Some upheld, recommendations

Summary

C complained about the care and treatment of their late partner (A) during multiple admissions to hospital. C raised concerns that a coronary angiogram (a scan to check for blockages in the blood vessels) was unreasonably delayed, which in turn meant necessary vascular surgery could not take place. C complained about a lack of cohesion between vascular, cardiology and renal teams, and a lack of communication with the family.

We took independent clinical advice from a cardiology adviser and a vascular adviser. We found that there was a lack of cohesion and coordination in the management of A’s treatment plan. We considered that multidisciplinary meetings should have taken place to agree a treatment plan, and provide the cohesion that was lacking in the approach to A’s treatment. Overall, however, we found that the clinical decisions made by each team were reasonable and reflected A’s clinical condition at the time. We found nothing to suggest that the lack of cohesion impacted directly on the treatment A received or the eventual outcome for A. In particular, we found that there were good reasons not to proceed with the coronary angiogram, and that it was unlikely any vascular intervention could have been provided due to A’s competing illnesses. On balance, therefore, we did not uphold the complaint that A’s clinical care and treatment was unreasonable.

However, we upheld the complaint about the communication with A and their family. The board had already apologised for the poor communication and acknowledged that the multidisciplinary team did not keep the family as informed as they could have. Notwithstanding this, the board considered that A had capacity to make decisions regarding their own care and treatment. However, this assertion did not appear to have been based on any formal assessment. We found that there was evidence only once in the records of a capacity assessment having been undertaken. We found this concerning, particularly as C had raised concerns that A had become confused as a result of their illness and strong pain medication. We also found that there was a failure to complete existing documentation to record A’s communication preference, which was suggestive of a systemic failure rather than an issue that affected only A. Overall, we found that the communication with A and the family was very poor. A had a complex illness with a number of competing factors which affected the types and timings of treatments that were available. We concluded that clearer communication with the family, and between healthcare professionals, may have avoided a lot of the distress and anxiety the family experienced.

Recommendations

What we asked the organisation to do in this case:

• That the board apologise to C 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 board conduct an audit into the hospital staff’s compliance with their obligation to complete the existing documentation and take steps to ensure the documentation is being used effectively to ensure patient-centred care.
• That the board provide us with evidence of the steps that they have taken to ensure multidisciplinary team meetings take place to discuss and plan treatments for patients with complex medical conditions.
• That the board share this decision notice with the teams that were involved in A’s care and treatment with a view to identifying any 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 care and treatment their grandparent (A) received when they were admitted to hospital. A was acutely unwell with a poor prognosis and was treated in the COVID-19 ward for a number of days. A's condition improved and they were discharged home. C complained that A did not have capacity to consent to treatment and that treatment to address A's confusion made their symptoms worse. C believed that clinicians failed to clearly communicate the treatment plan for A, that it was unreasonable for clinicians to focus on end of life treatment and that staff failed to meet A's basic needs.

In response to the complaint, the board explained that A was admitted with possible aspiration pneumonia and COVID-19. They said A was treated for COVID-19 and with antibiotics and that the care and treatment in this regard together with the assessment of A's capacity, was appropriate. Nursing staff gave A regular oral hygiene, but due to high flow oxygen therapy this was difficult. Appropriate assessment and treatment was undertaken with respect to A's skin.

We took independent advice from a consultant geriatrician (specialist in care and treatment of the elderly) and a nurse. We found that whilst many aspects of A's care were reasonable and of a standard expected, there was a significant failure with respect to the assessment of A's delirium. We also found that there were significant failures with respect to the level of personal care provided to A. Therefore, we upheld C's complaints relating to medical and nursing care and treatment.

In relation to communication with C and their family, we found that the records documented an appropriate level of communication with respect to decisions made about A's care. Therefore, we did not uphold this part of C's complaint.

C complained that the board failed to handle their complaint reasonably. We found that there was discrepancies and apparent inaccurate information contained in the board's response. Therefore it was reasonable to conclude that the board failed to carry out a reasonable investigation and upheld this part of C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to A and C for the failure to handle and respond to the complaint reasonably. 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 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:

• Staff to be compliant with HIS (2020) Prevention and Management Standards. All staff assessing pressure ulcer risk fully understand the risks and are able to put in place measures and equipment to minimise risk. Staff completing care rounding able to identify that patients at risk of pressure damage must have their position changed and not nursed in the same position for 24 hours.
• Relevant staff are familiar with the adult with incapacity process and the importance of delirium screening tools with patients where delirium is observed and evident.
• Staff responsible for undertaking oral care are trained and competent in assessing oral hygiene requirements, carrying out oral hygiene and accurately documenting this in the records.
• To ensure a person centred approach to assessment of continence and appropriate prescribing of continence management products.

In relation to complaints handling, we recommended:

• Complaints handling staff to be familiar with the complaints handling procedure. Clinical staff to be aware of the significance and importance of a thorough consideration of clinical records and reflecting on these in an open and transparent manner when offering responses to specific aspects of complaint.

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 actions of South Lanarkshire Council in relation to work that they carried out to a property adjoining C’s home. The work related to the change of position of a gas boiler flue. C considered that this has had an adverse effect upon them and their property. The council did not identify any failings, but changed the orientation of the flue as a result of C’s concerns. C remained unhappy.

C complained that, as a result of the change in position, the flue discharged dangerous gasses into their home. C also complained that the council had failed to respond to their complaint in line with their published Complaints Handling Procedure (CHP).

We found that the council had acted reasonably regarding the change in position of the flue. We did not uphold this aspect of the complaint. However, we found multiple failures by the council to adhere to their CHP. We upheld this part of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failings, in particular, the unreasonable delays identified in the handling of their complaint. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.
• The necessary systems and procedures should be in place to ensure that complaints are handled in line with the council’s complaints policy and procedure and that all staff are aware of the complaints handling policy and 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 the board failed to provide reasonable care and treatment to their late parent (A), who died following an admission to hospital. This included issues relating to A contracting COVID-19, that the board unreasonably failed to carry out an SAER/independent review, and that the board failed to reasonably respond to the complaint.

We took independent advice from a specialist in geriatrics (medical care for the elderly). We found that the board had carried out a review of A’s care and had accepted some failings, including that there had been an unnecessary transfer and a delay in cleaning. They apologised for this and had taken improvement action and organised training, which we welcomed and considered were appropriate.

Whilst there were a number of aspects of care provided to A which were appropriate and reasonable, given the unnecessary transfer, the apparent delay in cleaning, and failings with regard to communication, on balance, we upheld this aspect of the complaint.

We also identified complaint handling failings. Whist the complaint response was detailed and lengthy, and attempted to address all of C’s concerns, we upheld this aspect of the complaint, given the lack of detail in the complaint response regarding learning and improvement actions.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failings in communication, and the lack of information 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.

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

• The board are implementing an electronic handover which will reduce the risk of human error and highlight any issues timeously.
• Patients who have disabilities such as hearing impairments which may result in them and their families requiring additional support should have their communication needs fully supported and met.
• The board held Deaf Awareness sessions.

In relation to complaints handling, we recommended:

• Complaint responses should contain full information to explain decisions and should include information about learning and improvement actions.

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 is the parent of two children, A and B, who complained about the council's handling of child protection concerns raised in respect of A and B. C is concerned that due to lack of proper procedure, decisions made by the Court in respect of contact between their ex-partner and the children were based on inaccurate information provided in social work reports.

The council's own investigation of the complaint identified that there was inadequate recording of the child protection concerns reported by C and that a welfare report compiled by the social worker was not of an acceptable standard.

We took independent advice from an experienced social work adviser. We found that there were failings to make a verbatim record of the child protection concerns raised by C, that the welfare report prepared for the Court was below an acceptable standard, and that there was a poor record of the interviews conducted with the children. Based on the evidence available, it was agreed that given that the children did not make a further disclosure to the social worker when interviewed, there were no grounds to pursue a child protection investigation. However, on balance, we concluded that, in light of the failings identified, there was a failure in the overall handling of the child protection concerns raised and as such, we upheld this part of C's complaint.

C also complained about the council's handling of their complaint. We found this to be reasonable and did not uphold this part of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to conduct their enquiries in a clear and transparent way, failing to keep adequate records of their contacts with C, the child protection concerns reported by C, and of the interviews conducted with the children; and for the poor standard of the welfare report. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

Summary

C is a former patient of the medical practice. C complained to the practice that they failed to address their enquiries about their healthcare, which they submitted to the practice in writing and by email. The practice decided that they could not meet C’s expectations and concluded that there was a breakdown in the doctor/patient relationship. The pracitice subsequently removed C from their patient list. C complained to the practice but were dissatisfied with the response that they received.

C complained that the practice failed to respond to C's complaint and earlier correspondence, and that the practice did not follow reasonable process when removing C from their patient list.

In respect of how they responded to C’s correspondence, we agreed that the situation became complex. While C did not always get a response to their correspondence, we concluded that the practice acted reasonably overall. We recognised that the practice were trying to meet the individual needs of their patient, but the situation had become untenable. We did not uphold this aspect of C’s complaint, however we provided feedback to the practice on their handling of the complaint.

With regard to the decision to remove C from the patient list, we concluded that the practice failed to follow General Medical Council (GMC) guidelines as they did not warn C that they were considering removing C from the patient list. We upheld this aspect of the complaint and recommended that the practice apologise to C and take steps to ensure they have an appropriate policy in place.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to follow GMC guidelines and warn them that they were considering de-registering them from the patient list. 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 staff should be familiar with the requirements of the GMC guidelines for ending the professional relationship with a 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 that the council had failed to handle their planning application correctly. C said that the council had failed to communicate appropriately with their agent, adversely affecting their application. C also said that the council had prevented the Local Review Body (LRB, deals with requests from applicants for a review of planning decisions) from considering correspondence submitted by their councillors in support of their application. They were also concerned about the way the council had responded to concerns about a conflict of interest. C said that the objector to their application was an immediate relative of a senior planning officer. They believed this had not been properly addressed by the council. C's final concern was that the LRB had not considered the correct plans, noting the decision issued by the LRB had referenced incorrect plans.

We took independent advice from a planning adviser. We found that although there was evidence of some delays in responding to C's agent, the standard of communication was reasonable. There was no evidence that the LRB were prevented from considering correspondence from C's councillors. However, the correspondence was not part of the original application and the LRB would have had to determine specifically that it was relevant in order to include it in their decision making. The council were also able to demonstrate that the LRB had access to all the relevant plans when reaching their decision. Therefore, we did not uphold these parts of C's complaint.

In relation to the conflict of interest, we found that there was no evidence the decision on C's application had been affected by a conflict of interest. However, the council had not kept adequate records of how the acknowledged conflict of interest had been identified and managed. We upheld this part of C's complaint and asked the council to apologise but made no further recommendations as the council were able to show they had already taken action to address this.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the error identified in this decision notice. 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 about the care and treatment provided to their adult child (A) by the board. A had an extensive history of epilepsy and was diagnosed with ictal asystole (a rare but potentially devastating complication of epileptic seizures). A was referred by the board's neurology service (specialists in disorders of the nervous system) to the cardiology service due to ongoing seizures with loss of consciousness which could not be controlled with medication. A was fitted with a pacemaker but later developed severe headaches and a rash. A was advised to stop taking recently prescribed tablets and that the rash was likely caused by the ointment used when the pacemaker was fitted.

A few days later, A was finding it difficult to breathe and called NHS 24. Paramedics attended A at home but A was not admitted to hospital. A phoned NHS 24 again the following day and when paramedics attended, they took advice from an emergency medical consultant at the hospital who advised that A should take paracetamol and see the GP the following morning.

A was advised by the GP to attend the COVID-19 hub where A collapsed and was taken to hospital. A was admitted to hospital and died the following day from sepsis (a life-threatening reaction to an infection).

C complained that the board's cardiology service failed to provide reasonable care and treatment to A. We took independent advice from a consultant cardiologist. We found that there was a failure to provide a clear timeframe on the day of the pacemaker implantation and a failure to take reasonable action when A developed a rash following the procedure. We also found that the board failed to identify the asystole earlier but had already acknowledged this in their complaint response to C. Given these failings, we upheld this part of C's complaint.

C complained that an emergency medical consultant unreasonably told the paramedic that A should take paracetamol and see the GP the following morning. We took independent advice from a consultant in emergency medicine. We found that there were failings in the assessment of A and that given the deranged physiology (disturbance of normal bodily functioning), repeated presentation and symptoms, the advice provided by the emergency medical consultant was unreasonable. Therefore, we upheld this part of C's complaint.

Finally, C complained that a doctor in the COVID-19 assessment centre unreasonably told C to take A home and put them to bed. We found no evidence to support this. Therefore, in the absence of any supporting records, 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 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:

• Full and complete information should be obtained during any virtual assessment of a patient so that advice is appropriately provided and recorded on the basis of that information.

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 child (A). A developed facial weakness, which was initially diagnosed and treated as Bell's Palsy (temporary weakness or lack of movement affecting one side of the face). A's condition did not improve and MRI scans revealed a mass. It was considered this was likely a vestibular schwannoma (a rare, non-cancerous tumour) and follow-up in three months was arranged.

A later attended hospital with bleeding from the ear. C suspected this was related to the tumour but doctors treated A for an ear infection. A developed further ear symptoms and attended hospital again. Further scans showed significant tumour growth, requiring surgical debulking (removing as much of the tumour as possible). A's diagnosis was revised as para-meningeal rhabdomyosarcoma (a rare and aggressive form of cancer). A was treated with chemotherapy but they continued to deteriorate and died within a few months of this diagnosis.

C complained that the board's decision not to remove A's tumour when it was first detected was unreasonable. We took independent advice from four advisers: a paediatric neurologist (specialist in the diagnosis and treatment of disorders of the nervous system), a paediatric emergency medicine consultant, a paediatric neurosurgeon (specialist in surgery on the nervous system, especially the brain and spinal cord) and a paediatric oncologist (specialist in the diagnosis and treatment of cancer).

We found that there was inadequate documentation of the risks or benefits to A of performing a biopsy or resection of the tumour when it was initially detected. However, we considered that surgically it would not have been possible to carry out a full resection and that the risks of trying to obtain a biopsy in the specific circumstances were too high. We concluded that the decision not to remove the tumour when it was first detected was reasonable. Therefore, we did not uphold this part of C's complaint.

C also complained that the board's assessment of A's condition when they attended A&E was unreasonable. We found that the provisional diagnosis and management plan were reasonable, given the information available to the doctors at that time. Therefore, we did not uphold this part of C's complaint. We acknowledged that C had voiced their concerns that the appearance of A's ear related to the tumour, and noted the board had confirmed learning in terms of listening to parents' concerns.

Finally, C complained that there was an unreasonable delay in the board diagnosing A's condition. We took into account a number of factors including the fact that A's condition developed around the start of the COVID-19 pandemic, when services were severely restricted and face-to-face meetings were prevented from taking place. We found a number of shortcomings in A's care and treatment: insufficient record-keeping regarding the risks/benefits of resection or biopsy, failure to communicate clearly with A's family, the disputed position about whether it was reasonable to adopt a clear working diagnosis of schwannoma, the lack of opportunity of a second opinion, the delay in appointing the neurology referral, and a delay in writing to the GP following the initial multi-disciplinary team meeting. We considered that, taken together, these shortcomings were sufficient to have led to a delay in reaching an accurate diagnosis and upheld this part of C's complaint. Although the complaint was upheld, we acknowledged the advice from each specialism that earlier diagnosis would not have led to a different outcome.

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:

• Where treatment decisions are being made at multi-disciplinary meetings, there should be adequate documentation of consideration of the risks/benefits. There should also be evidence of discussion with family members in relation to diagnosis and management plan, where applicable. Where a patient appears to have a condition which is extremely rare, the patient records should reflect the differential diagnosis.

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 raised complaints about the nursing and medical care their parent (A) received whilst in hospital. English was not A's first language and C also raised complaints about the board's communication with A and their family and whether appropriate follow-up care was provided by the board following C's discharge.

The board had accepted that A's nursing care fell below a reasonable standard in several areas, including the standard of record-keeping, the failure to discuss A's personal care with their family, and the assumptions that were subsequently made about A's preferences in relation to this. The board provided us with the nursing action plan they had developed following C's complaint. We took independent advice from a clinical nurse lead and a consultant geriatrician (specialist in medicine of the elderly). We found that the board's actions and action plan had been reasonable overall but there were some areas where the action plan could be improved. We upheld this part of C's complaint.

Similarly, the board accepted that the standard of communication with A and their family fell below a reasonable standard and had apologised for this. We found that the board's verbal and written communication could have been significantly improved, including their record-keeping. While the majority of issues were addressed by the action plan, there were some specific issues where staff could receive further feedback. We upheld this part of C's complaint.

C had been specifically concerned about modifications to A's medication and monitoring and treatment of A's feet. We found that the board's actions in relation to these had been reasonable and that A's medical care had been, overall, reasonable. We did not uphold this part of C's complaint.

Finally, the board had acknowledged their management of A's discharge and the communications associated with it, fell below a reasonable standard and had taken action with the aim of preventing any recurrence of this. We found that the actions proposed by the board largely addressed the issues involved. Therefore, we upheld this part of C's complaint and made only one further recommendation.

Recommendations

What we asked the organisation to do in this case:

• Apologise to A's family, via C, that they failed to communicate appropriately with A and their family during A's admission, that they failed to provide A with a reasonable standard of nursing care whilst in hospital and for the failure to respond fully to all the issues raised in their complaint. 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:

• Ward nursing staff communicate with patients and families appropriately, in line with the following sections of the NMC code: Prioritise people, Practice effectively, Preserve safety, Promote professionalism and trust. Keep clear and accurate records relevant to your practice.
• Ward nursing staff are aware of the need to properly document patients' foot care as detailed in the The Activities of Daily Living Assessment and reinforced in the NHS Education for Scotland online module for CPR for feet.

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.