Upheld, recommendations

Summary

C complained about the care and treatment provided to their late child (A) by the medical practice. C was concerned that A had been misdiagnosed by their GP during a telephone appointment. During the appointment, A reported shortness of breath, experiencing breathlessness, and feeling faint when walking upstairs and putting on their shoes. A was diagnosed with anxiety and prescribed a beta blocker (drug that blocks the action of hormones like adrenaline). Later that week, A died suddenly due to pulmonary embolism (a blood clot that blocks and stops blood flow to an artery in the lung). C raised concerns that there was a delay in A receiving treatment, the treatment that A received was inappropriate, and that harm was caused as a result of A being given the wrong treatment.

We took independent advice from a GP adviser and subsequently from another GP adviser with a specialism in sexual and reproductive health. We found that there are numerous risk factors for pulmonary embolus and, in this case, the main risk factors were BMI, family medical history and prescription of combined oral contraceptive. Neither risk alone would preclude prescribing combined oral contraceptive, but consideration would be made for two risks, as in this case. We found that the health centre failed to provide A with reasonable medical care and treatment. We upheld C’s complaint.

Recommendations

What we asked the organisation to do in this case:

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

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

• Patients presenting with similar symptoms should be carefully considered and where appropriate face-to-face appointments offered.
• Prior to prescribing the combined oral contraceptive pill for patients who have two or more risk factors for pulmonary embolus, careful consideration should be given to the risk factors, and a shared discussion should take place with the patient on the additional risks, ensuring that they understand that there may well be additional risk. This should be documented.

In relation to complaints handling, we recommended:

• The health centre should ensure that all complaints are handled in line with the NHS Model Complaints Handling Procedure (MCHP), particularly in terms of the requirement to respond in a timely manner. In particular, where a response to a complaint cannot be provided within the MCHP timescales, complainants should be provided with an updated timescale as to when they can expect to receive a response. Significant Adverse Event reviews should be accurate and reflect and record the available evidence and information, which should be reflected in the investigation report (and where appropriate, complaint responses).

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, a solicitor, complained on behalf of a student at the University (A). C said that A had suffered a serious assault and due to the impact of this on their mental health, had sought an exemption allowing them to study remotely. This had been denied by the University on the basis that only individuals needing to shield from COVID-19 or caring for someone shielding were entitled to remote study. The University said that these were the sole criteria considered by the committee that refused C’s application.

We found that the evidence showed that the University had not adhered to their statement on Gender Based Violence (GBV) in their consideration of A’s appeal. The only option offered to A was for them to suspend their studies. This was at odds with the medical evidence A had submitted. It was also apparent the University’s consideration of the appeal had been concerned about the possibility of setting a precedent. We also found that the University’s refusal to treat the correspondence with C as a formal complaint was unjustified, as it related to the application of the University’s policies and procedures, which were areas which should have been covered by the complaints process. We upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to A for failing to handle their request for remote study reasonably. 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 University should clarify what adjustments can be made for students under their gender-based violence statement and policy.
• The University should ensure the Counselling service are aware of the academic options available to students, or that they have a named point of contact within each school to signpost students to for guidance on their academic options.
• The University should remind all staff that if the remit of an appeal hearing is constrained to specific issues, they should not introduce irrelevant considerations.

In relation to complaints handling, we recommended:

• The University should remind staff in the legal department of the provisions of the complaint handling procedure and ensure they are aware of when it should be applied.

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 parent (A) received. A had sight and hearing difficulties. Following a fall at home A was admitted to hospital where they stayed as an inpatient for several weeks before being discharged to a care home. A died a few weeks later.

C complained that the care and support that A received at home to encourage movement and general wellbeing was not continued while A was in hospital. As such, A’s mobility and mental health deteriorated and they developed pressure sores due to the length of time that they were immobile in bed. C did not consider that A’s blindness and hearing difficulties were taken into account by the hospital staff and complained that A’s calls for assistance were ignored.

We took independent advice from a nursing adviser. We found that the lack of a person-centred care plan led to the failure to support A to enjoy activities that would have provided some stimulation. This along with the restricted face-to-face visits due to the COVID-19 pandemic, meant that A was unreasonably isolated and this impacted on their anxiety and mobility.

We found that there were a number of issues with documentation and the management of A’s pre-existing pressure ulcer. The lack of clear documentation was concerning and the HSCP failed to have in place documentation and equipment to record, assess, review and treat a pressure ulcer that evidently deteriorated throughout A’s admission.

Overall, we found that A was unreasonably isolated throughout their admission due, in part, to a failure to adapt A’s care in recognition of their sensory impairments and that there were clear failures to maintain important documentation. We upheld this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C that they did not provide a reasonable standard of care to A. 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 hospital adopt person-centred care planning.
• The hospital are compliant with current Health Improvement Scotland (HIS) Prevention and Management of Pressure Ulcer standards 2020.

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 A by the Scottish Ambulance Service (SAS). A had a pacemaker fitted and developed a severe headache and rash. A phoned NHS 24 as they were finding it difficult to breathe. 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 sought telephone advice from a consultant at the local hospital. The consultant advised that A should take paracetamol and see the GP the following morning. A phoned the GP the next day and was told to go to the COVID-19 hub where A collapsed and was taken to hospital by ambulance. A was admitted to hospital and died the following day from sepsis (blood infection). C complained about the decision not to take A to hospital and is concerned that the paramedics failed to recognise the signs of sepsis and to take the appropriate action.

We took independent advice from a registered paramedic. We found that in hindsight it was unreasonable that SAS did not recognise the seriousness of A’s condition, including applying any weighting to past medical history, in particular recent surgery and the fact that the presence of infection could have been the result of sepsis. However, we found that many of the clinical signs and symptoms observed in A would have been present in a patient experiencing COVID-19. Based on the conditions and guidelines SAS were operating to at the time we found that it was reasonable that the paramedics’ working diagnosis was COVID-19.

Whilst we considered it was reasonable that A was not taken to hospital, we were critical that there is no evidence that A was informed of the risks and benefits of the option of staying at home, going to hospital or of any alternative options available. We also found that it was unreasonable that key information was not passed to the consultant during a call and that record keeping was unreasonable. Furthermore, we found that it was unreasonable that during the paramedics second attendance, the further set of observations taken 20 minutes later unreasonably failed to include A’s temperature. Finally, in relation to the first attendance, we considered it was unreasonable to conclude that A was improving, particularly without carrying out a further set of observations. Overall, we upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

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

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

• Patients should be appropriately advised of the risks and benefits of the available options, for example the option of staying at home, going to hospital or of any alternative options available. This information should be documented to confirm the advice given, and details of discussions held regarding treatment options.
• Full and complete information should be obtained during observations of a patient so that advice is appropriately provided and recorded on the basis of that information. Where appropriate, consideration should be given to carrying out a further set of observations prior to reaching a view on a patient's condition.

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) about the care and treatment provided by the board. A was scheduled for a hip operation after experiencing increased pain which was affecting their daily function. The operation was cancelled on the day as the anaesthetist was not prepared to go ahead due to the high level of risk associated with the procedure and significant concerns about complications. C complained about the hospital’s process which they said caused great distress.

We took independent advice from a registered consultant physician. We found that there was a failure by the surgeon to share their concerns about A’s surgery with clinical colleagues in a timely way. There was also a break-down in communication between the key teams involved in the pre-assessment, resulting in failures in process and cancellation of surgery on the day. We also found that there was a lack of coordination in arranging A’s discharge home when the operation did not go ahead.

We also found failings in the board’s handling of the complaint, such as the complaint not addressing all the issues raised by C. We therefore upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the specific communication and process 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.

In relation to complaints handling, we recommended:

• Relevant staff should be aware of the requirements of the complaints handling procedures, particularly with respect to addressing all the elements of a complaint and accuracy of 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

A’s spouse (B) was admitted to hospital for a knee replacement. The operation went well but during B’s recovery their condition began to deteriorate and B was transferred to the High Dependency Unit. B went into cardiac arrest, CPR was administered but it was unsuccessful and B died.

C raised complaints on A’s behalf about B’s treatment during their admission. The board undertook a Local Adverse Event Review (LAER), identified issues with B’s care and treatment and made recommendations to address these issues. The board also responded to the complaints raised by C regarding B’s treatment. In their response the board reiterated the conclusions of the LAER, their recommendations made in relation to some aspects of B's treatment, and concluded that other aspects complained of by C had been reasonable.

In relation to specific questions about B’s admission that C had shared, the board indicated that responses to most of these had been provided at a meeting that had taken place between B’s family and a consultant orthopaedic surgeon (branch of surgery concerned with conditions involving the musculoskeletal system) or in the LAER report. The board provided a response to one other question in the response to C.

We took independent advice from a specialist in orthopaedic surgery. We found that observations of B should have been increased, their care escalated and that antibiotics should also have been commenced sooner. We upheld this aspect of the complaint.

In relation to the provision of answers to questions raised in the complaints submitted, we found that clear responses from a clinician were available to the board’s complaints team within a month of the questions having been raised. The board provided answers to some of the questions at a meeting the following month but clear answers to the remaining questions were not provided until SPSO became involved and specifically asked for them almost two years later. Given this, we upheld this aspect of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to A for an unreasonable delay in an urgent assessment being undertaken, a failure to escalate B to the medical team and the decision to administer antibiotics not being made sooner. The apology should meet the standards set out in the SPSO guidelines on apology available at www. spso. org. uk/information-leaflets.
• Apologise to A that clear answers to the questions raised were not provided within a reasonable timeframe. 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 timely medical review and if appropriate antibiotic therapy commenced without delay.

In relation to complaints handling, we recommended:

• Complaints are properly 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 on behalf of their spouse (A) about the board not issuing a discharge plan at the point A was discharged from hospital for palliative care before A passed away. As their carer, C wanted to know how to provide care and support for A. C said that this plan was subsequently requested a number of times but not provided. C also complained that following A’s death, their GP provided a copy of the Inpatient Discharge Summary which said ‘Do Not Attempt Cardiopulmonary Resuscitation’ (DNACPR). C said that they had not been aware a decision had been made on this and as A’s Power of Attorney, and in order to safeguard A, DNACPR should not have been discussed with A without C being present.

We took independent advice from a registered consultant geriatrician (a doctor specialising in medical care for the elderly). We found that the board could not have provided C with a discharge plan as C did not attend hospital that day. We also found that A was not given clear discharge information despite this being complex and their care needs being high. There was also a failure to subsequently provide C with a copy of the discharge plan when requested, and record keeping failures during A’s discharge. We also found that the board failed to communicate with C that a DNACPR decision had been made with A. We upheld the 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:

• Open and honest discussions should be held with the patient and relevant others with regard to timely decisions about DNACPR and in accordance with relevant DNACPR guidance. This is particularly important where patients have Aphasia (language disorder) and where patients are discharged home for end of life care.
• Patients should be discharged with appropriate documentation which is clear and should be completed so that full discharge information is provided. This should include post discharge requests for further copies.

In relation to complaints handling, we recommended:

• The board's complaint handling monitoring and governance system should ensure that failings (and good practice) are identified and that learning from complaints is used to drive service development and improvement.

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

Summary

C complained that the board failed to provide them with reasonable care and treatment when they were admitted to an acute medical unit, specifically that they were discharged too soon and that there was a delay in diagnosing that they had suffered a stroke.

We took independent advice from an adviser that specialises in acute medicine. We found that the board incorrectly documented that a CT scan had been carried out. Given the seriousness of C’s symptoms and their outcome, it was of concern that this incorrect information was documented in C’s medical records. We found that C should have remained in hospital to be assessed in more detail before they were discharged. We found that more consideration should have been given to C’s symptoms and the possibility that they were related to a stroke. In particular, a CT scan should have been carried out earlier, which could have led to an earlier diagnosis and treatment with medication. On C’s readmission, C’s stroke was visible on a CT scan. It therefore was possible that a CT scan, on their first admission, could have shown C’s stroke.

In relation to C’s nursing care, we found that we would have expected to have seen more detailed nursing notes about C before their discharge, for instance, in relation to C’s walking ability. The board apologised for the miscommunication which occurred between nursing staff in relation to C’s fitness for discharge and said that learning had been put in place for effective communication. The board said that this was communicated verbally and therefore there was no paper evidence. We considered this to be unsatisfactory and we upheld the 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:

• Where a patient presents with neurological symptoms after a colonoscopy, consideration should be given to the possibility that they may be related to a stroke, that their suitability for discharge should be appropriately assessed and their condition appropriately reviewed to see if their symptoms settle and for relevant scans to be carried out prior to discharge. The rationale for a patient’s discharge should be properly documented with details of all relevant assessments fully documented. Information recorded in a patient’s records should be accurate.

In relation to complaints handling, we recommended:

• Complaint investigations should be carried out in line with the NHS Model Complaints Handling Procedure. The board should comply with their complaint handling guidance to ensure that a full and proper investigation is carried out. Where learning is identified, there should be clear evidence of the action subsequently taken.

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 partnership had not provided the correct care and treatment for their ear infection in their right ear. C did not consider that the ongoing ear infection had been correctly diagnosed or treated, noting that the antibiotics which were prescribed had not been effective. C was concerned that although a referral to ENT had been made, the referral was not correctly prioritised, which had caused a significant delay. It was only when C saw a doctor, who phoned ENT, did C receive specialist input.

We took independent advice from a GP adviser. We found that C had not been seen face to face for a six month period, the first was a routine referral and the second expedited referral did not reflect the clinical situation because C had not been examined. We also found that the overuse of antibiotics had likely aggravated the situation. Overall we considered that more could have been done to clinically assess and seek specialist input for C’s ear infection. We therefore upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C that they did not receive a face to face consultation for a six month period. Apologise to C that specialist input was not sought from ENT, on an urgent/high priority basis, at an earlier stage. 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:

• Ensure that Advanced Nurse Practitioners know when to request support and input from a GP.
• That written referrals to ENT have sufficient information and are prioritised at the appropriate time. Also that specialist ENT advice is sought via the on-call service when appropriate.

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 spouse (A) about the care and treatment provided by the board before they died. A was an end of life patient having been diagnosed with incurable lung cancer. A developed symptoms likely caused by an obstruction of one of the major blood vessels attached to the heart and was scheduled to have a stent inserted through the blockage. C complained about their experience on the ward on the day of the procedure which, they said, caused great pain and distress.

We took independent advice from a registered senior nurse. We found that A lacked person centred information to prepare them for admission which caused distress, that there was a failure to provide a clear pathway for a patient diagnosed with end stage lung cancer the Peripheral Vascular Cannula (PVC)(insertion of a plastic conduit across the skin into a vein) process was not followed. We found that a pressure ulcer risk assessment was not undertaken and a plan of care not developed or implemented to prevent pressure damage. We also found that there was a failure to provide A with their prescribed steroids, despite requesting this. We noted record keeping failures during A’s admission and found failings in the board’s handling of the complaint, with the complaint not addressing all the issues raised by C and failings to fully investigate and respond to C about the PVC process. We upheld the 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:

• Patient records should be accurately completed, signed and dated with the appropriate level of information included, in accordance with the relevant nursing and midwifery standards.
• Patients should be appropriately assessed to prevent pressure ulcer damage, in accordance with the current pressure ulcer prevention and management standards.
• Patients should receive appropriate information to prepare them for a procedure, and to manage expectations about the admission. The board has said a draft patient information leaflet relating to the Superior Vena Cava Stent Insertion procedure has been developed and awaits final approval. The board should consider updating this leaflet to address person centred concerns.

In relation to complaints handling, we recommended:

• Relevant staff should be aware of the requirements of the complaints handling procedures, particularly with respect to investigating and addressing all the elements of a 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.