Some upheld, recommendations

Summary

C complained about the care and treatment that they received from the board following a stillbirth. C complained that the board had failed to provide them with adequate support following the birth of their child. C also complained that a consultant had acted unreasonably by discussing their child’s post mortem results with them, without prior warning and without the presence of their partner, during a consultation several months later to discuss the progress of a new pregnancy.

The board did not identify any failings with the support provided to C. However, they apologised for the distress caused to C during the meeting with the consultant. They said that the consultant was required to make a plan of care for the new pregnancy and that this inadvertently led to the discussion and counselling of C’s previous pregnancy. The Board said that C’s partner was unable to attend the meeting due to restrictions on hospital visiting in force at the time due to the pandemic.

C remained unhappy and asked us to investigate. C complained that the support provided to them was inadequate. C also complained that the consultant had acted unreasonably.

We took independent advice from a consultant obstetrician. We found that inpatient care discharge arrangements, including handover of C’s care to community midwives was as expected. We did not uphold this complaint. However, we found that there had been a failure to adequately prepare for C’s consultation. In the circumstances, we found that it was unreasonable to have progressed with C’s consultation without offering them the choice of re-scheduling so that consideration could have been made to their partner attending, or offering a remote appointment. We upheld this 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:

• The findings of this investigation should be fed back to the staff involved, in a supportive manner, for reflection and 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’s parent (A) was receiving palliative chemotherapy, following a diagnosis of terminal cancer, which was suspended as the COVID-19 pandemic worsened. A was admitted to hospital following a prolonged period of vomiting that had not responded to treatment. A remained in the hospital for several weeks before passing away. C raised complaints with the board detailing C’s family’s concerns about A’s cancer diagnosis, decisions about A’s chemotherapy, aspects of the care and treatment of A, and communication with C and their family during A’s hospital admission. The board’s responses indicated that they considered A’s care and treatment had been reasonable overall, but accepted that there had been some aspects that could have been improved. They accepted that there were aspects of their communication that could have been improved, particularly that they should have contacted A’s next of kin when A’s condition deteriorated over a particular night.

C was dissatisfied with the board’s responses and brought their complaint to us. We took independent advice from a specialist in palliative care. We found that A’s treatment had been reasonable overall and that while there were certain aspects of A’s care that could have been improved, overall the board provided reasonable care to A.

In relation to the aspects of the complaint about the board’s failure to contact A’s next of kin when A’s condition deteriorated over a particular night and about the board’s responses to C’s complaints, we upheld these aspects of the complaint. In relation to the board’s handling of C’s complaints, we found that there were delays in responding, failure to address various clearly raised issues in responses, unreasonable action around the arrangement of a promised meeting within a reasonable timescale and the inclusion of statements that were not supported by evidence. We upheld these aspects of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C that they did not respond reasonably to their complaints. The apology should include specific reference to the board’s failure to address various issues raised in the complaints, failure to maintain reasonable action around the arrangement of a promised meeting, and inclusion of statements in the complaint response that were not supported by evidence. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets. The board should consider C’s request that the apology be provided at an in-person meeting at which C has an opportunity to read a personal statement.

In relation to complaints handling, we recommended:

• Complaints are properly investigated and responded to in line with the board’s Complaints Handling Procedure.

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

Summary

C complained about the attitude of a doctor during an inpatient admission. C stated that the doctor had treated them in a dismissive, derogatory and unprofessional manner. C further complained that the doctor removed their diagnosis, stopped their medication and made no arrangements for them to receive support following their discharge. C told us that the actions of the doctor had resulted in them not receiving a reasonable standard of care.

We found that the inpatient doctor's communication and documentation did not meet the required professional standards and impacted on the board's overall communication of C's care and treatment needs. The clinical records evidenced a dismissive and disrespectful attitude towards C. The doctor's documentation lacked a clear clinical rationale for the decisions that they made about C's diagnosis and medication. Therefore, we upheld this part of C's complaint.

In relation to the standard of care C received, we found that board staff had ensured that C's care and treatment needs were met. The decision to discharge C from inpatient care was reasonable and the community-based care that was provided was appropriate to C's identified needs at the time. When it was clinically indicated, the board arranged a further inpatient admission and reviewed C's diagnosis and treatment plan. There was evidence that the doctor did not stop C's medication. 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 the unprofessional language used by the doctor, the doctor's communication regarding diagnosis and medication, the impact the doctor's communication had on C and not adequately reflecting that the board recognised that the doctor's communication was unreasonable in the complaint response. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.
• The board should review the support being provided to C to assess whether the current level of support is appropriate and sufficient; and ensure that C is able to access medical assessment and review from a doctor other than the doctor at the subject of the complaint, if required.

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

• Communication with patients is professional and respectful. Documentation evidences that clinicians work in partnership with patients. Concerns and disagreements are documented using professional, non-judgmental language.
• There should not be a pattern of poor practice.

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 their care and treatment following a hysterectomy (a surgical procedure to remove all or a part of the uterus). C complained that they were not provided with adequate pain relief following the surgery, and that they were not fitted with an abdominal drain (a thin plastic tube which is inserted into an abnormal collection of fluid to help remove it from the body). C was discharged a few days later but disputes whether they were fit to be discharged home at this point. C was later readmitted suffering from a blood clot and an infection. C was discharged with oral antibiotics and again disputes whether they were fit to be discharged at this point.

A few days later, C began to bleed heavily. An ambulance was called but the wait was likely to be significant and C was taken to hospital by their partner. C was triaged but asked to sit on a chair in a corridor, despite suffering from obvious heavy vaginal bleeding. C was reviewed by a consultant and sent up to the gynaecology ward where they were then taken for emergency surgery.

We took independent advice from a consultant obstetrician (specialists in pregnancy and childbirth) and a consultant in emergency medicine. We found that C received a reasonable standard of care following their surgery and was appropriately discharged on both occasions. Therefore, we did not uphold these parts of C's complaint.

In relation to C's attendance at A&E, we found that they were not triaged sufficiently quickly and the way C was asked to wait was not appropriate given their condition. C was medically assessed within an appropriate timescale within A&E and appropriately transferred. The board had accepted there were failings in C's care, but they had not set out clearly how they planned to address these issues. Therefore, we upheld this part of C's complaint.

C also complained that the board failed to handle their complaint reasonably. We found that the board handled C's complaint appropriately and did not uphold this part of their complaint.

Recommendations

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

• Complete an assessment of the delay in triaging C.
• The board should consider what it can do to improve the experience of patients who require privacy when awaiting medical assessment.

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). A had a history of Chronic Obstructive Pulmonary Disease (COPD, a group of lung conditions that cause breathing difficulties). A was suffering from constipation which was treated by the district nursing team at home. When this did not resolve, A was admitted to hospital for review and treatment of their constipation. C said they asked that A be treated and discharged home as quickly as possible. A fell whilst in hospital and fractured their shoulder. A developed a chest infection and subsequently died in hospital.

C believed A's condition could have been treated in the community. C felt A's vulnerability had not been recognised by nursing or clinical staff in hospital. C said that A had been designated as an adult with incapacity (AWI) and do not attempt cardiopulmonary resuscitation (DNACPR) without discussion with them as A's power of attorney (POA). C felt A's fall was avoidable had staff listened to the family's requests for 1-to-1 nursing.

We took advice from a registered nurse and a consultant respiratory physician. We found that A was not provided with a reasonable standard of nursing care in the community, as more could have been done to treat their constipation at home. Therefore, we upheld this part of C's complaint.

In relation to A's care while in hospital, we found both the standard of nursing and medical care to be reasonable. Therefore, we did not uphold these part's of C's complaint.

In relation to communication with C as A's next of kin and POA, we found there was a lack of communication regarding A's care and in particular decisions around designating A as AWI and DNACPR. Therefore, we upheld this part of C's complaint.

Finally, we found that A's death certificate should have included the fall as a secondary factor in their death. Initially it was believed that C would need to request this amendment, but the responsibility in fact lay with the board, who have been asked to ensure that the death certificate is amended. We upheld this part of C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the issues highlighted 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 develop a bowel management guideline to ensure appropriate prescribing and escalation if no response to treatment. This should include clear escalation pathways for patients with deteriorating health.
• That the board remind the clinical team of the importance of discussing and recording discussions about DNACPR and AWI decisions with patients and their next of in/powers of attorney, including ensuring that all parties understand how and why the decision has been reached.
• The responsible consultant should contact the Death Certificate Advisory Service and have the full amendment made as soon as possible.

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 in relation to knee replacement surgery. C said that a surgeon failed to adequately advise them of the potential risks of a total knee replacement and therefore failed to obtain their informed consent for the operation. C also complained that the surgeon failed to adequately examine their leg either pre or post operatively. C said that they had experienced a mal-alignment of their leg as a result of the operation leading to significant pain and loss of mobility.

The board was unable to identify the cause of the mal-alignment of C's leg, but did not identify any failings in their care and treatment.

We took independent advice from a consultant orthopaedic surgeon (a specialist in the treatment of diseases and injuries of the musculoskeletal system). We found that, despite some failings, the consent process in C's case was reasonable. We also found no evidence that the board's surgeon failed to adequately examine C's leg either pre or post operatively. Therefore, we did not uphold these parts of C's complaint.

C also complained that the board failed to adequately investigate or respond to their complaint. We found that the board's complaint response was unreasonable and 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-leaflet.

In relation to complaints handling, we recommended:

• Complaint investigations should be carried out in line with the NHS Model Complaints Handling Procedure. The investigation should be thorough, and the complaint response should be accurate in their findings and conclusions and supported by relevant evidence such as medical records. Where there have been failings in surgery, the case should be presented and discussed within a departmental surgical morbidity and mortality meeting.

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 infant (A). C's concerns related to A's urinary function. C had concerns about the monitoring they had received whilst pregnant with A, the care provided to them and A immediately post- birth as well as during A's early years. C raised issues about the assessment of A's bladder function, A's renal health and the pain and discomfort A was suffering. C also felt that the family had not been listened to and their concerns dismissed or minimised. C had sought a second opinion at a hospital in England and believed board medical staff criticised the family for taking this step. They also said that the board failed to liaise with the hospital in England, resulting in A not receiving treatment or care for an extended period.

The board had accepted that communication with the family could have been better but considered the standard of care and treatment provided to A was reasonable.

We took independent advice from a consultant paediatrician. We found that A's symptoms were reasonably investigated initially and that they were referred to urology timeously. We also found no clear evidence that A's bladder had been damaged by failings on the part of the board. Therefore, we did not uphold these parts of C's complaint.

We found that the impact on A and their family of their condition was not adequately acknowledged and that the board had failed to communicate appropriately with C and their family. We also found that the board did not act when it became apparent that A was no longer being cared for by a hospital in England, resulting in avoidable delays in their care. Finally, we considered that the board failed to handle C's complaint reasonably. We upheld these parts of C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to A's parents for the failures 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.

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

• The board should share this decision with the staff involved in A's care with a view to identifying any aspects of the care and treatment that could have been improved. This should include consideration of whether there are any immediate actions which need to be taken to address A's ongoing issues.
• Patients' families should receive clear explanations and be provided with appropriate information which addresses their concerns.
• The board should reflect on the experience of A's family with a view to identifying any ways that communication and care planning for A could have been better managed.

In relation to complaints handling, we recommended:

• The board's complaint monitoring should ensure that failings, as well as good practice are identified and that learning and information gathered from complaints is used to drive service 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 parent (A) during their admission to hospital for a knee replacement. A said that they woke up during their surgery.

The board responded to the complaint noting that there was no evidence A woke up during surgery. C and A were unhappy with this response and brought their complaint to our office.

We took independent advice from a consultant anaesthetist (specialist doctors responsible for providing anaesthesia and pain management to patients before, during and after operations and surgical procedures) and asked the board to comment on issues we had identified.

The board explained that A had been under a deep sedation during the procedure and provided further details about the management of A's sedation. They confirmed that A had to receive a 'top up' in medication during the procedure and had reflected on the manner of their complaint response and the detail they had originally provided and offered to make an apology to A.

We found that the procedure was undertaken with a spinal anaesthesia and sedation rather than under general anaesthetic. We noted that the board's explanation with respect to managing A during the procedure was reasonable but confirmed that A did wake up. A did not appear to be aware this could be a possibility given they were not under general anaesthetic.

We considered that while A did wake up, this was not due to inappropriate or unreasonable levels of care. Indeed, it was possible it could happen and it was handled appropriately. Therefore, we did not uphold C's complaint.

However, we concluded that the board should have acknowledged that A woke up during the procedure and provided C and A with an explanation as to why this happened and how this was managed. Therefore, we found that the hospital failed to appropriately investigate and respond to C's complaint and made a recommendation to address this.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C and A for the lack of detail contained in the complaints response and for providing misleading information regarding the circumstances of A becoming aware during the surgery. It would be appropriate to acknowledge the significant impact the lack of a clear response from the outset has had on both C and A. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

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

Summary

C complained that the practice failed to provide them with reasonable care and treatment. C suffered from inflammatory conditions of the skin and joints and was under the care of rheumatology (specialists in the diagnosis and management of chronic inflammatory conditions such as rheumatoid arthritis), dermatology (specialists in the in the diagnosis and treatment of skin disorders) and the practice. C was being prescribed an immunosuppressant and the practice was in a shared care agreement with the NHS board for monitoring bloods in regards to the prescription. C required a liver transplant due to liver cirrhosis induced by the treatment. C complained that the practice had not properly monitored their bloods, had not picked up on warning signs and had not communicated appropriately with the relevant specialists or with C. C noted that they had also been incorrectly prescribed an antibiotic containing penicillin.

We took independent advice from a GP. We found that the practice had monitored bloods appropriately, and where there were gaps in monitoring, C's attendance had been requested. We also found that the practice had sought specialist advice and followed NICE guidelines appropriately. We noted that the practice had verbally apologised for the penicillin mistake. Therefore, we did not uphold this part of C's complaint but fed back to the practice that it would be appropriate to apologise in writing.

C also complained that they were immediately removed from the practice register after making a comment on social media expressing concerns about their treatment. C noted that they were given no warning and that their poor health, vulnerability and their requirement for continuity of care were not taken into account. We found that the practice had not followed guidelines in respect of removing the patient from the register, without warning. Therefore, we upheld this part of C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for prescribing an antibiotic containing penicillin, which they were allergic to. 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 manner in which their removal from the practice register was handled. 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:

• Reconsideration of the social media policy and patient removal policy and process, such that they are in line with BMA and GMC 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 provided to their parent (A) who had dementia.

C believed nursing staff had failed to provide A with a reasonable standard of care. They complained that A had been confined to bed inappropriately and that no assessment had been made of the impact this would have on A's mental health. C said that there were issues in arranging for suitable equipment to allow A to be transferred out of bed. C also complained about the communication of decisions about A’s care with them, A's next of kin and registered power of attorney. C said that after they complained, the Partnership told them that A was receiving end of life care but that this was not true and was a rationalisation of what had happened after A’s death.

C also noted that the Partnership had been obliged to respond more than once to their complaint, after they had pointed out factual inaccuracies in their response. C suggested that this showed that there had not been a proper investigation into their complaint.

The Partnership accepted that communication with C could have been better. They maintained, however, that A’s care had been of a reasonable standard and that staff had been clear that A was being provided with end of life care. They accepted that this should have been specifically set out in A’s care plan and noted improvements were being made to ensure this going forward.

We took advice from a registered nurse with experience of medicine for the elderly. We found that A’s care and treatment had been reasonable. We did not uphold this aspect of the complaint.

We found that there was failure to communicate with C appropriately. The communication with C fell below a reasonable standard, particularly as C was not informed that A was receiving end of life care. We upheld this aspect of the complaint.

The Partnership acknowledged that staff could have done more to ensure A had the requisite specialist equipment. There could have been better communication between the professionals involved in sourcing the specialist mattress A required. We upheld this aspect of the complaint.

We also found that the handling of C’s complaint fell below a reasonable standard, as the Partnership had issued a response containing factual errors. We upheld this aspect of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failings identified in this complaint, which resulted in inaccurate complaints responses being issued. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

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.