Some upheld, recommendations

Summary

C complained about the care and treatment that they received from the dentist during a period of eight months. C is a bariatric patient and is unable to recline due to their medical condition. C attended for an examination with the dentist and complained of a broken front tooth and decay on the upper left second molar. Treatment options were discussed and it was agreed that at the next visit, the dentist would apply fillings to both teeth.

C attended for treatment to both teeth 11 weeks later. The dentist explained to C that a referral to the Public Dental Service (for individuals who cannot access an independent dentist) would likely be the best option going forward as they were unable to gain proper access to treat C. C agreed to a referral and the next examination was scheduled for six months’ time. C attended for an emergency appointment six weeks later, complaining of pain. The tooth was filled and the dentist made a referral to the Public Dental Service, resending it six weeks later.

C emailed complaints to the practice on two occasions but did not receive a response to either.

C attended for a further examination complaining of ongoing pain. Treatment options were discussed and the dentist booked C in for an appointment for treatment.

C emailed the practice to ask for a response to their previous two complaint emails. C was advised by the practice to speak with the dentist during their appointment the following day. However, C decided to cancel future treatment as they had lost faith in the dentist.

C received a complaint response from the dentist and contacted the practice the following day to express their dissatisfaction with the response. The dentist issued a further response in an undated letter. C wrote to the practice again and the dentist subsequently issued a further letter to C saying that they believed they had already addressed all of C’s concerns.

In considering C’s complaint, we took independent advice from a dentist. We found that overall, the care and treatment provided to C by the dentist was reasonable and that there was no unreasonable delay in referring C for treatment. We did however find that C’s complaints were not appropriately identified and responded to in line with the complaint handling procedure and upheld this complaint. We also provided feedback to the dentist in relation to communication.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the specific failings identified. 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 dentist should ensure complaint investigations conform to the NHS Model Complaints Handling Procedure, particularly in terms of the requirement to respond in writing and in a timely manner. They should review their handling of this complaint with a view to identifying areas for learning and improvement.

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 late partner (A) who was admitted to hospital due to abdominal pain, severe lower back pain, weight loss and reduced appetite. A CT scan identified a left hepatic vein thrombosis (a blood clot in the vein draining the liver). A was commenced on anticoagulant (blood thinning) medication. A further CT scan showed that A had new thrombus in the portal vein (the main vein draining into the liver). Following discussion with haematology (specialists in conditions of the blood), A’s anticoagulation medication was changed.

Several days later A complained of a headache and vomiting and was given pain medication. The following morning A was found to be unresponsive by nursing staff. Levetiracetam (an anticonvulsant medication) was administered and A was taken for a CT scan which showed extensive intracerebral haemorrhage (bleeding into the brain tissue). Protamine (medication that partially reverses the effects of the anticoagulation medication) was administered and advice sought from neurology (specialists in conditions of the nervous system) who said that on review of the scans, the extent of the bleeding was not survivable. A died shortly after.

C complained that the board unreasonably failed to warn A of the risks of anticoagulation medication and unreasonably administered protamine and levetiracetam shortly before A's death. C complained that the board unreasonably failed to include anticoagulation medication on the death certificate and failed to communicate to A’s family that it was a cause of death.

We took independent advice from a consultant in acute medicine. We found that the use and timing of both levetiracetam and protamine was reasonable. We did not uphold this part of C's complaint. However, we found that the board failed to warn A of the risks of the anticoagulation medication before commencing the treatment. We also found that the board unreasonably failed to include the anticoagulation medication on the death certificate and failed to communicate that it was a cause of death to A’s family. Therefore, we upheld these parts of A'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 inthe SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

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

• Patients prescribed anticoagulation medication should be given appropriate information on the risks and benefits of anticoagulants, in line with relevant clinical guidance and this should be clearly documented within the patient records.
• Relevant information about a patient’s death should be effectively communicated to their family.

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 their sibling (A, a prisoner) with medication in a reasonable manner. C complained that the injection for A’s condition was not administered in line with the prescribing consultant’s instructions and that the board’s view that the acknowledged delays did not negatively impact A was unreasonable. C was also unhappy with the way that A’s other medications were managed.

We took independent advice from a GP. We found that there was an unreasonable delay when one of the injections was administered and guidance did not support the board’s view that no detriment would have been caused by this delay. We also found that the record keeping for the other medications administered during that period did not indicate that other medications were provided at regular intervals. This was unreasonable. Therefore, we upheld this part of C's complaint.

C also complained that the board unreasonably failed to arrange or rearrange hospital appointments for A. We found that some elements of this complaint were outwith the board’s control, in relation to third party organisations being involved in transportation. Whilst there were instances where A’s transport requests were not sent within the timeframes set out by guidance, overall we considered that the board’s efforts to schedule transport were reasonable. Where an appointment was cancelled due to transport issues, the board took quick action to reschedule the appointment and rearrange transport. This was reasonable. Therefore, we did not uphold this part of C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to provide A with medication in a reasonable manner. 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:

• Medication should be prescribed in line with specialist advice.
• When there are multiple delays in administering medication action is taken to avoid the issue repeating.

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 council’s social work service during the pre-adoptive process of their child (A). C complained about the council’s decision to temporarily suspend A’s nursery placement and about the council’s communication of their decision. C complained that the council failed to have an appropriate level of contact with A during the pre-adoptive process, and that the council failed to reasonably prepare and submit a report which is required from an adoption agency for court, regarding the suitability of the prospective adoptive parents.

The council apologised for failing to communicate information about A’s suspended nursery placement at a time when open and honest communication could take place.

We took independent advice from a social worker with experience in fostering and adoption. We found that the council’s decision to temporarily suspend A’s nursery placement was made without consultation with A’s pre-adoptive carers or nursery, who should have been part of the decision-making process. We upheld this point of C’s complaint. We found the council’s social work visits to A did not meet the frequency or timing set out in the council’s policy or legislation. We upheld this point of C’s complaint. We found the council prepared and submitted the required report within the statutory timescale and reasonably communicated with C about the report. We did not uphold this point of C’s complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to the complainant for the failings identified by this investigation. 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:

• Social workers should visit children in pre-adoptive placements in line with their statutory requirements as per the Looked After Children (Scotland) Regulations 2009, and the council’s procedure.
• The social work department should appropriately consult with key partners in pre-adoptive placements (such as carers and nursery) on decisions related to a child’s care, and communication with partners should be timely.

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

Summary

C complained on behalf of their parent (A) who suffered from dementia and was admitted to hospital with multiple medical issues including a chest infection, delirium, kidney failure and poor mobility including recent falls.

C raised a number of complaints, including that there were failures in the medical care provided to A with respect to falls and post falls care and seizures. C also complained of failings in nursing care relating to diet and nutrition, hygiene and cleanliness, and the general monitoring and awareness of A’s condition. Lastly, C complained regarding restrictions on visitation and poor communication.

We took independent advice from a consultant specialising in the care of the elderly and a second experienced nursing adviser. We found that the medical care provided appeared to have been reasonable. We therefore did not uphold this complaint, however, we were critical of the standard of medical record keeping and we provided feedback to the board about this.

We found that there were failures to complete the necessary risk assessments and care documentation including the risk assessment tool for malnutrition, monitoring fluid balance and applying appropriate wound care and a failure to identify and respond to a deterioration in A’s condition. We therefore upheld this complaint.

We found that general communication with the family appeared reasonable, and that pandemic restrictions were an unfortunate reality for many patients and families. However, it appeared that there had been a failure to notify the family that A had significantly deteriorated. This resulted in the family not being present when A passed away and on this basis we upheld the complaint regarding communication.

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 be appropriately assessed by nursing staff in particular in relation to malnutrition, fluid balance, wound care and nursing care provided in line with the assessments carried out. Any significant deterioration should be appropriately recognised and acted on as required. Records about a patient’s care and treatment and decisions made should be clearly and accurately documented and accord with the relevant professional standards and guidelines. Patient’s records should include clear details explaining why a decision about care and treatment has been made.

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 by the board in the lead up to the delivery of their twin babies. One of the twins (A) was stillborn.

C complained that the board failed to provide reasonable care and treatment during C’s pregnancy. We took independent advice from a consultant obstetrician and gynaecologist (specialist in pregnancy, childbirth and the female reproductive system). We found that while many aspects of the care and treatment were reasonable, the omission of some key measurements and tests was unreasonable and did not accord with guidelines. This impacted on clinicians being able to reach a fully evidenced position on what care was appropriate. Therefore, we upheld this part of C's complaint.

C complained that the board failed to reasonably communicate the risks and options available to them. We found that the records indicated that the board reasonably communicated with C in relation to the risks and options available to them. Therefore, we did not uphold this part of C's complaint.

C complained that the board failed to reasonably investigate C’s concerns. We found that many aspects of the reviews which were carried out were reasonable. However, we found that the reviews failed to identify that the significance of the lack of the measurements being taken was unreasonable, leading to a delay in identifying learning that could be taken forward. 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 as identified in this investigation. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/informati on-leaflets.

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

• Where adverse event(s) occur the review should be thorough and identify all relevant learning from the event.
• Where it is considered that there are growth issues in relation to a fetus, appropriate investigations and tests, including measuring the pulsatility index as required, should be carried out in line with relevant national guidance.

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 late parent (A) received whilst in hospital. A was admitted to hospital with light headedness, dizziness, and pain in the hip and leg. C had concerns about the board’s failure to consider A’s previous medical history, decisions made during surgery, communication, care provided, and what was recorded on the death certificate.

The board said that investigations into A's blood loss found no issues and that they planned to discharge A. However, due to further bleeding A was not discharged and required emergency surgery. A was made aware of the risks associated with the surgery. This operation was successful, however, a further procedure was required to remove a section of A's bowel. Due to further changes in A’s condition, the board moved A to palliative care.

We took independent advice from a consultant in intensive care and acute medicine, a general surgery consultant and a registered nurse. We found that A's care and treatment was reasonable. However, A's medical history was recorded incorrectly by medical staff, affecting the treatment plan, investigations, and diagnosis. We found that A's operations were carried out reasonably. However, the surgical team failed to examine A in person when consulted which was unreasonable. Overall, we considered that the care and treatment provided to A was unreasonable and upheld this part of C's complaint.

In relation to nursing care, we found that the care and treatment provided to A was reasonable. We also found that A's death certificate was not completed incorrectly. Therefore, we did not uphold these part's of C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failure to take an accurate medical history on admission, there was a missed opportunity for the vascular team to identify the correct diagnosis during their review of A, the failure to consider a diagnosis of aorto-enteric fistula earlier, and particularly, once the CT scan findings were available, and the failure of the surgery team to review A in-person. 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:

• Accurate medical history should be established by clinicians and investigations, including CT scans, that are carried out should be critically reviewed when considering diagnosis alongside the history. Medical records should be viewed to establish/confirm the correct medical history.
• When asked, the surgical team should fully review the presentation and history of the patient. Where necessary the patient should be seen in-person.
• When a specialist review is requested such as vascular, the specialist team should fully review the presentation and history of the patient.

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 relative (A) and A’s child (B) about the health and social care partnership, of which the counil administered the complaint investigation. B was removed from A’s care. Following a short period of kinship care by B’s grandparent, they were placed with foster carers. C and their partner applied to be B’s kinship carers as soon as B was taken into care. However, they were not made B’s kinship carers until several years later.

C complained that the partnership had unreasonably delayed in assessing their kinship care application. C also complained that there had been failures to facilitate B’s contact with their family, to address concerns about B’s foster carers, to provide them with support following B’s kinship care placement and to provide specified information. The partnership accepted that there had been delay in assessing B’s kinship care and identified learning from this. They did not identify any other service failures.

We took independent advice from a social work adviser. We found that there had been a failure to progress the kinship care placement timeously and to take reasonable steps to facilitate B’s family contacts. We also found that there had been a failure to provide specified information. We upheld these complaints. However, we found that there had not been a failure to address concerns about B’s foster carers or to provide C with support following B’s kinship care placement. We did not uphold these complaints.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C and their family for the failings identified. The apology should meet the standards set out in the SPSO guidelines on apology available at http://www.spso.org.uk/meaningful-apologies.
• Provide C with an explanation on why there had been undue delays in completing B’s kinship care assessment and/or information about the findings/recommendations and actions taken from the CSWO review.

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 to the board about various aspects of the board’s care and treatment of their partner (A) and their communication with C and A during an inpatient admission covering the end of A’s pregnancy and the birth of their child (B) by caesarean section. The board accepted that a number of areas of communication had not been reasonable and apologised for this. The board explained what action would be taken to address these areas for improvement. The board also accepted that in a few specific cases, A had not received reasonable care but indicated that they considered A’s care and treatment had been reasonable overall. In response to a specific complaint from C, the board stated that A had not had sepsis (blood infection) or been treated for it during their admission. A few months later, however, the board wrote to C and stated that their labour had been complicated by sepsis.

We took independent advice from an appropriately qualified midwife. We found that, overall, A and B received good care and appropriate standards of treatment that were in line with relevant professional standards. Given this, and that reasonable actions to minimise recurrence were taken in relation to areas where the board had accepted care was not of an acceptable standard, and where communication could have been improved, we did not uphold the complaint that the board had not provided reasonable care and treatment to A.

We found that A had had sepsis during their admission and receive prompt and appropriate care. However, we considered that the board’s repeated altering of their position on whether A had sepsis, both minimised A’s experience and, potentially risked inadequate care and treatment responses being provided to patients with suspected sepsis in the future. We upheld the complaint that the board’s response inaccurately stated that A did not have sepsis and was not treated for sepsis during their admission.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C that their response inaccurately stated that A did not have sepsis and was not treated for sepsis during their admission. 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 board staff have a clear understanding of the symptoms and diagnosis of sepsis and the actions to take in treating sepsis and suspected sepsis.

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 was concerned about a number of issues regarding their care and treatment, and that of their child (A), during their pregnancy, A’s birth and afterwards. C raised complaints with the board and were dissatisfied by their response. The board’s response accepted that there had been issues with aspects of the boards complaint handling and a number of issues with their communication, but did not indicate that the board considered that there had been any issues with C or A’s care or treatment.

We took independent advice from qualified advisers with experience of obstetrics, neonatology and midwifery (the medical specialisms for pregnancy, childbirth etc.). We found that, overall, C and A had received reasonable care and treatment from the board and that, where areas for improvement around communication had been identified, reasonable actions had been taken to address these. We did not uphold these part's of C's complaint. We noted that the board had accepted that C had been assigned to an incorrect consultant’s waiting list for a post-birth debrief and upheld this complaint. We also noted that the board had appropriately apologised to C for this. However, we considered that the board should have taken steps to minimise the possibility of a similar situation recurring in the future.

In considering the board’s response to C’s complaints, we found that there were specific areas where the board’s response and actions could have been improved. However, taking into account those areas for improvement in complaints handling the board had identified, the apologies provided to C and the specific circumstances of the time C raised their complaints, overall the board responded reasonably to C’s complaint. We did not uphold this part of C's complaint.

Recommendations

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

• Steps are taken to minimise the possibility of patients being assigned to incorrect consultant’s waiting lists for post-birth debriefs.

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.