing care A received was appropriate. Therefore, we did not uphold this aspect of C's complaint. However, we found that A's discharge did not adequately consider their vulnerability and whether A would be safe in the community. We considered that the board did not communicate appropriately with social services and addiction services. 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 failings identified in the report. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflet.

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

• When discharging vulnerable individuals, particularly when they live alone, the board should ensure that the level of support being provided in the community is recorded. Where appropriate, this should be discussed with the patient and /or their family as well as social services.

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 suffered with lower back and right hip pain. C complained about the care and treatment provided by the practice in relation to their diagnosis of Hip Osteoarthritis. C said that despite raising concerns with the practice, they failed to take appropriate action to ensure C’s symptoms were further investigated.

We took independent advice from a qualified GP. We found that the management of C’s symptoms was reasonable and appropriate steps were taken to investigate C’s symptoms. We did not uphold this aspect of the complaint.

With respect to the handling of C’s complaints, we found that the practice’s complaints handling procedure was not compliant with current requirements. We also found that, whilst their complaints response demonstrated that they had investigated the complaint, the practice unreasonably failed to provide further response to C’s subsequent communications or the communications from our office. We therefore upheld this aspect of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for unreasonably failing to provide an appropriate response to C’s concerns and to the communications of our office requesting a further response to C. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

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

• The practice should provide complete responses to complaints raised. Those handling and responding to complaints should be aware of the complaints handling procedure and the importance of providing full responses both to complainants and the SPSO.
• The practice's complaints handling procedure is consistent with and reflects the Model Complaints Handling Procedure.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

Summary

C’s parent (A) was admitted to the hospital's A&E three days after a fall. A had a complex medical history including chronic pain. On admission, A reported lower right-sided chest pain, associated with gradually increasing shortness of breath. A chest X-ray showed no evidence of r ib fractures but a subsequent CT scan showed multiple right-sided rib fractures (from ribs 3-10), a flail segment (when three or more consecutive ribs are fractured in two or more places, causing a segment of the rib cage to become detached from the rest of the chest wall), an intercostal haematoma (solid pooling of blood between the ribs) and a right sided pleural effusion/haemothorax (build-up of fluid/blood between the ribs). A was treated in the Intensive Care Unit (ICU) for one week before being stepped down to the Medical High Dependency Unit (MHDU). A was reviewed by the ICU team as and when required and after becoming acutely unwell they were transferred to ICU again, where they died a few days later.

In relation to A’s admissions to MHDU, C complained about problems with A’s medication, concerns around pain management and the nursing care A received, in particular issues around fluid and nutrition, and not responding to alarms or adhering to observational guidelines. C also complained that staff in the MHDU failed to provide appropriate care and treatment in response to A's deterioration.

We took independent advice from a consultant in critical care and a senior critical care nurse. We noted that management of A’s condition was complex given their history of chronic pain together with a severe acute injury. We found a number of failings in A’s pain management, including doses of sustained release oxycodone being administered outwith the appropriate dose interval, an increase in dose of oxycodone which was not clearly justified, and lack of involvement of the acute pain service for ongoing support after A returned to the MDHU from ICU. Taking all of this into account, we found that the board failed to provide a reasonable standard of pain management and upheld this aspect of C’s complaint.

We found that NEWS (National Early Warning Score, a tool for identifying deterioration of patients in acute settings) observations were irregular and that there was evidence that nursing staff failed to escalate appropriately when NEWS scores were 5 and above. Nursing records were lacking in detail and there was no evidence of A receiving oral care. On balance, we upheld C’s complaint about the standard of nursing care.

We found that overall the response to A’s deterioration was reasonable. A was regularly reviewed by consultants, with escalation as appropriate. We did not uphold this aspect of C’s complaint. However, we were critical of the board’s complaint handling, noting long delays in compiling the complaint response and a failure to keep C updated, and that the board’s own investigation did not identify failings picked up by our own investigation.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failings identified as a result of our investigation. 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:

• Observations are undertaken in accordance with the board’s observations policy and National NEWS Scoring and Guidance, with appropriate escalation. Nursing staff have an understanding of Person Centred Care Plans. Documentation is sufficiently detailed.
• Opioids are administered strictly in accordance with relevant dose periods. Decisions to increase medication doses are clinically justified.
• The board should review how patients with severe chest trauma are managed by the acute pain service after regional analgesia has been removed, and the patient has been stepped down from critical care. Their consideration should include triggers for referral and consideration of policies to ensure that access to the acute pain service for this group of patients is not determined by the choice of step-down environment or nominated parent team, but rather by the extent of the patient’s injuries and likely complexity of their ongoing analgesia management.

In relation to complaints handling, we recommended:

• Complaint responses should consider and respond fully to the issues raised in accordance with The Model Complaints Handling Procedure. They should take into account any relevant national or local guidance in both the investigation and response, and identify and action learning. Complainants should also be kept updated on their complaints in line with the Model Complaints Handling Procedure. Additionally, learning from complaints should be shared throughout the organisation so that actions and improvements can be implemented to prevent the same issues happening again.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

Summary

C complained about the care and treatment that their spouse (A) received during two admissions to hospital. C complained that the board had failed to provide A with adequate personal care during both admissions and failed to adequately manage their medication during their first admission. C also complained that A had been unreasonably discharged following their first admission and that there had been inadequate preparation for A’s second discharge.

The board apologised for failures in A’s care and for aspects of their communication. They also apologised for a failure to adequately prepare A’s medication prior to their second discharge. They identified learning from these failures. However, C remained unhappy and asked us to investigate.

We took independent advice from a consultant in geriatric medicine and an advanced nurse practitioner. We found that A was unreasonably discharged at the end of their first admission. Therefore, we upheld this part of C’s complaint. However, the board managed A’s medication reasonably and provided adequate personal care during A’s first admission. Therefore, we did not uphold these part’s of C’s complaint.

In relation to A’s second discharge, we found that there had been a failure to provide A with adequate personal care and that they had been discharged at the end of this without adequate preparation. We upheld these parts of C’s complaint.

Recommendations

What we asked the organisation to do in this case:

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

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

• Where a patient has a lack of bowel movements for several days, this should be highlighted and discussed with the relevant nursing, medical and allied healthcare teams.
• Where blood tests have been carried out, the patient’s results should be reviewed prior to their discharge.
• Where there is a delay in a patient being discharged, they should receive any medications they are due whilst waiting to be discharged. Patients should receive all appropriate prescribed medication when they are discharged. All relevant patient discharge documentation should be completed.
• Staff should obtain the precise details of a patient’s usual medication regime for Parkinson’s and act upon this to improve patient care.

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 parent (A) by the practice. A was described as fit and well but had developed severe diarrhoea. Although the diarrhoea subsided, A continued to feel unwell and breathless. A was seen by an advanced nurse practitioner (ANP) and referred for an electrocardiogram (ECG) as an outpatient a few days later. A attended for these tests, but was not seen by a doctor, and returned home. A suffered a stroke that afternoon and died in hospital the following day.

C complained that although A spoke with a doctor by telephone, they were not seen in person by a doctor over a series of appointments. C believed that A should have seen a doctor much sooner and that A should have been considered for hospital admission at their appointment with the ANP. They also said that A’s ECG results were abnormal, had been misinterpreted by the practice and should have resulted in A’s admission to hospital as an emergency. C believed that had the practice provided a reasonable standard of care, A’s death could have been prevented. Although C met with the practice and received two responses to their complaint, they continued to believe the practice’s response was inadequate and brought their complaint to this office.

We took independent advice from a GP. We found that A’s care prior to their ECG was of a reasonable standard. It was noted that C disagreed with A’s medical records, but it was not possible to determine precisely what was said at A’s appointments. We did not uphold these parts of C’s complaint.

We found that A’s ECG was highly abnormal, indicating A’s heart was lacking in oxygenated blood flow. This should have resulted in a face-to-face appointment, followed by an immediate hospital referral. Therefore, we upheld this part of C’s complaint. However, it was not possible to determine whether A would have survived with an earlier admission as the cause of A’s death was a bleed on their brain. This was an unfortunate but recognised side effect of the medication given to A to treat the stroke they had suffered.

Finally, C complained about the practice’s complaint handling. We found that the practice failed to handle C’s complaint reasonably and upheld this part of their complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failings 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.
• Apologise to A’s family for the failure to provide A with a reasonable standard of care on the day of their ECG. 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:

• ECG results should be accurately interpreted, taking into consideration the condition of the patient and their medical history.

In relation to complaints handling, we recommended:

• Complaint investigations should be carried out in line with the NHS Model Complaints Handling Procedure.
• The practice’s complaint investigations should ensure that failings are accurately identified.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

Summary

C complained that the board failed to provide them with reasonable care and treatment when they attended the emergency department with pain and swelling in their leg. C was advised that their symptoms did not indicate a pulmonary embolism (a blood clot that blocks a blood vessel in the lungs) and that they were on appropriate medication. C was also referred to the deep vein thrombosis (DVT, a blood clot in a vein, usually in the leg) clinic for further investigation.

We took independent advice from a consultant in emergency medicine. We found that the medical care and treatment provided to C in the emergency department was reasonable. Therefore, we did not uphold this part of C’s complaint.

C also complained about the care and treatment that they received when they attended the DVT clinic several days later. C was advised at the clinic that it was highly unlikely that they had a DVT. However, around two weeks later, C attended the emergency department again due to worsening symptoms. C was diagnosed with a pulmonary embolism.

We took independent advice from a consultant in general medicine. We found that an advanced nurse practitioner did not give sufficient consideration to C’s significantly high D-Dimer blood test result (a test used to check for blood clotting problems) and did not seek input from medical staff. In addition, the board’s DVT protocol at the time was too simplistic to take into account all of C’s risk factors. It did not mandate the recording of those risk factors and deviated from the national guidance at the time, which recommended a repeat scan six to eight days later. Therefore, we upheld this part of C’s complaint.

C also complained about the Significant Adverse Event Review (SAER) the board had carried out. We found that the SAER fully recognised the omissions in the board’s protocol and changes were subsequently made to this. However, when carrying out the SAER, the review team did not seek input from C in line with national guidance. 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 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:

• All relevant staff should be aware of the board’s revised DVT protocol.

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 and their autistic child took up their tenancy, having been offered the property following assessment for priority for allocation.

C reported anti-social behaviour that they were experiencing from neighbours to the council. The behaviour ranged from communal areas being untidy and vandalised, to evidence of drug taking, loud noise and aggressive behaviour from neighbours and others entering the block.

C was dissatisfied with the action that the council took in response to numerous reports of anti-social behaviour, and they were very concerned about the impact that this was having on their child. C was also dissatisfied with the council’s handling of their application to be allocated another tenancy in a different area, and their refusal to consider sheltered housing given their child's needs.

The council responded to C’s concerns explaining that they had responded appropriately to reports of anti-social behaviour and did not uphold C's complaint. The council also explained that they considered that C’s initial allocation of housing was appropriate and in accordance with policy.

We found that the council could not evidence that they consistently responded to C’s concerns of anti-social behaviour inline with their policy and upheld this complaint on this basis. With respect to the complaints on the assessment of C’s housing application, we found that this had been assessed in accordance with policy and did not uphold the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failures 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:

• Relevant council staff should be aware of the relevant policies including Antisocial Behaviour Neighbour Complaints Policy and Procedures , with respect to logging, investigating and responding to complaints of anti-social behaviour by tenants.

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 spouse (A) about the standard of care and treatment received in the months before A died. The board partially upheld the complaint, including failings in communication and a lack of privacy and dignity shown to A.

We took independent advice from a registered nurse. We found that while the board had acknowledged some failings, they had not identified other issues with person-centred care planning, care delivery and documentation. We therefore upheld this part of the complaint.

C complained that the board had failed to communicate with A and their family to a reasonable standard. The board acknowledged that despite C being A’s carer, and it having been agreed to utilise email communication, information was not always shared with the wider team, which may have contributed to C’s perception that communication was lacking. We found that the board’s position that there was no record of any upset between A and individual staff members was factually incorrect. We thereby upheld this part of the complaint.

C complained that there was no record of a care plan, and that the package of care was not adequate for A’s needs. The board acknowledged the lack of a suitable care package had an impact on discharge planning, and that they had failed to establish a more detailed person-centred care plan once A was discharged. We found that there was detailed planning and discussion around discharge involving C and A. We did not uphold this element of the complaint because, on balance, while the delivery of care did not match C and A’s expectations, this did not make the plan unreasonable in the circumstances.

C also complained that the board’s response to their complaint was unreasonable and delayed. We found that C’s complaint was complex and multi-faceted accounting to some extent for the delay. However, the response had inaccuracies and failed to identify all the failings in care. For that reason, on balance, we upheld this aspect of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failures 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:

• The board should ensure that person centred care planning is person specific and staff are knowledgeable on how to create a person-centred care plan; that care rounding is completed appropriately, that pain is assessed to the appropriate level and using the correct tools, that privacy and dignity is maintained by all staff for all patients and that staff are aware of how to promote continence and are competent in the use of products used to promote continence.
• Communication with patients and families should be person-centred, full, and accurate.

In relation to complaints handling, we recommended:

• Complaint responses should be accurate and identify all failings.

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 Lothian NHS Board (Board 1) unreasonably failed to maintain records of specialist advice they provided to another board (Board 2). C attended A&E at Board 2 with symptoms of significant pain, problems passing urine and lack of sensation. On the specialist advice of neurosurgery at Board 1, C was admitted to the Orthopaedics department of Board 2’s hospital and an MRI was carried out the following day. The MRI scan results were discussed with the Board 1's neurosurgery team, following which C was discharged. C later required emergency surgery and considers the outcome would have been better if they had undergone surgery when they originally attended hospital.

When C complained to Board 2, they confirmed that they had relied on the Board 1’s specialist advice but Board 1 had failed to keep a record of the referral. C complained that Board 1 unreasonably failed to maintain records of the specialist advice provided to Board 2. C also complained about the neurosurgery advice provided by Board 1 to Board 2.

We took independent advice from a consultant orthopaedic surgeon in relation to the complaint about maintaining accurate records. We found that Board 1 unreasonably failed to maintain records of the specialist advice provided to Board 2. We upheld the complaint.

We took independent advice from a consultant neurosurgeon in relation to the complaint about neurosurgery advice. We found that C had been appropriately assessed with a thorough examination. As such, we did not uphold this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failing 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:

• A system is in place which ensures when advice is provided by the board for tertiary patients there is a record of this as a permanent part of that patient’s electronic record.

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.