Some upheld, recommendations

Summary

C complained about the care and treatment provided to their late parent (A) by the board. A was under the care of another board and investigations undertaken were suggestive of cancer in the bile drainage system, which was initially thought to be operable. A was referred to the board and admitted to hospital for a percutaneous transhepatic biliary drain (a procedure to drain bile to relieve pressure in the bile ducts caused by a blockage) and biliary biopsies. This was carried out and the three biopsies taken were sent back to the ward with A.

The duty consultant and the clinical nurse specialist met with A and relayed the findings of the multi-disciplinary team discussion the previous day. The specialist radiologists felt that there was a thickening of the lining of the abdomen that may suggest the disease had spread and that the nature of the tumour was unresectable. A check tubogram (a dye test to check whether the stent had opened up) indicated that the stent inserted had not fully drained the bile ducts and a second stent was inserted, with the external component of the biliary drain removed.

A was discharged shortly afterwards. At a multi-disciplinary team discussion less than two weeks later, it was highlighted that there were no biopsies currently in the pathology laboratory. Further investigation found that A’s biopsies had been disposed of. Four months on, A was made aware by the referring board that the biopsies had not reached the laboratory. A died after a short period.

We took independent advice from a general and colorectal surgeon. We found that whilst A had been given sufficient information regarding their care and treatment and the need for a biopsy, the board unreasonably lost biopsy samples and failed to inform A that they had been lost. We also found that the communication between departments, wards and with another board was unreasonable. We upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the specific failings identified in respect of the complaint. 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 for the specific failings in communication with them, between departments and with another board. 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 treating hospital should ensure all outstanding results are reviewed and subsequent forward planning is done. The episode of care should not be viewed as complete until all results are reviewed rather than the discharge status.
• Biopsy samples should have the correct form, details of the responsible clinician on the form and should be sent from the originating area. There should be a process in place to correct errors in specimen direction.
• The treating clinician should be responsible (directly or delegated) for notifying a patient as soon as is reasonably possible regarding a biopsy loss.
• Investigation of a datix incident should be thorough and ensure appropriate and adequate learning from the events.
• There should be clear communication between departments and wards regarding planned procedures. Patients should be informed without delay of any cancellation, and where appropriate a prompt apology made to reduce distress.

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 was suffering from dementia. A had been found in a neglected state by C’s sibling. A had vomited and it appeared that A had been left unattended overnight with no personal care. A’s incontinence pad had not been changed for what appeared to have been a significant period and was soaked in urine. C believed this failure in care led to A’s resulting aspiration pneumonia (inflammation that's caused by bacteria entering the lungs and causing a severe infection) which was the cause of their death. C also had concerns about other aspects of A’s nursing care including the frequency, quality and recording of care, A's skin care and the monitoring and recording of their vital signs. Lastly, C complained that their complaint had initially been designated a “concern” rather than a formal complaint.

We took independent advice from a nurse and a consultant geriatrician (a doctor specialising in medical care for the elderly). We found that there had been a failure to provide reasonable nursing care to A which had been acknowledged by the board. However, we found further issues with respect to ongoing risk assessment, skin care in relation to pressure ulcers, malnutrition screening and the implementation of person centred care planning. It was noted that there were difficulties in definitively assessing the standard of care delivered due to failures to adhere to Nursing and Midwifery Council record keeping standards. Therefore, we upheld this aspect of the complaint. Additionally, we found that unreasonable care had been provided with respect to pain relief. We upheld this aspect of the complaint.

We also found that the complaint had not been handled in line with the board’s complaints handling procedure. While there were areas for improvement, on balance, communication with the family had not been unreasonable and we did not uphold this aspect of the complaint. In relation to Cs complaint around the handling of their complaint, we found that the board failed to appropriately handle the complaint in line with their complaints handling procedures. We upheld this aspect of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C and A’s family for the failings in nursing care. The apology should meet the standards set out in the SPSO guidelines on apology available at www. spso. org. uk/information-leaflets.
• Apologise to C and A’s family for the failure to increase A’s medication. 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 the relevant assessments and care planning that reflects their needs. All relevant patient documentation should be completed and recorded in the nursing records in accordance with the NMC Code.
• Patients should be prescribed and receive appropriate palliative medications at all times.

In relation to complaints handling, we recommended:

• Complaint investigations should be carried out in line with the NHS 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 complained that when they developed complications in their pregnancy, the care that they received fell below a reasonable standard. C was six weeks pregnant and considered a high-risk pregnancy due to four previous caesarean section procedures, as well as surgery to reverse a previous sterilisation. C said that they were treated with a lack of empathy and courtesy by staff during scanning. C also complained that they were refused admission despite being known to be a high-risk pregnancy and despite developing vaginal bleeding. When C was admitted they believed that their surgery was unreasonably delayed, resulting in an avoidable rupture to their fallopian tube.

We took independent advice from both a registered nurse and a consultant obstetrician (the branch of medicine and surgery concerned with childbirth and midwifery). We found a number of failings on the part of the board. However, the board submitted new information, which included sections of C’s medical records which had not been provided previously. The board acknowledged that this was a failing on their part. We reviewed this information and determined that some of the original questions over the actions of the board were answered by this information. We upheld the complaint that the board failed to provide a reasonable standard of care during C's admission. In relation to C's complaint about being unreasonably refused admission, we found that C was treated reasonably and that the board demonstrated that their procedures were followed by staff. 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 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:

• A standard operating procedure (SOP) should be developed for the reporting of results in early pregnancy, so that the roles and responsibilities of those working in this area are clearly defined.
• Consideration should be given by the board to identifying appropriate communication training for healthcare workers in the early pregnancy unit.

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 they received from the board. In particular, C complained that the board failed to adequately investigate their presenting symptoms of pain and nausea, or keep adequate medical records during an attendance at the Surgical Immediate Assessment Unit (SIAU).

Following their attendance, C wrote an account of their experience on Care Opinion (an independently operated platform for individuals to post comments about their care experiences). The board contacted C in response to their post asking that they write to them about their concerns. Despite doing so, C said that they did not receive a response from the board, and that they subsequently submitted a formal complaint through the board’s complaints handling procedure.

The board’s response to the complaint said that C had been assessed properly and that the clinical findings did not indicate that further investigation was required. The board acknowledged that C had not been seen by a senior clinician as planned, however, they noted that they had left the SIAU against advice before they were able to see C.

We took independent advice from a consultant general and colorectal surgeon. We found that C did not receive an adequate clinical examination. We found that the documentation of this encounter was unreasonable, noting that there was little information relating to the discussion which took place with a senior clinician, and no documentation of the worsening advice given to C. As C had already followed a 4-week plan by their GP to ‘watch and wait’ without any improvement in their symptoms, it was unreasonable to discharge C without undertaking or planning further investigation at this time. It was also noted that the emergency and final discharge letters from this attendance were not sent until several months after this attendance. We upheld this aspect of the complaint.

In relation to the board’s handling of C’s complaint, we noted that C had first posted a comment about their experience on Care Opinion. C later complained to the board directly when they did not receive a response, despite the board contacting them about their Care Opinion post. Once C had made a formal complaint via the board’s complaint process, we found that this had been timeously managed in keeping with the board’s complaint handling procedure. While we noted some factual inaccuracies in the board’s letter of response to C, we were otherwise satisfied that a reasonable investigation of the complaint had taken place. 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 in relation to the physical examination and assessment that they received at the SIAU, and in relation to the documentation of the episode of care. 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:

• Medical records should clearly and accurately document consultations with patients, including where senior advice or guidance has been sought. Decisions regarding discharge and worsening advice should be documented. All entries should be signed and dated and, where appropriate, the record should identify the name of the person providing senior clinical advice.
• Patients should be offered a chaperone, and the decision should be documented in the medical record.
• Staff should introduce themselves to patients by name and grade.
• Patients should be assessed and examined appropriately in keeping with their presenting symptoms and relevant past medical history.

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). C complained that actions taken shortly before and after A’s discharges were unreasonable as was the board’s response to the complaint.

We took independent advice from a consultant in general medicine and a registered general nurse. We found that appropriate assessments were carried out prior to discharge and that the board reasonably discharged A. As such, we did not uphold these parts of C’s complaint.

We considered C’s complaint regarding the level of support offered after A’s falls. We found that the board’s response to these falls were reasonable. Action taken after the fall in the car park were in line with policy and the level of staffing available on the day, and in relation to the fall while being admitted, the care as documented was considered to be reasonable. As such, we did not uphold these parts of C’s complaint.

In relation to the complaints handling, we found that there were failings in the response to C’s verbal and written complaints, with no response issued to the verbal complaint, and not providing a full response to the written complaint. While there were some aspects of the board’s response which were reasonable, overall we upheld this part of C’s complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to reasonably respond to the complaints regarding A’s discharges and the response to A’s fall in the car park. 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:

• All staff must be aware of the complaints handling procedure and how to handle and record complaints at the early resolution stage.
• Complainants should be advised prior to the deadline if the board will not meet the 20 working day target for responding to a complaint, and be advised of the reasons for the delay.
• Responses to complaints should be clear and answer the points of concern raised.

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 they received from the board. C suffered a subarachnoid haemorrhage (a form of stroke caused by bleeding on the surface of the brain). Following a period of admission to different hospitals, C was discharged home. C complained that the board failed to communicate appropriately with them after their admission, that they were not fit for discharge and that inadequate rehabilitation plans were made in the community. C chose to stay at a relative’s property and was eventually admitted to a rehabilitation unit but believed this had affected their prognosis. C also complained that the board failed to respond reasonably to their concerns about the COVID-19 vaccine they had received.

We took independent advice from a consultant neurologist (specialist in the diagnosis and treatment of disorders of the nervous system) and an occupational therapist. We found that communication with C was unclear and confusing and did not always address the main points C was raising. Therefore, we upheld this part of C’s complaint.

In relation to C’s discharge, we noted that more consideration could have been given to supporting C prior to their discharge, given C’s concerns at the time. However, we found the decision making to be appropriate and did not uphold this part of C’s complaint.

In relation to plans for C’s rehabilitation, we found that the board made reasonable plans and attempted to commence the initial assessment that would have established what support C required. However, we found that there was a failure to provide C with written information about the plans for their rehabilitation. C was unable to retain this information when given verbally which meant they were unaware of the plan and could not access the support available to them when they were unable to return to their property as quickly as anticipated. Therefore, we upheld this part of C’s complaint.

We also found that the board failed to follow up on a commitment given to C to explore any potential link between the COVID-19 vaccine and C’s brain injury. They also failed to support C’s attempts to gather information to assess the risk of further vaccine doses. Therefore, we upheld this part of the complaint.

C also complained about the board’s handling of their complaint. We found that although there were some failings, in the circumstances the board were operating under at the time these were apologised for and reasonably addressed. 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 the issues identified in this decision. 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:

• That the board confirm what action they have taken to ensure patients with brain injuries are provided with discharge information in a format they can understand and refer back to after leaving hospital. The Board should share this decision with the clinical team involved in C’s care with a view to identifying points of learning.

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 handling of allegations that their child made against them, including decisions taken to remove their child from the family home on the evening of the incident, but then considered safe to return the following day. C also complained about a lack of support for their family following the incident. C made a subsequent complaint about the council’s handling of disclosures made by their child to social workers regarding a previous overdose.

In response to the complaints, the council said that once a child protection issue was raised by C’s child, this was responded to quickly and in line with child protection procedures. Decisions about where C’s child should stay whilst police investigations were ongoing were taken in collaboration with the family and it was determined following a risk assessment that there was no grounds to require C’s child to stay away from the family home. The council explained the nature and purpose of follow up meetings.

With respect to disclosures made by C’s child that they had previously taken an overdose, the council said that the social worker’s professional opinion was that it was not necessary to pass this information on to the child’s parents, and instead recorded a note of the incident. The council did however acknowledge that there was no record of why the social worker had come to this determination and course of action.

We took independent advice from a social work adviser. We found that whenever information is provided concerning actual or alleged abuse, this must be investigated and we considered that actions taken by the council’s social worker to be reasonable in this regard. With respect to decision making around removing C’s child from the family home, whilst the circumstances are disputed, the records indicated that there were discussions with the family about the decision making in this regard and additional factors, including the lateness of the day, were taken into consideration. The approach in the circumstances was therefore considered to be reasonable.

With respect to C’s child returning to the family home the following day, we found that there was no immediate risk to C’s child should they stay at home and it was reasonable for them to return home the day following the incident. On this basis, we did not uphold C’s complaint about the appropriateness of the council’s Child Protection investigation.

In considering C’s concerns about the handling of their child's disclosure of a previous overdose, we acknowledged the council’s position that it may be appropriate in some circumstances not to share such information with a child’s parents, such as in circumstances where the child does not want the information shared. However, we found that there was no evidence of such a discussion having taken place, or of the reasoning behind decisions taken not to share this information with C or their partner. We therefore found that there was a failure by the social worker to record a discussion with C’s child and the reasons for not informing their parents of the overdose. On this basis, we upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C and their partner for the issues highlighted. 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:

• That the council share this decision with the social work team with a view to reminding them of the importance of recording all discussions and decision making considerations in child protection case notes.

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 council about a local access route that was closed off by the landowner. C said that the route had historically been asserted as a right of way (RoW) and a planning condition imposed to protect it. In response, the council declined to take action to re-open the route. They explained that, notwithstanding the route being referred to a RoW in the planning process, the route had not been asserted and had no legal status. They explained that the planning condition (to provide an upgraded alternative route through the site) had also been removed on appeal. However, in a further response, the council stated that the condition remained valid but was found to be ultra vires and unenforceable as the alternative route was not in the landowner’s ownership. They declined to take any further action on the basis a suitable alternative route, in their ownership, had been provided and remained open.

C complained that the council had failed to take reasonable action to keep open the claimed RoW. C said that the council had been very clear in the planning process that the claimed route had been established as a RoW, and Scotways had also considered the route had met the criteria to be a RoW. They said that the council had also failed to take reasonable enforcement action in respect of the planning condition and had provided contradictory responses to their complaints about these matters.

We took independent advice from a planning adviser. We found that the council had provided a reasonable explanation regarding the status of the route but highlighted that it would be for the courts to determine the status of a disputed RoW if C disagreed with the council’s position. We also found that the decision not to take any further action to keep the claimed route open was a discretionary matter which the council were entitled to take. For these reasons, we did not uphold this aspect of C’s complaint.

However, we provided feedback to the council in respect of the original planning application. Specifically, we noted that the council had appeared to determine the application as including the diversion of a claimed RoW without confirming the status of that route. We reminded the council that, when dealing with planning applications which make reference to a RoW, to firstly confirm the actual status of such route and where required, to amend the application description if it is deemed that the route is not a RoW prior to making any determination.

Notwithstanding the unenforceability of the planning condition itself, we found that there had not been any failure by the council in respect of enforcement matters. We found that the council’s position that the planning condition had now been complied with as a suitable alternative route through the site had been provided, to be acceptable. For these reasons, we did not uphold this aspect of C’s complaint.

We also found that the council failed to provide a clear and consist explanation in their response to C’s complaints and had incorrectly applied terminology and/or language. We upheld this aspect of C's complaint. We also reminded the council to ensure that where responses cannot be provided within the timescales set out in their Complaint Handling Procedure, they should write to a complainant to explain the reasons for the delay and provide a revised timescale for response, and that where they are unable to respond to a request for information from our office within the timescale specified, they should contact us as soon as possible and without delay.

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.

In relation to complaints handling, we recommended:

• Ensure that all relevant staff are reminded of the need to use the correct terminology when referring to matters in which the terminology has a particular meaning.

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 they received in respect of their cancer. C was diagnosed with colorectal cancer which had spread to their liver and required surgery. The surgery was to be performed in two stages. C complained that the second surgery was not performed within a reasonable timescale and about poor pain relief following the second surgery.

The board apologised to C for the poor communication about the arrangements for the second surgery and explained that repeating imaging was required before arranging the surgery and that they did not consider the delay to be significant. The board provided an overview of the pain relief provided and noted that any issues identified were addressed at the time.

We took independent advice from a colorectal and surgical consultant. We found that communication with C about when they could reasonably expect to have their second surgery was poor and there was an unexplained delay in their case being reviewed by the multi-disciplinary team. This resulted in a delay of around one month, however we did not consider this would have caused further spread of C’s cancer. We upheld this complaint.

We noted that there were some issues with the equipment used to deliver pain relief post surgery, however these were rectified and appropriate additional pain relief was provided promptly. We found the post surgical care and treatment provided to be reasonable and we did not uphold this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the issues 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:

• That the board review their approach to communication with patients to ensure that cancer patients are proactively kept informed of progress in their treatment plan.
• That the board review their processes for prioritising the review of important cases by the MDT to ensure that such cases are progressed without delay.

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

Summary

C, an advocate, complained on behalf of A about treatment that they received after sustaining a knee injury. A ruptured the anterior cruciate ligament (ligament connecting the thigh bone to the shin bone) and underwent an arthroscopy of the knee (a type of keyhole surgery). This was followed up with a second surgery at a later date to complete the reconstruction of the ligament.

During the surgery, the surgeon’s scalpel snapped and to remove the tip of the blade, the surgeon had to create a larger incision. C raised concerns about the actions taken following the incident. The board acknowledged the incident and explained that damage to instruments is a rare but known complication of surgery.

We took independent advice from a consultant orthopaedic surgeon. We found that when the blade snapped, appropriate care was provided to A. It was appropriate to create a larger incision and the incident was appropriately communicated to A. However, we found that whilst a datix incident report was completed, a more in-depth investigation could have been carried out. There was no evidence that the board considered either the possibility of improper use of the instrument or that there was a defect in the instrument. We also considered that the board should have discussed the incident at a departmental level. In conclusion, we upheld C’s complaint about care and treatment in relation to the initial surgery. We did not uphold the complaint about the post operative care provided to A as we were satisfied it was reasonable.

Recommendations

What we asked the organisation to do in this case:

• Apologise to A for failing to thoroughly investigate the adverse event where by the scalpel broke during A’s surgery. 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:

• Operation notes should be sufficiently detailed, particularly when an adverse event has occurred.
• The board should ensure that adverse events are thoroughly investigated and that appropriate reflection and learning is 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.