Upheld, recommendations

Summary

C complained about the care and treatment provided to their late parent (A). A underwent surgery to treat hypertension (high blood pressure). A few days later, A’s condition deteriorated with the cause thought to be sepsis (a life-threatening reaction to an infection). A’s condition worsened further and they were transferred to the High Dependency Unit (HDU). A died later that day.

C complained that there had been a failure to administer antibiotics that A had required and that there had been unreasonable delays in transferring A to the HDU, which resulted in A being left in a state of distress. C also complained about the conclusions that the board had reached about A’s care following a Significant Clinical Investigation (SCI).

The board stated that A had been monitored every 30 minutes and that there had been no delay in providing antibiotics to A. The board accepted that there had been a failure in communication between nursing and porter staff which had led to a delay in A being transferred to HDU. However, the board considered that this would not have resulted in a different outcome although it was acknowledged that this would have reduced A’s family’s distress.

We took independent clinical advice from an acute medicine and nursing adviser. We found that there were a number of failings in the care provided to A following the initial deterioration in their condition. This included failure to initiate tests to identify sepsis, failure to commence intravenous fluids (medical technique that administers fluids, medications and nutrients directly into a person's vein) and failure to perform necessary blood tests, as had been outlined by A’s consultant. There was also no evidence that A had received antibiotics nor had been monitored with the frequency stated by the board. We also found that nursing staff failed to escalate a further deterioration in A’s deterioration and that there had been an unreasonable delay of around two hours in transferring A to HDU. In addition, we found that several aspects of the nursing records fell below the professional standards required by the Nursing and Midwifery Council and that the board’s SCI had failed to identify areas of learning arising from this case. For these reasons, we upheld this complaint.

Recommendations

What we asked the organisation to do in this case:

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

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

• Significant Clinical Incident reports should:
• (i) be reflective and learning processes that consider events against relevant standards and guidelines,
• (ii) ensure failings are identified and any appropriate learning and practice improvements are made and,
• (iii) be in line with Learning from adverse events through reporting and review - A national framework for Scotland: December 2019 (healthcareimprovementscotland.org)
• Treatment plans should be comprehensive and document the working diagnosis. Patients should receive the treatment plan recorded in the medical records following consultant review unless there is a change of plan. If this happens this should be clearly recorded.
• Where the cause of a patient’s deterioration is suspected to be due to sepsis, the sepsis bundle should be initiated.
• Patients should be assessed, in accordance with the NEWS guidance relative to the patient's NEWS score. Where there is deviation from this, this should be recorded. In addition, patients who are assessed to have a NEWS score of five or greater should be escalated urgently for further assessment in line with NEWS guidance. NEWS scoring documentation should be fully completed and recorded.
• For patients where there is the presence of red flags indicating an ECG, this should be acted on without delay.
• Where blood tests are requested in order to investigate a deterioration in patient's condition they should be processed and reviewed as soon as possible. Patients should receive the appropriate blood tests to adequately assess the cause of deterioration and any tests that have been specifically requested by clinicians.
• Where a deteriorating patient requires to be transferred from the ward for more intensive treatment, the transfer should take place as soon as possible and without undue delay. A record should also be made showing which member of staff has requested the transfer, the time at which the transfer was requested and to whom the request was made.
• Nursing records should be documented in real time, as far as it is reasonably practicable to do so. They should also include a clear timeline of events, the actions taken by nursing staff (including in what order) and details of all communication with relatives and other healthcare professionals.

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 taken by Borders NHS board in relation to diagnosing their child (A) with attention-deficit hyperactivity disorder (ADHD, a condition that affects people's behaviour, including restlessness and impulsiveness). C said that A’s initial referral was rejected and when an assessment did take place it failed to diagnose A’s ADHD. Requests for second opinions were then refused. C said that A was diagnosed with ADHD but not until some years after the initial referral and this was an unreasonable length of time.

We took independent advice from a consultant child and adolescent psychiatrist. We found that while the initial refusal of the referral and first assessment were reasonable, the decision to refuse the request for a second opinion and further assessment was not. This led to an unreasonable delay in diagnosing A with ADHD. As such we upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C and A 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 a request for a second opinion is made and the initial assessment demonstrated some indicators of a developmental disorder e.g. ADHD, then a second opinion should be carried out, particularly for developmental disorders where changes may have occurred in the intervening time period.

In relation to complaints handling, we recommended:

• Responses to complaints should be clear and accurate.

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 how the university handled their complaint that related to their disability and housing. We found that the university's decision to request further information from C about their disability to be reasonable and in line with their policy. We also considered it reasonable that the university asked C for further information about some serious allegations that they had made.

However, we found that the complaint should have been progressed to stage 2 of their complaints handling procedure from the beginning, with the delay of 18 days, which in the specific circumstances here appeared unreasonably inflexible.

On balance, we upheld this complaint as we did not believe it was properly processed and the university's communication with C could have been better.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to progress their complaint through the proper process, at the proper stage. 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:

• The university are aware of the emphasis on them to ensure a complaint progresses through the correct process. We also need to be satisfied that the university are aware of the characteristics of a stage 1 and 2 complaint and finally that they exercise reasonable discretion when a request to progress a complaint to stage 2 is submitted out with the normal time limits.

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 a parent who lives with their partner (B). An allegation was made that C had used physical punishment to discipline their children and the children were removed from C and B's care. C complained that the children were removed without any evidence of wrongdoing on C's part.

We took independent advice from a social work adviser. We found that the reason for the removal of the children was justified on the basis of the evidence available at the time.

However, we considered concerns about the apparent lack of investigation into allegations which were made about B, incomplete forms, and the decision to return the children to C and B's care in advance of the outcome of the case. For these reasons we upheld the complaint.

Recommendations

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

• Staff should complete all relevant sections of paperwork. Staff should reflect on the outcome of this case.

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 deceased grandparent (A) about care and treatment provided by the board during an admission to hospital following a fall and broken hip. C complained that A received poor nursing care, poor rehabilitation support, had not received enough nutrition and fluids, and had developed necrotic (dead) tissue on the back of their heels. C also complained that communication with the family and the incident management response had been unreasonable.

We took independent advice from a nursing adviser. We found that pain relief, personal care and rehabilitation support had been appropriate. However, we found that there was no evidence that assistance was provided with eating and drinking, and that fluid and nutrition charts had been poorly completed. We also found that the pressure sores on A's heels were poorly managed, that there were significant gaps in repositioning and that effective preventative measures were not appropriately implemented.

We found that information given to the family was insufficient and incorrect. We also found that the incident management response was unreasonable, as the necrotic heels were not deemed to be serious avoidable harm and therefore no serious adverse event review or duty of candour was undertaken. We therefore upheld C complaints.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for not offering sufficient support with eating and drinking and for not preventing and treating the pressure ulcers on A's heels appropriately. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.
• Apologise to C for not recognising the seriousness of the incident and the avoidable harm caused. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.
• Apologise to C for providing incorrect and incomplete information about their grandparent'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:

• Nursing staff are aware and correctly implement HIS Pressure Ulcer Prevention Standards 2020 (including introducing 2 hourly repositioning, therapeutic mattress and skin protection at the point that skin becomes red). Nursing staff know how to correctly diagnose and grade pressure ulcer damage (including “ungradeable”), correctly follow CPR for feet guidelines (such that they make timely referral to a Tissue viability specialist) and develop person centred treatment plan for the pressure ulcer. Nursing staff provide relevant handover information and relevant equipment such as therapeutic mattress and boots when moving a patient between wards.
• Nursing staff should ensure that fluid balance and MUST charts are completed to a reasonable standard. The board should also be reassured that they have appropriate processes in place to monitor performance in this area.
• That a duty of candour review is considered in the light of the SPSO findings.

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 sibling (A) had not received appropriate care and treatment from their GP practice in relation to symptoms of an infection. C felt the on-call GP failed to arrange for A to be admitted to hospital and that the practice failed to see and examine A, who died the following day of sepsis (an infection of the blood stream).

C also complained that they were unable to access the practice, and that the practice failed to follow its emergency protocol. As such, C complained that the practice had failed to provide reasonable care and treatment to A. The practice considered the care and treatment provided to A had been reasonable.

We took independent advice from an experienced GP adviser. We found that it was reasonable for the on-call GP not to admit A to hospital as this was a decision for the Scottish Ambulance Service (SAS) to make and paramedics expressed no concerns. It was also reasonable for the practice to not examine A as they had already been assessed by the Out-of-Hours Service, the District Nurse and paramedics.

However, we fund that the practice failed to follow the emergency protocol and C and A were unable to access the practice. We also found that the practice's handling of C's complaint was unreasonable due to the quality of investigation carried out. Therefore, on balance, we upheld these complaints.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to follow the emergency protocol when they attended in person to seek an appointment for 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:

• For SAER's to be carried out within prescribed timescales.
• Patient Problem Lists should be appropriately summarised with major diagnoses and events to be included.

In relation to complaints handling, we recommended:

• For administrative staff to be reminded of their duty of candour.
• For all complaints to be dealt with empathetically and sincere apologies provided.

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 made a complaint about the care and treatment provided to their late spouse (A) by the board. C was concerned that A had sepsis (an infection of the bloodstream) at the time of their discharge. C considered that A would not have died had they remained in hospital.

We took independent advice from a consultant in geriatric medicine (a doctor who specialises in treating older patients) and general medicine. We found that there was a failure to properly assess A's blood and urine test results prior to their discharge. Had this been done, there would have been a greater likelihood that infection could have been diagnosed and treated prior to A's discharge from hospital. Although A may still have died had they remained in hospital, this could have given A a better chance of surviving their illness.

We found that there were failures in communication with A's family. A's family should have been provided with 'safety netting' advice about repeating A's temperature or looking for other potential signs of infection once A had returned home. We also found that there were failings in the board's handling of C's complaint. The board's own complaint investigation did not include all relevant staff for comment, the response was brief and did not provide fully accurate information in relation to A's condition.

In light of the above, we found that the board 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 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:

• Patients whose test results are suggestive of an underlying infection should be fully and appropriately investigated, in line with recognised guidelines. When a patient is discharged, appropriate 'safety netting' advice about worsening condition should be provided.

In relation to complaints handling, we recommended:

• The board's complaints handling system and their investigation should ensure that relevant staff have the opportunity to comment, that complaint responses appropriately address the issues raised and are accurate and that failings (and good practice) are identified, and enable learning from complaints to inform 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 about the care and treatment provided to their late spouse (A) by the board while they were an in-patient at hospital. During A's admission they were diagnosed with stage 4 cancer and COVID-19. A died of COVID-19 in hospital.

C complained to the board about A's care and treatment. C also complained about communication with A's family. The board apologised for aspects of their communication, but did not identify any failings with A's care and treatment. C remained unhappy and asked us to investigate.

C complained about the care and treatment A received for COVID-19 and about the communication A's family received regarding their COVID-19 diagnosis. C complained that the board had failed to adequately investigate the complaint and had failed to adequately investigate how A caught COVID-19.

We took independent advice from a general medicine adviser. We found that aspects of the care A received after their COVID-19 diagnosis, along with aspects of the board's communication with A's family regarding A's COVID-19 diagnosis and treatment were unreasonable. We also found that the board's response to C's complaint contained inaccuracies and that there was a lack of detail. We found that the response failed to adequately address, from a medical perspective, the concerns C had raised, in particular, in relation to A's COVID-19 diagnosis. We upheld C's complaints.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C and their family for the failure to provide A with reasonable care and treatment, failure to adequately investigate C's complaint and for failure to communicate adequately with C about A's COVID-19 infection. 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:

• DNACPR forms should be appropriately completed by staff who should ensure its implications are discussed with and fully understood by the patient and/or family members at the time of completion. When a patient tests positive for COVID-19, in particular where they have other serious underlying illnesses, a detailed medical review of the patient should be carried out as soon as possible. The reasons for treatment decisions should be clearly documented on a TEP. Prompt consideration should be given to closing a ward where an outbreak of COVID-19 occurs.
• Patients families should receive clear explanations, and be provided with appropriate information that addresses their concerns when responding to complaints.
• Communication with patients and/or their families should be proactive and timely, especially in relation to a serious diagnosis. Where discussions have taken place they should be 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 provided to their parent (A) by the practice. Over a period of several months, A and/or family members had multiple contacts with the practice. A started to physically decline more rapidly and was experiencing severe pain which was presumed to be from a prolapse (a displacement of a part or organ of the body from its normal position).

Shortly afterwards, there was a more acute clinical deterioration and an Out-of-Hours medical assessment concluded that A was terminally ill and in need of end-of-life care. There were subsequent assessments by the practice and discussion on best management. A's care was continued at home with general practitioner (GP) and district nurse involvement until A's death.

We took independent advice from a GP adviser. We found that there were occasions where a face-to-face review or examination of A would have been appropriate, or where a more comprehensive assessment of the history and more detailed management discussion would have been reasonable.

Whilst a number of the reviews and adjustments of medication made by the practice were reasonable, we found that there was a lack of medication review on two occasions.

We found that the documentation of the consultations was often lacking in detail and that there was little history or clinical findings to support clinical decisions taken. On some occasions, consultations were not documented at all. Overall, we upheld the complaint that the practice failed to provide reasonable care and treatment to A.

Recommendations

What we asked the organisation to do in this case:

• Apologise to 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 www.spso.org.uk/information-leaflets.

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

• Consideration should be given to assessing elderly patients with confusion face to face following communications about a deterioration in their condition and any decisions should be recorded. If a decision is taken not to assess a patient in this way, the reasons for this should be recorded.
• Consideration should be given to examining patients following communications about a deterioration in their condition and any decisions should be recorded. If a decision is taken not to assess a patient in this way the reasons for this should be recorded.
• Pain medication should be appropriately reviewed to see if it is adequately working.
• Patients should be given timely, clear and accurate information about the management options for their condition.
• The position in relation to referrals to other specialist services should have been discussed in a timely way without delay.
• The practice should ensure the standard of record keeping meets General Medical Council Good Medical Practice standards.

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 from the board. A was admitted to hospital and later discharged into a care home. C complained that during A's admission to hospital, communication with the family was very poor. Despite numerous requests for a call from clinical staff, no contact was made and the family were left with very little information as to A's condition or the treatment that they were receiving. C complained that as a result of this the family did not have sufficient information to make informed decisions about A's care. C said that they could see that A's health was declining. A died a few days later.

A's discharge notes recorded that they had vascular dementia (a condition caused by the lack of blood that carries oxygen and nutrient to a part of the brain. It causes problems with reasoning, planning, judgment, and memory), significant cognitive impairment, and lacked capacity for health and welfare decisions. C highlighted that A's hospital records made no mention of a dementia diagnosis and that this was never discussed with the family. C questioned whether A's capacity to consent to changes in their medication and about treatment was properly assessed.

C complained about poor communication from the clinical team and about the assessment and treatment of A prior to the decision to transfer them to the care home. C said that, had the family known the extent of A's deterioration, they would have arranged for them to be cared for at home, rather than in the care home.

In their response to C's complaint the board acknowledged C's concerns about not speaking with clinical staff. They said that attempts were made for A to be assessed by a Mental Health Liaison Nurse but that this was not possible due to A's level of distress. A was deemed medically stable for discharge to a care home. C was dissatisfied with the board's response and brought their complaint to our office.

We took independent advice from a consultant geriatrician adviser (an expert in the health and care of older adults). We found that A was initially appropriately assessed for capacity to make decisions but that this was not appropriately reviewed during their admission. Further reviews could have resulted in further investigations of A's condition. As a result, we found that the assessment and treatment of A was unreasonable.

With respect to the assessment of A prior to discharge, we found that discharge went ahead without proper consideration of their condition at the time and was therefore unreasonable. We upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• 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/informa.on-leaflets.

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

• The board should provide us with a full and detailed update as to the outcome of the reviews outlined in their action plan and any resulting changes to policies or procedures.

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.