Upheld, recommendations

Summary

C complained that the Scottish Prison Service (SPS) failed to appropriately investigate their lost property claim. C submitted a claim for lost items which went missing during a transfer to another prison. C complained about the handling of the claim, including the timescale for receiving a decision. C maintained that three bags of property were missing, whereas the SPS concluded that only one bag was unaccounted for. This office does not provide a route of appeal, and it was not our role to assess what property was missing or what compensation should be offered. Our focus was on the administrative handling of the claim, including whether the SPS assessed all relevant information and provided a clear explanation as to how they reached the conclusion that they did.

The evidence we received from the SPS of their assessment of the claim was difficult to follow. It was unclear to us how they concluded that one bag of property was unaccounted for. We found that this was based on a bag seal check eight months after C’s prison transfer. C noted in the claim that much of the missing property had been kept in storage at their previous prison and was not in their possession (‘in use’). The SPS said that C packed their own property prior to the transfer. It was not clear from the records what items C had ‘in use’ at their previous prison, and there did not appear to be a method in place for itemising ‘in use’ items packed from a prisoners cell prior to being placed within a sealed bag for transfer. C also alleged that some items were damaged during the transfer and we found no evidence that the SPS assessed this part of C's claim. The SPS communicated their final position more than three years after C initially raised matters following their prison transfer. It was not clear why this took so long. Therefore, we upheld C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the unreasonable length of time it took to progress their claim and communicate a final outcome. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.
• Reconsider C’s claim and communicate their finding to both C and the Ombudsman, explaining how the issues identified in this decision were considered.

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

• In light of the issues identified in this decision, the SPS should consider what improvements could be made to the process of maintaining accurate and legible records of prisoners property to ensure any claims for missing or damaged property can be considered efficiently, and without unreasonable 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 complained about the council’s handling of communal repairs at a tenement in which C owned a property. Extensive work was required following a fire. The council owned the majority of properties in the building and took the lead in arranging and managing the work. During the work to repair the fire damage, extensive dry rot was identified. Work was completed around four years after the fire.

The invoice C received from the council for the dry rot works was approximately £15,000 over what C had expected to pay, based on the estimates for work given two years prior. C complained about the council’s management of the repairs, including their communication.

We found that the council’s communication with C during the period of works and in respect of the increasing costs was unreasonable. The council also failed to follow their own processes or act in line with their obligations under the Tenements (Scotland) Act 2004. The final invoicing included substantial costs for which C was not liable, and which should not have been included in the invoice. The council also failed to notify C of the costs of an emergency repair to the roof following a storm within a reasonable period of time, resulting in C missing the opportunity to submit an insurance claim for the costs.

Overall, we found that the council’s management of communal repairs was unreasonable. Therefore, we upheld this part of C's complaint. We considered that regardless of communication issues and delays, the costs would likely have been incurred and therefore are duly payable by C. However, given the multiple failings in relation to communication and administration, we recommended that the council refund the administration fee to C.

C also complained about the council's handling of their complaint. We found that the council’s complaint handling was unreasonable. The council failed to identify C’s expression of dissatisfaction as a complaint, failed to respond within a reasonable timescale or provide timely updates, misinterpreted C’s complaints, and made contradictory statements in the complaint response. 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 failure to reasonably manage the communal repairs and the failure to reasonably handle C's complaint. The apology should meet the standards set out in the SPSO guidelines on apology available at HYPERLINK "http://www.spso.org.uk/information-leaflets" www.spso.org.uk/information-leaflets .
• Clarify whether the scaffold and site establishment costs were charged to C, and consider whether these funds should be reimbursed.
• The council should make a financial payment to C of £2,278, the equivalent of the 7% administration fee charged by the council for these works, in recognition of the poor standard of administration and failure to act in line with their responsibilities under the Tenements (Scotland) Act 2004 when arranging for these repairs to be carried out.

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

• The council should manage repairs carried out under the terms of the Tenements (Scotland) Act 2004 in line with their obligations. When managing repairs, the council should ensure tenants and homeowners are updated of the progress of the project regularly, particularly where the scope of the works and the costs escalate.

In relation to complaints handling, we recommended:

• Complaint handling should be in line with the Model Complaint Handling Procedures. We offer SPSO accredited Complaints Handling training. Details and registration forms for our online self-guided Good Complaints Handling course (Stage 1) and our online trainer-led Complaints Investigation Skills course (Stage 2) are available at  HYPERLINK "https://www.spso.org.uk/training-courses" https://www.spso.org.uk/training-courses .

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 personal care and treatment to their sibling (A). A was admitted to hospital to initiate and titrate Clozapine (an antipsychotic drug used to treat schizophrenia and other psychotic disorders). A had a history of diabetes and experienced episodes of incontinence which placed A at greater risk of infection. C complained that the discharge letter did not mention a pressure sore which was treated by A's GP upon discharge. This could have resulted in A’s Clozapine treatment being temporarily suspended.

We took independent advice from a mental health nurse and from a wound-care specialist nurse. We found that A’s feet were examined following concerns raised by C. However, no treatment was prescribed and the doctor's advice about caring for A’s feet was not passed on to C. We found that there was no conclusive evidence to determine whether A had a pressure sore or an ulcer which might have impacted on A’s Clozapine treatment. We also found that it was reasonable for the board to conclude that the wound A had was not a pressure ulcer. However, the board failed to evidence that relevant assessments relating to pressure ulcer risk and skin inspections were carried out. We also found that there was no person centred care plan in place to identify A’s needs in relation to activities of daily living, including personal hygiene. We found that the immediate discharge letter was dated the day after discharge which suggests it was not available to C at the point of discharge, or on the same day, when it should have been. Therefore, we upheld C’s complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the specific personal care and treatment failings. The apology should meet the standards set out in the SPSO guidelines on apology available at HYPERLINK "http://www.spso.org.uk/information-leaflets" www.spso.org.uk/information-leaflets .

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

• Patients should be appropriately assessed and treated by staff. Where clinical needs are identified via assessment, corresponding interventions should be planned and initiated to address the situation and prevent complications arising. Care should be provided in line with the assessments carried out and in a timely manner. 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 and reflect a person-centred approach. Patient's records should include clear details explaining why a decision about care and treatment has been made, and show that this has been communicated appropriately.
• The board should ensure that immediate discharge information reaches the GP as soon as is practicable in every case, ideally on the day of discharge, in order that GPs receive essential information that enables continuity of care.

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

Summary

C complained about the standard of care provided by the board to their parent (A). A had a complex medical history including depression for which they were on three types of anti-depressants. This was noted when A was admitted to hospital but staff failed to provide A with their prescribed medication and inform A and their family that the medication had not been given to them. This led to A’s mental health deteriorating.

We took independent advice from a registered nurse. We found that the board failed to deliver the required service in relation to medicines, maintain adequate recordkeeping, communicate appropriately, recognise the harm done to A and undertake the appropriate review. Therefore, we upheld this part of C’s complaint.

C complained that the board failed to deal with their complaint in a reasonable way. We found that the board’s investigation did not look into an important part of the complaint and that their response did not address the impact on A as a result of the medication being withheld. Therefore, we upheld this part of C’s complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failings identified in this investigation in relation to the standard of medical care and complaint handling. The apology should meet the standards set out in the SPSO guidelines on apology available at HYPERLINK "http://www.spso.org.uk/information-leaflet" www.spso.org.uk/information-leaflet .

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

• Clinical records should appropriately document the action taken to ensure prescribed medication has been reconciled and administered to the patient and medicine reconciliation documentation appropriately completed. Where clinical staff are unable to do so, there should be appropriate communication with the patient and/or their family about this.
• Where an adverse event occurs there should be a thorough review in line with relevant national guidance to ensure that there is appropriate learning and service improvement to enhance patient safety. Where an incident occurs that falls within the Duty of Candour legislation, the board's Duty of Candour processes should be activated without delay.
• Patients admitted to hospital should have their prescribed medicine reconciled without delay and in line with the relevant standards.

In relation to complaints handling, we recommended:

• Complaints should be investigated fully and the complaint response should address all the points raised in line with the Model Complaints Handling Procedure.

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

Summary

C complained about the care and treatment provided to their spouse (A). A had a history or recurring urinary tract infections (UTI's) and was self-catheterising. The board gave A an indwelling (long-term) catheter to be changed every three months. Over the next several months, A attended A&E five times before being admitted and diagnosed with bladder cancer. C complained about the lack of arrangements to change A’s indwelling catheter, that requests for appointments were ignored and that A was only admitted after multiple visits to A&E.

We took independent advice from a consultant urologist (specialist in the male and female urinary tract, and the male reproductive organs), consultant in emergency medicine and a medical director specialising in palliative care. We found that, as the indwelling catheter was a trial, the board should have followed up with A on their progress. There was also unreasonable delays in A being seen by urology and in being advised of their cancer diagnosis. While it was reasonable that A was not admitted by A&E for examination sooner, the board acknowledged that there was a missed opportunity. Therefore, we upheld this part of C's complaint.

C also complained that A’s cancer diagnosis, discharge and care arrangements were not clearly explained. We found that the board made reasonable efforts to explain the cancer diagnosis to C and A. However, they did not reasonably communicate how they might manage once A was discharged home, and about the challenges associated with A reaching end of life. Therefore we upheld this part of C's complaint.

In relation to complaint handling, we found that the information provided to both C and this office was inaccurate in places and incomplete. Therefore, we made a recommendation to improve the board's complaint handling.

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 HYPERLINK "http://www.spso.org.uk/information-leaflets" www.spso.org.uk/information-leaflets .

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

• When a relevant adverse event occurs, the board should carry out a Significant Adverse Event Review (SAER) to investigate the cause and identify any potential learning.
• Patients should receive timely review, follow-up appointments and information based on their clinical needs and presentation and in accordance with relevant guidelines. A's case should be reviewed at the local Morbidity & Mortality meeting with a view to identifying opportunities that were missed to progress A's diagnosis and ways of ensuring similar delays do not affect future patients. The Board should consider whether this case could be used as an opportunity to reflect and improve the interface between the urology and emergency departments in order to minimise the risk of a similar case occurring again.
• Discharge planning should be person-centred and holistic and clear to patients, families and community services. In particular, the palliative care team may support complex discharges but it is the ward team who are best placed to support the patient's discharge. Teams should not just focus on their area of interest e.g. urology but on caring for the whole person. Patients with palliative care needs should be supported within their limited function to live well. Expectation of rehab should be realistic. Staff should explore what is realistic, what the patient and their families' concerns are and also be brave and explore where there are gaps in the system of support, what the best possible mitigation is. There should be thorough documentation of this. Spiritual / other support should be available. They are non-denominational / nonfaith and provide support to patients and families. Learning sessions should occur around recognising a palliative deterioration or the acute deterioration covered by NEWS. Recognising someone heading to the end-of-life phase is essential, as are developing communication skills to support staff to engage with patients and families.

In relation to complaints handling, we recommended:

• Information provided to SPSO and the complainant should be accurate and complete. All relevant records in relation to an SPSO investigation should be provided from the outset of our enquiries.

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 their late partner (A)’s discharge from hospital was unreasonable. A was admitted to hospital with pneumonia and was discharged after ten days. Less than two weeks after discharge, A collapsed and was readmitted to hospital. A died a few days later. C questioned whether A had been fit for discharge. They also raised concerns about not receiving adequate education on the new medications that A was prescribed on discharge.

The board noted that A’s infection had improved with antibiotic therapy and that they had been stable and well enough for discharge home. They explained the rationale for the medications that A had been prescribed and apologised that medical staff did not have a better discussion with them at the time of A’s discharge.

We took independent advice from a consultant in acute and general medicine. We found that A's oxygen levels had been stable and their discharge was clinically reasonable. However, we noted that A's sodium level had been low during their admission but had improved on discharge. We found that no follow-up arrangements were made to ensure that A's sodium level was continuing to improve after their discharge. The working diagnosis on A's readmission was that they had had a seizure due to low sodium which led to hypoxia (deficiency in the amount of oxygen reaching the tissues) and cardiac arrest. It is possible that the fall in A's sodium level could have been detected had there been follow-up to re-check this. Therefore, we upheld C's complaint.

We also noted a discrepancy between the working diagnosis on A’s re-admission and the recorded cause of death on the death certificate. This was not identified by the board. Therefore, C was not provided with a coherent narrative of events surrounding A’s death and we made a recommendation to address this.

Recommendations

What we asked the organisation to do in this case:

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

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

• There should be robust discharge systems and processes in place, ensuring appropriate communication with patients and carers, and adequate detail in discharge documentation.
• Patients who are discharged with moderately low sodium levels, should be followed up to check that improvement is maintained. There should be clear guidance in place around this, to ensure it happens where indicated.
• The death certification process should be accurate and consistent with the clinical 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 that the board failed to reasonably communicate with their family when their parent (A) was admitted to hospital. A was taken to A&E following a fall at home.

A was moved to a ward following an x-ray and medical review showing that A had broken their hip. A underwent an operation later that day and remained in hospital until their discharge nearly seven weeks later. C also complained about the nursing care that A received.

We took independent advice from a nurse. We found that there was a failure to communicate with the family about the consequences of delirium. We also found that there was a failure to ensure A had access to bread/toast and milk. There was a lack of acknowledgement and details regarding A’s lost dentures, a failure to inform A or C that A had developed a hospital acquired pressure ulcer, poor record keeping and a lack of evidence of appropriate nutritional care interventions being followed. Therefore, we upheld C’s complaints.

Recommendations

What we asked the organisation to do in this case:

• Apologise to A and 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 HYPERLINK "http://www.spso.org.uk/information-leaflets" www.spso.org.uk/information-leaflets .

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

• Where appropriate, there should be discussions with family members in relation to diagnosis, treatment and management. An appropriate record of this should also be made.
• Blankets should be available for patients on wards, particularly those that care for elderly, frail patients. When wards run out of blankets, there should be a process in place to obtain replacements without delay.
• Bread and milk should be made available on the ward in line with the Food in Hospitals specification. Toast should be made available to patients where this has been specifically agreed.
• Patients should be changed into nightwear as appropriate or offered a hospital gown where no personal nightwear is available.
• Patients experiencing delirium should be given additional assistance to help secure or monitor their personal possessions and in particular, dentures.
• Staff should be compliant with the Duty of Candour legislation and inform patients/relatives if they come to harm.
• Patient documentation should be completed to an appropriate standard and in line with the required standards of the Nursing and Midwifery Council: The Code in relation to record keeping.
• Patients admitted to hospital should receive appropriate nursing care including appropriate nutritional and fluid intake monitoring and recording. In addition, this should be appropriately documented.

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 adult child (A) received from the practice following their discharge from hospital.

C complained that A had struggled to get an appointment with a GP and that the practice failed to provide a reasonable standard of care in relation to pain management, A’s mental health needs, and follow-up with the health board.

The practice said that they were short-staffed and had been working on an emergency-only basis at the time of the complaint. When A had enquired about seeing a GP, there had been no indication that an emergency appointment was required. A was advised to phone again the next day or to attend A&E.

In respectof A’s pain, the practice said that the discharge medication had been managed in accordance with their policy and in recognition of the nation-wide shortage of the drugs prescribed. A was given an appointment to discuss pain when they reported that the medication was not working and a prescription for nerve pain was given.

In reference to A’s mental health, the practice said that this was discussed during a phone appointment. However, A had breached the practice’s zero tolerance policy during the conversation. A was issued with a warning letter after the incident but was not removed from the practice (as would be policy) in recognition of the mental health difficulties that they were experiencing.

This incident was reviewed as a part of a Significant Event Analysis Review (SEAR) and the practice identified learning to manage this type of occurrence in the future.

In respect of A’s follow-up with the health board, the practice confirmed no post-discharge requests had been made and that it was the responsibility of the hospital to issue clinic appointments.

We took independent advice from a GP. We found that the practice had reasonably managed the discharge prescription for pain medication. While A had been appropriately directed to other services when no appointments were available, we found that the messaging could have been clearer and that reception staff had unreasonably provided advice about pain medication.

We considered A’s appointment with the GP to discuss pain was unreasonable as there was a failure to document any assessment or information to support the nerve pain conclusion reached.

In terms of A’s mental health, we considered that the phone consultation had been reasonably managed, as was the decision to issue a zero tolerance warning letter. The conclusions reached by the SEAR on this matter were also reasonable. We found that the practice’s actions in relation to A’s follow-up with the hospital was reasonable.

On balance, we considered that the care and treatment provided fell below a reasonable standard and we upheld C’s complaint.

Recommendations

What we asked the organisation to do in this case:

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

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

• Advice relating to medical matters should be given by GPs or appropriately qualified members of staff.
• The practice should keep reasonable records of consultations undertaken with patients that clearly record any assessment undertaken and the basis for the 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 complained about the care and treatment provided to their spouse (A) when they attended A&E. A had fallen from a height and injured their shoulder. A was x-rayed and diagnosed with a soft tissue injury to the shoulder and a minor head injury. A was discharged home and advised to use regular simple pain relief for the shoulder injury. A was later diagnosed with a rotator cuff injury which required an operation. C said that A should have been correctly diagnosed by the doctor in A&E and that the delay left A in significant pain and distress.

We took independent advice from a consultant in emergency medicine. We found that A should have been reviewed by a senior doctor before discharge. We also found failings in relation to a lack of follow-up and record keeping. Therefore, we upheld C’s complaint.

We also found that C’s complaint was not handled reasonably as there were clear inaccuracies in the board’s complaint response and no reflection on the failings. We made a recommendation to address this.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failings identified in this investigation in relation to the standard of care at the A&E and complaint handling. The apology should meet the standards set out in the SPSO guidelines on apology available at  HYPERLINK "http://www.spso.org.uk/information-leaflets" www.spso.org.uk/information-leaflets .

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

• Patients who attend the A&E with a significant soft tissue injury should be provided with a reasonable standard of medical care in relation to the referral process and follow-up.

In relation to complaints handling, we recommended:

• Complaint responses should be clear that failings and their impact are recognised and that any findings from the investigation are supported by the clinical records.

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 parent (A). A was admitted to hospital and received treatment for a chest infection and pleural effusion (a build-up of fluid in the chest). A remained in the hospital awaiting discharge arrangements. During a visit to A, C was told that A's bed was needed for a more acute patient and that A would be transferred to a maternity ward as a boarder. C complained that A was not included in this conversation, and that the family felt pressured to accept an unsuitable move. They were concerned that it would negatively impact A’s care and wellbeing due to noise, disruption and the availability of equipment.

The board stated that A had been identified as a patient suitable for boarding and that ward moves are necessary when there is extreme pressure on capacity. The board also considered that the care provided to A was not affected by the move.

We took independent advice from a consultant specialising in acute medicine. We found that A was not considered suitable for boarding under the board's policy. We also found that there had been a failure to conduct and record a full risk assessment, and to record the reasons for this deviation from policy. There was evidence that the move caused A distress leading to a deterioration in their behaviour and acceptance of treatment. Therefore, we upheld this part of C's complaint.

C also complained that the board’s complaint response focussed on allegations of aggressive behaviour from A’s family towards hospital staff. C did not consider that this accurately represented events.

We found evidence of challenging behaviour documented in the available records. However, the board’s complaint response unreasonably focussed on these events, which were not ongoing. Therefore, we considered that the board failed to handle C's complaint reasonably and upheld this part of their complaint.

Recommendations

What we asked the organisation to do in this case:

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

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

• All decisions regarding boarding patients should be made following appropriate clinical considerations and a formal risk assessment. These should be clearly documented. Should a situation arise when a decision is made to deviate from the board's policy due to exceptional pressures, a clear rationale should be documented outlining why the decision has been made and how the risks have been weighed.

In relation to complaints handling, we recommended:

• Complaints should be investigated and responded to in accordance with the NHS 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.