Upheld, recommendations

Summary

C complained that the practice failed to refer them for an x-ray following a fall, which contributed to a delay in diagnosing fractured vertebrae.

C attended A&E following their injury and then attended the practice a few days later (first consultation). C then had a GP telephone appointment the next day due to ongoing pain (second consultation), and subsequently attended the practice again in person some weeks later (third consultation). C complained that their symptoms were not fully investigated and an obvious bend in their neck was overlooked.

We took independent medical advice from a GP. We found that the practice’s actions at the first and second consultations were reasonable in relying on the outcome of the recent A&E assessment, and that an onward referral for x-ray imaging was not indicated at that point. We found, however, that C’s ongoing pain should have been considered persistent by the time of the third consultation, and that their spinal tenderness should have been regarded as significant. We found that these symptoms should have been regarded as ‘red flag’ symptoms (possibly indicative of a more serious pathology), and should have triggered onward referral for imaging assessment.

Instead, C was referred for physiotherapy following the third consultation. C subsequently contacted the practice on a fourth occasion to request that this referral be expedited. A GP received this message and concluded that C did not meet the criteria for an urgent referral. The GP did so without taking a history and/or examining C. We found that it was unreasonable to make this decision without evidence. If an examination had been arranged following this fourth contact by C, it may have given rise to an x-ray referral.

We concluded that the practice unreasonably missed opportunities to refer C for an x-ray at the third consultation, as well as at the time of C’s subsequent contact regarding the physiotherapy referral. On balance, we upheld this complaint. We noted the practice had already reflected extensively on their management of C and identified things they would do differently in future.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to refer them for further investigation following the third consultation, and for concluding that they did not meet urgent referral criteria without taking a history or examining 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:

• Patients should be referred on for appropriate investigation when they present with red flag symptoms. The practice should ensure that they follow relevant guidelines and that they are aware of and alert to red flag symptoms.

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 end of life care that their partner (A) received at home from district nursing services during the final weeks of their life.

C complained that the nurses did not listen to their concerns about A’s deteriorating condition, that A’s condition was not adequately assessed and managed, and that they were not included in discussions about A’s care. C considered that there were missed opportunities to admit A for earlier hospice care.

We took independent advice from an advanced nursing practitioner. We found that the care provided to A was generally in line with recognised practice for end of life care, with review and prompt action around pain control and symptom management. However, we found that there were significant gaps in communication and clinical assessment which impacted on the care delivered to A.

While the nurses recorded C’s reported changes in A’s condition, this did not appear to have prompted any specific action or investigations. We found that there was a lack of clinical examination, and a failure to check and act upon C’s reports of excessive fluid in A’s legs. The board acknowledged that there was a failure to monitor A’s baseline observations when they began to deteriorate, and we found it concerning that this did not happen. The board also accepted that communication with A and C could have been better managed and they committed to raising this with staff. As A’s main carer, we noted that C’s views should have been central to care planning and to ensuring that the care being provided remained suitable as A’s condition changed. We found that there was an unreasonable failure to act upon C’s concerns and consider whether a need for hospice care was indicated. We therefore 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:

• Patients receiving end of life care at home should be appropriately assessed and monitored in line with their symptoms and any deterioration acted on. Patients and their carers should be communicated with effectively and their views appropriately taken into account.

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 appropriate care for their parent (A).

C said that the lack of care resulted in A falling from their bed, while the bedrails were in place. As a result, A fractured their hip. C said that staff had been made aware that A was confused a very disorientated at the time.

We asked the board to provide an explanation as to how A was able to fall from the bed if bedrails were in place. The information provided by the board showed that A had been found trying to get out of bed on two previous occasions. This led us to question what interventions were put in place to try and prevent a fall from happening and why this appears not to have been successful.

We took independent advice from a nursing adviser. We found that the lack of a proper assessment of A’s mental capacity and their previous attempts to climb out of bed contributed to the fall incident and that this was a significant oversight. Additionally, we found that the board failed to maintain accurate and appropriate records, particularly in relation to the 4AT (Rapid Clinical Test for Delirium Detection), on the two occasions that A was found trying to get out of bed, and the fall itself. We therefore 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 reassessed when there is a change in their behaviour and, if bedrails are in use, consideration given to carrying out a reassessment of their use.
• Patients over 65 should be assessed in line with the board’s admission procedures including a 4AT so that a full assessment of the patient risk is achieved.

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 taxi driver, complained about the way the council had handled their medical examination which they were required to attend to determine their fitness to DVLA Group 2 medical standards (medical standards for driver licencing refer to two groups, with Group 2 licence holders usually requiring substantially higher medical standards).

C had passed the medical examination pending the results of an Exercise Tolerance Test (ETT). However the council did not follow up on the results of this test. As such, C was unaware until their next medical some years later that their ETT had met the threshold for referral to DVLA for further consideration of their fitness to drive. C had continued to work as a taxi driver throughout this time. On recognising this oversight, C’s taxi licence was suspended to be later re-instated after an assessment undertaken by an NHS cardiologist (heart specialist) was reviewed by the council’s occupational health provider and they were considered fit to drive. In complaining to the council, C was advised the matter would be investigated internally and no further response was received, despite their requests for further updates.

We found that the council’s administration of C’s medical examination was unreasonable, noting that the ETT results had not been followed up on as they should have been, and that this oversight had not been noticed until C’s next medical examination some years later. Therefore, we upheld C’s complaint.

We found failings with the council’s complaint handling, noting they had not fulfilled their duties in keeping with the Model Complaint Handling Procedure for local authorities. Therefore, we also upheld this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to process their taxi driver licence application reasonably and for failing to reasonably respond to their complaint. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

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

• The council should ensure the status of driver licences pending further medical tests are checked to ensure they remain valid.

In relation to complaints handling, we recommended:

• Complaints should be accurately identified and dealt with through the 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 late adult child (A). A had been admitted to hospital from police custody due to cellulitis in their hand. A was monitored overnight and discharged the following day. A was readmitted several days later following a cardiac arrest. On resuscitation, a cannula (a tube that can be inserted into the body, often for the delivery or removal of fluid or for the gathering of samples) was found in A’s arm dated the day of their initial admission. A’s condition deteriorated and they died a few days later.

C was concerned that A’s mental health issues were not taken into consideration and that it had been unreasonable to discharge A without these being assessed. C also believed it was unacceptable for A to have been discharged with a cannula in place given A’s known drug misuse. C believed that these failings led directly to A’s death as they had used the cannula to administer drugs immediately before suffering a cardiac arrest.

The board had carried out an Adverse Event Review (AER) following C’s complaint. This found a number of failings in A’s care. It made recommendations to try and address these.

We took independent medical advice from a consultant in emergency medicine. We found that there had been a full investigation of the case. The key learning points had been identified and actions were being taken to reduce the likelihood of a similar incident occurring in future. There was no evidence of failings which had not been addressed by the AER.

We upheld C’s complaints due to the acknowledged failings in A’s care.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failings in the care and treatment, and discharge processes, in relation to A’s admission to hospital. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

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

Summary

C complained to the board about the care and treatment provided to their late parent (A) regarding hip problems they suffered.

A was admitted to hospital with worsening mobility having suffered a number of recent falls. Under the care of older people’s services they were reviewed by occupational therapy and received physiotherapy, before being moved to another hospital for rehabilitation. A month after being discharged, A was readmitted and underwent an X-ray CT scan. A was initially diagnosed with a broken femur. A underwent hip replacement surgery and passed away a month later.

C complained that despite being informed by the board that A had sustained a fracture of their right femur, possibly present some years prior, they were later told that A had not sustained a fracture. Nevertheless, A’s death certificate had recorded a fracture of the right femur as one of the causes of death. This confusion caused the family significant anxiety. In their complaints response the board concluded that junior medical staff had been responsible for misdiagnosing A and apologised for the miscommunication. They also apologised for the misdiagnosis having been included on A’s death certificate.

We took independent advice from a medical adviser with expertise in orthopaedics (treatment of diseases and injuries of the musculoskeletal system), and further advice from a radiologist (specialist in diagnosing and treating disease and injury through the use of medical imaging techniques such as x-rays and other scans). We found that while A did not have a broken femur, the board had failed to act upon a CT scan taken some years previously that showed A was suffering from significant arthritis which therefore went untreated over the subsequent years. Additionally, the board had emphasised the role of a junior doctor in misdiagnosing the fractured femur despite the involvement of more senior management in signing off on this diagnosis. In view of these specific failings, 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:

• Care should be taken by staff to ensure that patient records are correct and as full as they can be. Where discussions have taken place what was said should be documented. A’s case should have been discussed at the board’s Radiology Events and Learning Meeting (REALM). If this had not happened they should happen in order to highlight the importance of reporting significant osteoarthritis as an incidental finding, if it has not been depicted on prior imaging.
• The board’s complaint handling monitoring and governance system should ensure that complaints are appropriately investigated and that failings (and good practice) are identified and learning from complaints are 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 provided their late parent (A) with inadequate care and treatment when they were an in-patient in hospital.

C complained to the board that they had failed to provide A with adequate personal care, nutrition and hydration. C also complained that the board had failed to accommodate A’s disabilities. The board identified failures in A’s care and apologised for these. C remained unhappy and brought their complaint to us.

We took independent advice from a consultant geriatrician (a specialist in medicine of the elderly). We found that more consideration should have been given to A’s minimal fluid intake, and the impact of this in terms of delirium and escalation to medical staff. In addition, we found that it appeared that more could have been done to support A in relation to their toilet needs.

Therefore, we upheld the complaint.

Additionally, we found that the board did not provide C with sufficient explanations related to the learning and improvement taken from A’s experience. We also found that the board had delayed in providing C with copies of minutes from a meeting and that no appropriate apology had been made for this. We made recommendations in light of these failings.

Recommendations

What we asked the organisation to do in this case:

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

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

• Where a meeting with a complainant is held to discuss their concerns, the meeting should try to ensure that full explanations of what occurred and of any learning and improvement action being taken as a result are provided to the complainant at the time. Following up on a meeting with a copy of the minutes of that meeting and the board’s final response letter should be issued to the complainant as soon as possible thereafter.

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 submitted objections to an application for the erection of a house close to the boundary of their property on the grounds of overlooking. The council produced a report of handling which included their responses to C’s concerns. The application was approved subject to conditions including a condition relating to the interests of C’s residential amenity. When the development was begun, C was concerned that the overlooking issue remained. C contacted the council advising of their concerns and the council requested the relevant condition to require a fence to be erected along part of the boundary line. C raised complaints with the council highlighting specific concerns with the report. The council responded advising that they considered the report had given reasonable consideration to the matters raised.

We took independent advice from a planning adviser. C complained that the report contained material errors and grossly understated the extent to which their property would be overlooked. We found that certain key information was not included in the council’s assessment of the potential for overlooking, that insufficient attention was given to the height difference between the two properties and the close proximity of C’s property to the proposed house, and that the assessment of the existing vegetation and trees was inaccurate and that these could be considered a material error in the report. We found that available evidence should have highlighted to the council that there would be significant overlooking from the proposed house and that measures should have been taken to mitigate this either through conditions to retain the natural screening, or changes to the positioning of the proposed house. We also found that the requirement to build a fence was unlikely to address all of the overlooking issues. We found that overlooking from the proposed house was foreseeable and that the report failed to recognise this or to include measures to mitigate the impact on C’s residential amenity. We upheld C’s complaints.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C that the Report of Handling contained material errors and failed to recognise the extent to which the proposed house would overlook C’s property. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.
• Contact C with a view to discussing and implementing further measures to mitigate the overlooking from the proposed house.

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

• That the council review this case with their planning service and consider ways of improving the scrutiny of reports prior to their sign off.

Summary

C complained on behalf of their client (B) about the care and treatment provided to B’s late sibling (A). A had attended the A&E in mental distress, had attended their GP the same day, and had a hospital appointment with the crisis team a few days later. At this appointment it was considered that hospital admission was not required. A completed suicide a short time later. B felt that the board had failed to provide reasonable care and treatment to A.

We took independent advice from a mental health nursing adviser. We found that the board had carried out a detailed review of A’s care and had taken some action which was reasonable. However, we found that the risk assessment carried out by the board when A presented at A&E lacked transparency and rigour. The assessment carried out a few days later provided more detail, however, it lacked a structured risk assessment and the clinical reasoning behind not offering any ongoing planned follow-up and the weighing of current and historical risk indicators against protective factors was not fully transparent. The record keeping of the risk management decisions was also not sufficient to show the way in which risks factors and protective factors were balanced. We also found that it was unreasonable that the board’s administrative systems resulted in an erroneous early diagnosis of borderline personality disorder being recorded. We found that the Adverse Event Review process did not appear to attempt to establish why things occurred as they did, rather than simply establishing what occurred. Therefore, we upheld the complaint

Recommendations

What we asked the organisation to do in this case:

• Apologise to A’s family for failing to provide reasonable care and treatment 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:

• Processes for risk assessments should ensure that information is gathered from all professional and non-professional sources, and that decision-making is a transparent, structured process based upon best possible evidence.
• The AER process should explore the influence of factors such as systems and processes, supervision, team-working, management decision-making, patient factors, resources, training, and policies / protocols in order to establish why things occurred as they did.

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 sibling (A) by the practice. A had previously been diagnosed with breast cancer a number of years ago. A became ill and attended the practice on several occasions over the year. The GP considered A had gastroenteritis (inflammation of the stomach and intestines). A’s symptoms persisted and A was referred to hospital for a colonoscopy (examination of the bowel with a camera on a flexible tube). The request was rejected. A presented at the practice with the same symptoms on two further occasions and the practice made an urgent ‘suspicion of cancer’ referral to the health board. A scan showed a tumour attached to A’s right kidney. A died some months later.

C complained that despite A’s multiple attendances at the practice and concerns that the cancer had returned, the practice failed to reasonably respond to A’s worsening condition and delayed or failed in carrying out appropriate investigations and associated tasks.

We took independent advice from a GP adviser. We found that initially there was no unreasonable delay in the practice recognising the seriousness of A’s symptoms and that the appropriate referrals for a colonoscopy and ultrasound scan (a scan that uses sound waves to create images of organs and structures inside the body) were made. We also noted that it would not have been appropriate for the practice to have undertaken a CEA blood test (carcinoembryonic antigen test, a blood test used to help diagnose and manage certain types of cancers) and that the actions of administrative staff in filing away test results was appropriate and in line with established good practice.

However, we found that there was a failure to include clinically important information in referrals and in consultation documentation, and that there was a delay in sending A’s suspicion of cancer letter. We also found that the practice should have considered undertaking some additional blood tests when it was clear A was deteriorating, or documented the awareness of any blood tests undertaken by the hospital during this period. Therefore, on balance, we upheld the complaint.

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:

• Appropriate and timely blood tests should be considered when it is clear a patient is deteriorating in cases similar to A’s or awareness of any blood tests undertaken e.g. by hospital documented.
• Notes of consultations should include appropriate detail including a description of the length and progression of symptoms along with any potentially relevant past history.
• Referral letters should include a clear history, examination and relevant background 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.