Upheld, recommendations

Summary

C complained about the care and treatment that their late adult child (A) received from the board about symptoms of productive cough, breathlessness and occasional wheeze. A was referred by their GP to the board and received two outpatient chest x-rays. Separately, A also self-presented at the A&E owing to their symptoms, where they were discharged with a trial of steroids and inhaler. A’s first of the two outpatient chest x-rays was reported as normal and their GP routinely referred them to the respiratory department for further investigation of their symptoms. The second of the two outpatient chest x-rays was considered to show changes suggestive of pulmonary oedema (a condition in which too much fluid accumulates in the lungs, interfering with a person's ability to breathe normally). At this point, A’s GP upgraded the respiratory referral to urgent. On vetting by a respiratory consultant, A’s GP was contacted with advice to commence a diuretic (drugs that enable the body to get rid of excess fluids) straight away and urgently refer A to cardiology, on suspicion of heart failure.

A was seen at the cardiac function clinic, with the plan being made to see them at the heart failure clinic. A’s condition deteriorated before being seen at the heart failure clinic and the GP arranged for their immediate admission to the coronary care unit (CCU). A suffered a cardiac arrest shortly after admission requiring resuscitation, and they were subsequently transferred to another health board for surgery where they died.

C complained about the delays by the board to assess, diagnose and treat A’s condition, especially as A had presented to the A&E, and after the follow-up x-ray showed significant deterioration within a 4 week period. Having been referred to cardiology, C complained that the board failed to treat A’s condition with the urgency it required. C also complained that A had been transferred to another health board for surgery when it was known A’s condition was such that this intervention would have been futile.

The board’s response to C’s complaint advised that the treatment A received at the A&E was appropriate to their presenting condition at the time. The board did not comment on the timings of the cardiology appointments or assessments, however they explained the immediacy of A’s condition was understood at the time of the admission to CCU, with appropriate treatment being provided at the time, including in relation to A’s transfer to another health board for surgery.

We took independent advice from three clinical advisers, a consultant radiologist, a respiratory and general medical consultant and a consultant cardiologist (specialist dealing with disorders of the heart). We found that the treatment provided to A at the A&E was reasonable, based on what was known at the time.

We found that the first of the outpatient chest x-rays which had been reported as normal was in fact abnormal and required clinical correlation in respect of A’s presenting symptoms. Had this happened, a cardiac cause for A’s symptoms could potentially have been made sooner. With regards to the second chest x-ray, we found that the board failed to use the radiology alert system in place to flag urgent and/or unexpected findings.

We also found that the vetting process by the respiratory consultant had been reasonable, as was the advice to urgently redirect to cardiology and immediately commence A on a diuretic. On the matter of the timing of A’s cardiology review, we found that this was unreasonable in light of them having significant indicators of heart failure, known to date back. We found that A received reasonable care and treatment on being admitted to CCU and ICU. On balance of the above, we upheld C’s complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the delays in assessing and treating A’s condition. 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 presenting with signs of heart failure should be appropriately assessed including in relation to deciding to manage patients in an inpatient or outpatient setting.
• Abnormal findings on x-rays should be appropriately identified and reported.
• X-rays which are considered critical, urgent and/or where unexpected significant findings are identified should be flagged to the referrer using the significant finding alert system.

In relation to complaints handling, we recommended:

• The board should ensure SPSO requests for documentation and evidence are responded to in line with the time frames requested and that they are fully compliant with their complaints handling guidance when responding to SPSO 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.

When this report was first published on 21 February 2024, it referred to A as 'late child' of C.  However the summary was amended to read 'late adult child' on 26 March 2024 for clarification.  We apologise for any confusion caused.

Summary

C complained about the actions of the council in relation to repairs required at their home. They considered the communication, quality of repairs and time taken to carry out and fully resolve the repairs were unreasonable.

While it was noted that there were significant efforts made to seek to resolve the issues, and some delays were outwith the council’s control, overall, we considered the council failed to reasonably respond to repairs. While some repairs were completed in the target timescale, others were not, and for other repairs there was no record provided to indicate whether they were complete and no mechanism to escalate the situation where repeated attempts to repair the same fault were unsuccessful. As such we upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to reasonably respond to C’s repair requests. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.
• Ensure that the seven repair requests have now been completed.

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

• Have a system in place to ensure repairs information for each property is recorded in a way that is clear and accessible. Ideally this will also include a record of seeking verification from the tenant that they are also satisfied with the repair.
• Have a system in place to identify and respond to situations where multiple repairs have not resolved the issue.

In relation to complaints handling, we recommended:

• Responses to complainants and the SPSO are thorough and complete, ideally in one response.

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 surgery performed to remove material from their leg was not carried out to a reasonable standard. C broke their leg and underwent an operation to insert pins, plates, and a device known as a ‘TightRope’ (a device where string is passed through a channel in the bone and secured with ‘buttons’ at each side) to stabilise their leg. C developed an infection in their leg and subsequently underwent a further procedure to remove the ‘TightRope’. The procedure was not successful, some material was retained in C’s leg and the infection persisted. C then underwent further procedures to have the material removed completely, however, the infection proved to be too advanced and C had a below knee amputation. C complained that the board did not appropriately remove the ‘TightRope’ material during the initial procedure when they should have done.

The board said that although there was an intention to remove all of the ‘TightRope’, the material is not always visible. Cutting through the ‘TightRope’ in order to pull it through, staff expected all of the material to come out. Staff assumed that they had removed all of the suture, however, some of the material had stayed behind. The only way to have fully confirmed this would have been to make a larger hole through the bone, which could have allowed further spread of the infection.

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 the surgeon who carried out the initial procedure to remove the ‘TightRope’ should have been familiar with the device, including the volume of material, and should therefore have been able to assess whether removal was complete. The surgeon should have curetted (cleaned/scraped) the channel in the bone to ensure that all material was removed. We noted that an experienced surgeon would likely have undertaken a more complete removal of the material and suggested that the board could consider reviewing their arrangements for supervision of surgeons who are not experienced in a specific procedure. We considered that the initial surgery performed to remove the ‘TightRope’ material was not carried out to a reasonable standard. Therefore, we upheld this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failure to carry out the procedure to an acceptable standard resulting in some material being retained in the TightRope channel and for the impact this had on C. 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:

• Operations should be carried out to a high standard.

In relation to complaints handling, we recommended:

• Complaint investigations should be carried out in line with the NHS Complaints Handling Procedure. Particular notice should be given to the responsibility to ensure that staff learn from complaints, especially when mistakes have been identified. Good practice should be followed when compiling the complaint response.

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 arterial surgery. The board accepted that there were issues related to the systems in place at the time for the sharing of information between board sites and communication, and apologised for this.

We took independent advice from a cardiology adviser. We found that there was nothing to suggest that there was poor clinical practice or decision making and found that, the issues related to the sharing of information between board sites and communication meant that aspects of the care and treatment C received fell below the standard C could reasonably expect. We upheld C’s complaint.

Recommendations

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

• That the board review their policies and practice regarding inter-hospital transfers, specifically around documentation accompanying patients and verbal ward-to-ward handovers and that the board feedback the findings of this investigation to the medical team involved with C to highlight the poor communication with C and their family whilst they were in hospital.

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). A was admitted to hospital but was discharged later that month. Two days after discharge, A was readmitted and died a short time later.

We took independent advice from a consultant in geriatric and general medicine. We found that some aspects of A’s care were reasonable particularly in relation to COVID-19, A’s diabetes, and detailed assessments from physiotherapists and occupational therapists prior to discharge. However, we found that while A’s last blood tests were normal, A was then unwell for several days which could have developed into kidney impairment if levels of hydration in the body became low. A’s blood tests were not repeated prior to discharge. Had A received blood tests prior to discharge, taking into account A’s blood tests on readmission, it is likely that the test would have been abnormal which would have resulted in A remaining in hospital. We considered that the board failed to provide A with reasonable care and treatment. Therefore, we upheld this part of C’s complaint.

C also complained that the board unreasonably failed to consider their concerns in sufficient detail when responding to their complaint. We found that the board’s complaint response did not reasonably address C’s specific concern in relation to the comments of a nurse. We also found that when investigating the complaint there was a lack of attention given to the reasons for readmission and a lack of reflection by the medical team to ensure lessons were learned. 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 provide reasonable care and treatment to A and to appropriately consider and respond to C’s 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:

• Patients should be appropriately assessed prior to discharge and any tests required e.g. blood tests carried out in accordance with their symptoms.
• The board should ensure that their complaint investigations and responses appropriately consider and respond to the points raised by the complainant and that, where appropriate, there is reflection on the issues raised by the staff involved, for example discussion at a team meeting/huddle.

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 spouse (A). A had a history of Parkinson’s Disease (a condition in which parts of the brain become progressively damaged over many years), dementia and cerebrovascular disease (a range of conditions that affect the flow of blood through the brain). A was admitted to hospital with a suspected urinary tract infection but their condition deteriorated and they died a few months later.

C complained that the board failed to provide A with appropriate nutrition and hydration in the first few weeks following admission, that staff had not treated A with dignity and ascribed A’s symptoms to their pre-existing conditions rather than treating individual needs. C also complained about the personal care provided to A, particularly with respect to management of their skin during admission.

The board considered that they provided A with reasonable care and treatment but acknowledged and apologised for a delay in inserting an nasogastric tube (NG tube, a tube that carries food and medicine to the stomach through the nose).

We took independent advice from a consultant geriatrician (specialists in care of the elderly) and a registered nurse with experience in tissue viability care.

We found that the management of A’s hydration was reasonable. However, there was a period of up to two weeks where A was Nil by Mouth without any other arrangements in place to ensure their nutritional needs were being met. We also found that staff were aware of A’s Parkinson’s Disease and it remained a priority during their admission. However, whilst specialist advice was sought, there was only limited input from relevant specialists and we found it unreasonable that there was not more direct involvement from relevant specialities. We also found that there was a failure to document the reasons for the provision of different medication and changes in delivery method. In relation to wound management, we considered that there were gaps between wound assessments and that the documentation was not completed appropriately, resulting in no structured or measurable approach to assessing A’s pressure sore. Therefore, we upheld C’s complaints.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the issues highlighted 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.

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

• Decisions in relation to medication changes should be appropriately documented and, where appropriate, the risks and benefits of a particular medication regime and its delivery fully considered and documented.
• Patients at risk of or with existing pressure sore damage should receive appropriate and timely pressure sore care in accordance with relevant local and national guidance.
• Patients that have complex care needs should receive appropriate input and care from all the relevant clinical specialities when requested.

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 following the council's decision to decline C’s request for financial kinship care assistance in respect of their grandchild (A). C complained that the council failed to adequately consider their eligibility when there was a change of circumstances in the family home and they became the primary carer for A.

In responding to C’s complaint, the council upheld their original decision to decline C’s request for kinship allowance on the grounds that the decision for A to reside with C had been a private family arrangement and that they had not formally placed A in C’s care. The council did acknowledge that conflicting information was given to C regarding their eligibility for kinship allowance, that the provision of information regarding eligibility on the council’s website was lacking, and that the process for challenging the council’s decision on C’s application for kinship allowance was unclear. They agreed to take a number of improvement actions in response.

We took independent advice from a social work adviser. In addition to the failings identified from the council's own complaint investigation, we found that when there was a reported change in circumstances in the family home, the council failed to carry out an assessment of A’s wellbeing or seek their views to determine whether they were a child at risk of being looked after (an eligible child). We found that when C made a request for kinship allowance, the council’s assessment was lacking in detail and reasoning, and failed to consider A’s wellbeing and seek their views. We found that the council’s position that C was not eligible for kinship allowance failed to adequately take into account the relevant legislation and national guidance or the changed circumstances in the family home. We also found that the council failed to provide a full and informed response to C’s complaint. Therefore, 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:

• The outcome of assessments for kinship care allowance should be appropriately completed and the rationale for decision-making, and specifically whether a child meets the relevant eligibility criteria, clearly documented and clarified as necessary.
• When there is a reported change in circumstances of a child, and/or an application for kinship care allowance is made to the council, or a kinship care order is granted following an application having been made, wellbeing and eligibility assessments should be undertaken in line with relevant legislation and national guidance in relation to kinship care assistance.
• Decisions to award kinship allowance should be based on a robust assessment of eligibility, which take into account a child’s wellbeing and views, circumstances/change of circumstances, and the relevant legislation and national guidance in relation to kinship care assistance.

In relation to complaints handling, we recommended:

• Complaint responses should be informed and accurate, and take account of any relevant legislation and national 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 on behalf of their partner (A) that their initial CT scan was misread and their symptoms misdiagnosed as ischaemic colitis (injury to the colon as a result of reduced blood flow), leading to a delay in treatment and diagnosis of a bowel obstruction. C felt as A’s condition deteriorated, further investigation should have taken place to identify the cause of A’s symptoms.

The board maintained that there was no misdiagnosis as the first CT scan showed the appearance of ischaemic colitis, with no obstruction reported. A was treated appropriately with antibiotics and there was no evidence of deterioration during the period of observation. When A developed symptoms after the reintroduction of food, a second CT scan was ordered and the bowel obstruction identified. The board considered that A had an incomplete or evolving obstruction on admission, which was not picked up by the CT scan.

We took independent advice from an experienced general and colorectal surgeon. We found that while the reading of the scan was reasonable, the failure to consider clinical presentation alongside the scan was unreasonable. We found that this led to a focus on treating ischaemic colitis and no consideration was given to identifying the underlying cause. There was minimal investigation carried out to identify the cause and consideration should have been given to endoscopic investigation, a contrast enema, a colonoscopy and listening to bowel sounds. All would have identified a bowel obstruction, resulting in the correct diagnosis and earlier treatment for A. We also found that as the delay led to A’s deterioration and an increase in treatment, the incident met the Duty of Candour threshold, which the board failed to identify. As such, we upheld C’s complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to A and 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:

• For the board to undertake the Duty of Candour Process. It is important to note that should C or A not wish to meet with the Board in person an alternative way of including them in the process should be explored.
• Staff to be reminded that NEWS and blood tests can appear normal in patients with a bowel obstruction and can deteriorate later.
• Staff to be reminded that scans should not be read in isolation and a patient’s clinical presentation must be considered along with the reason for requesting the scan.
• That staff recognise ischaemic colitis is the consequence of an underlying problem and investigations should continue until a cause is identified.

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

Summary

C complained to the board about the midwifery care and treatment that they received during and following the birth of their baby. In particular, C complained that they had been unsupported during the birth, that their birth plan had not been followed, that the umbilical cord had snapped during delivery and that no meeting had been arranged to discuss the incident despite requesting one. C also complained that there had been a failure to recognise that this had been a traumatic incident for them, and that the board’s response to the complaint had lacked empathy.

The board’s response advised that C had been assisted during the birth, however they apologised that C's expectations had not been met at the time. The board also apologised that it had not been understood that C had intended to use the water pool for pain relief only, and that they did not want to give birth in the pool. In relation to the cord snapping, the board explained that this had been recognised as an emergency incident straight away, but on reflection, the emergency buzzer could have been activated sooner. In terms of communication, the board explained that the circumstances of the birth had been discussed with C by the delivery midwife during a post-natal visit to C's home. When a further meeting was requested, the board said a meeting date had initially been offered by text message which C declined. In hindsight, the board recognised it would have been better to arrange this with C by phone. It was further explained that C had been given contact details to arrange discussion with a consultant in keeping with their request, however C had not gone on to take up that offer.

We took independent advice from a consultant of obstetrics and gynaecology. We found that a minimum standard of care had not been met on this occasion. We noted that key aspects of the medical notes and birth plan had not been read, as C’s preference not to birth in the pool was clearly documented but had not been known by the midwife. In reference to the cord snapping, we found that it can snap spontaneously after either an attended or unattended birth, and in the pool or out. It was difficult to say what this was attributable to the birth, nevertheless bringing the baby above the surface of the water was likely to have been more important than care of the cord. We highlighted that the board’s complaint response had said it was recognised by the midwife that the cord snapping was an emergency incident, however we could see no evidence from the notes of an acute crisis.

In reference to communication, we found that the board had recognised that it would have been better to phone C rather than text them to arrange a time to discuss their concerns. We found that it would have been better for the board to arrange the debrief meeting with the consultant, rather than to expect C to arrange this themselves. On balance, 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 decision notice. 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:

• Midwifery care should be informed by the patient’s records.
• Midwifery care should be clearly and accurately recorded and include reference to any incidents and the actions taken in response.

In relation to complaints handling, we recommended:

• Complaint responses should be clear and fully respond to the issues raised. This should include a full explanation of what occurred and a description of what happened and/or what should have happened at the time.
• The board should offer C a debrief meeting at a mutually convenient time to discuss the events which occurred and to answer C’s questions regarding the circumstances of the birth.

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) who was admitted to hospital with pain, spams and weakness in their right leg which was later diagnosed as being caused by an infection in the iliopsoas muscles (a group of muscles running from the lower spine to the thigh). A is a dialysis patient and had also previously suffered a stroke, leaving them with weakness on the right side and wheelchair bound. C therefore usually supports A with dialysis and medication.

The complaint centres around an incident in the first week of A’s admission when both C and a nurse separately administered A’s evening medication. C stated that they had previously been given the medication by ward staff to support A. C had administered the evening medication and gone out for a few hours. On return, they had found A to be unresponsive. A nurse said that they had also administered evening medication. C complained that this overdose of medication had occurred and that record keeping and incident management had been unreasonable.

We took independent advice from a nursing adviser. We considered that this incident should not have happened, and that it indicated a lack of clarity, process, recording and communication within the ward.

We found that record keeping before and after the incident had been lacking, as there had been no clear record in a person centred care plan to state that the medication was being held and administered by C, that there had been a 24 hour gap in nursing records over the period of the incident and that no extra observations or conversations with a doctor had been recorded following the incident. We found that categorisation and management of the incident had been unreasonable. We upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C and A for poor record keeping. 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 that an extra dose of medication was administered. 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.