Upheld, recommendations

Summary

C complained to us about the care and treatment that they had received from their GP practice. C told us that the practice had failed to carry out appropriate prostate specific antigen (PSA) testing after they found out that C was at increased risk of prostate cancer genetically. They told us that after an initial test, which was normal, there was a delay of around four years in carrying out a further test, at which time the test showed elevated results and they were subsequently diagnosed with cancer. C considered that this delay had a considerable impact on their prognosis, as their cancer had by that time spread, which they had been told was unlikely to have been the case had they been diagnosed earlier.

C also complained that the practice had failed to appropriately respond to their concerns about this, both in the way that they had investigated the concerns, and the manner in which they had responded, which C had found to be uncaring.

We took independent advice from a GP adviser. We found that the practice had failed to handle C's testing appropriately. In particular, that they unreasonably assessed that regular testing was not required based on guidance intended for those not at increased genetic risk and that they unreasonably failed to seek further advice and clarity from specialist services on the request to consider regular testing. We also noted that when the test was subsequently agreed as part of other blood tests, this was missed in error, and they then failed to identify this had been missed or notify C, leaving them with the impression that this had provided normal results.

Therefore, we upheld C's complaint that their testing had been mishandled.

Our investigation also found that the practice had not responded reasonably to C's concerns, as the Significant Event Analysis (SEA) they carried out was not of a reasonable standard, and they had failed to provide appropriate apologies for the failures that were identified by their own investigations.

On this basis, we also upheld C's complaint that the practice had not responded reasonably to their concerns.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to provide appropriate PSA testing. 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 failing to respond reasonably to their concerns. 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 practice should appropriately consider the results of any tests requested to ensure that they are fit for the purpose they were requested for.
• The practice should ensure that there is clarity around any request received from secondary care services that they choose to accept.
• The practice should provide appropriate screening for any patient at increased risk of developing cancer.

In relation to complaints handling, we recommended:

• All complaints should be processed in line with the Model Complaints Handling Procedure and any apologies offered in complaint responses should meet the terms of the guidance on apology.
• All SEA (Significant Event Analysis) investigations should include an assessment of whether the treatment provided was of a reasonable standard, and a consideration of the root causes of any failings 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 that there had been an unreasonable delay in their late parent (A) receiving a prescription of antibiotics following a consultation with an out-of-hours GP from the unscheduled care service, operated by the board. During the consultation, the GP considered that A had developed a lower respiratory tract infection (an infection of the lungs), which should be treated with Co-amoxiclav (a type of antibiotic). However, the GP had attended the consultation without a prescription pad and did not carry the medication in their vehicle. The GP subsequently arranged for A's prescription to be faxed to a pharmacy on their return to base to be provided to A the next day. However, the pharmacy to which the prescription had been faxed was closed the following day due to a public holiday, which resulted in a delay of 48 hours before the prescription could be provided to A.

In response, the board apologised that the GP had attended the consultation without a prescription pad and for the distress that this had caused A and their family. The board stated that it could not explain why the GP had attended without a prescription pad but had reminded staff in a monthly update to ensure that prescription pads were checked prior to carrying out home visits and that prescriptions were only faxed to pharmacies that could provide medication in a timely manner. The board also confirmed that it was in the process of developing a checklist system and a written policy and protocol specifying the checks that staff were required to complete at the start of each shift prior to commencing home visits.

We took independent advice from a GP. We found that it had been unreasonable for the GP to attend the consultation without a prescription pad and to fail to ensure that the antibiotics A required were available to them sooner based on A's presentation at consultation. We also considered that the reminder provided by the board to staff was insufficient to ensure that a similar occurrence did not happen again. However the checklist system and written policy and protocol the board had indicated it was developing was likely to be appropriate to address the issues arising in this case.

For these reasons, we upheld C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to provide A with reasonable care and treatment. 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:

• Out-of-hours GPs should be in possession of all required equipment prior to the commencement of each shift. In addition, where a patient's clinical presentation requires medication to be prescribed, out-of-hours GPs should take all reasonable steps to ensure that there is likely to be no undue delay in the prescription becoming available to the patient.

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 had a wisdom tooth extracted by the board. Subsequently C experienced an altered sensation in their tongue and was advised that this was likely the result of nerve damage, which was a possible side effect of the extraction of a wisdom tooth. C complained that they were not advised of this possible side effect prior to the extraction taking place. A handwritten note on the consent form C signed included mention of altered sensation but C disputed that this had been present when they signed the form.

We took independent advice from a dentist. While evidence gathered as part of our investigation could not definitively determine which of these positions was most accurate, we considered that based on the available evidence, the board did not make C reasonably aware of why the extraction was considered necessary, what the risks and benefits of extraction, alternative treatments or no action were, what the percentage likelihood of nerve damage was or what 'altered sensation' meant. Therefore, we found that the board did not reasonably advise C that nerve damage was a possible side effect of the extraction of a wisdom tooth as required and upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to reasonably advise that nerve damage was a possible side effect of the extraction of a wisdom tooth. The apology should make clear mention of each of the points the board did not make C reasonably aware of. 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 are provided with clear information of the nature of the proposed dental treatment, the purpose of treatment, the risks and benefits to treatment in comparison to no treatment and any alternative treatment options, and valid consent is obtained and recorded in line with the General Dental Council's Standards For The Dental Team Principles.

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 they received following their hip replacement surgery. Immediately following the surgery, C began experiencing severe and continual pain. The cause of C's pain was eventually confirmed to be loose cement from the surgery causing irritation. C complained that, although the surgeon who had carried out their hip replacement was aware of the loose cement, this was not conveyed to C. Instead, C had consultations with a total of five consultants before the source of their pain was identified two and a half years after their surgery and remedial treatment successfully provided.

C raised a number of concerns regarding the attitude shown towards their symptoms by the board's consultants and the delays to diagnosing and resolving their pain.

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 C's surgery was carried out reasonably and that there was no immediate indication of the complications that they would subsequently experience. We noted that it is not uncommon for patients to experience pain for up to 12 months following a hip replacement. We were generally satisfied that the board's staff took C's pain seriously and carried out reasonable investigations to establish its cause. We also noted that leaked cement is not uncommon and would not initially be viewed as a likely source of a patient's pain.

We considered that the complications C experienced were extremely rare and required specialist intervention. We found that it was not until an x-ray taken a year after surgery that it became apparent that a large amount of cement had leaked from the surgical site and a later MRI scan identified that C had a degree of psoas tendinopathy (an inflammation of the tendon or area surrounding the tendon).

Whilst we were satisfied that the clinical team followed a reasonable path to establishing and treating the cause of C's pain, we were critical of the time taken to conduct a CT scan following the MRI scan and of the time taken to provide surgery to resolve the issue. Therefore, we upheld C's complaint on that basis.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the unreasonable delays during the diagnosis of and in arranging the treatment of C's postoperative complications. 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 board should arrange for this case to be presented at a local clinical governance meeting (with radiologists present) where the case and imaging should be reviewed.

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 treatment that they received from the Golden Jubilee National Hospital. C had surgery to address a non-union of the bones in their mid-foot. Just under a year after their surgery, C submitted a complaint to the hospital, noting that the surgery had failed and that they required a second operation due to the non-union of the affected joint in their foot. C said that they accepted that non-union was a known risk of this surgery. However, having reflected on their experience and having discussed their case with another orthopaedic specialist (a specialist in the treatment of diseases and injuries of the musculoskeletal system), C believed that the care provided by their consultant was inadequate and may have been a contributing factor in the failure of their surgery.

We took independent advice from a consultant orthopaedic surgeon. We found that, whilst there was some confusing communication as to the type of surgery that C would undergo, the consultant's choice of procedure was reasonable and the reasoning behind it was valid. C's case was not straightforward due to a previous failed fusion surgery. We were satisfied that the clinical treatment provided was reasonable and that the actions of the board's staff did not contribute to the failure of the joint to fuse.

However, we were critical of the board's decision to discharge C before it was clear that their surgery had been successful. Whilst the outcome would not have been any different for C surgically, ongoing monitoring and review would have allowed for potential issues to have been identified sooner and for the clinical team to have had discussions with C regarding the status of their fusion and their ongoing treatment options. Overall, whilst we found that the clinical care and treatment was reasonable, we were critical of C's early discharge and the quality of the communication from the clinical team. Therefore, we upheld C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the issues highlighted in this decision. 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 Golden Jubilee National Hospital should share this decision with their orthopaedic staff with a view to identifying ways that they can improve the care and treatment provided to future patients.

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). A had Alzheimer's disease (the most common cause of dementia) and C had a full power of attorney (POA) in place that was active at the time. This enabled C to make decisions about A's welfare.

A was admitted to Forth Valley Royal Hospital via the acute assessment unit, and was later transferred to a ward. C said that when admitted to hospital A was continent, could walk with a stick, slept through the night, and was eating and drinking. C said that the board made inappropriate changes to A's medication during their admission, and that, when later discharged, A had lost weight, was not eating and drinking, was very frail and could not stand up, and was doubly incontinent. C also had concerns about the way A was treated and spoken to by nursing staff, and that they were discharged with a very large pressure ulcer.

The board apologised for the way in which A was spoken to and treated by nursing staff and that the staff involved have received training and would be monitored going forward. The board also said communication with family members was not documented as it should have been.

The board said it would be expected for A's weight to reduce as they lost excess fluid. They explained that there was a change in A's appetite during their admission, however acknowledged that a referral to a dietician should have been made in light of this change in A's appetite.

The board said that A's mobility was at one point assessed as unsafe, but later it was recorded that A could mobilise with a walking frame. A's continence was recorded as variable during their stay and that A would often get up and mobilise to the bathroom.

In relation to A's pressure ulcer, the board said that A had pressure damage to their sacrum (lower back) on admission to the ward and that it was documented regularly over A's admission.

We took independent advice from a consultant geriatrician (a doctor who specialises in medicine of the elderly) and a nurse. We found that the medical care and treatment provided by the board, including changes in medication, was reasonable. However, the overall nursing care, and particularly the record-keeping, was unreasonable. We also found that the board did not communicate reasonably with C about A's care, discharge, or their ongoing needs

Therefore, we upheld C's complaints.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failures which the board have not already offered an apology for in previous correspondence. 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:

• Communication with those with POA should be of a reasonable standard. When a patient has been assessed as not having capacity, POA holders should be included in discussions and arrangements for a patient's care and discharge. The board should follow their process for assessing capacity including obtaining a copy of the POA paper work and keeping it within the clinical record of the patient.
• Patients with increased confusion should be appropriately assessed in line with Healthcare Improvement Scotland guidance and relevant records (such as the TIME bundle) completed as appropriate.
• Pressure ulcers should be assessed and appropriately graded, in line with the board's guidance for pressure care management.
• Records should be accurate and up-to-date. All charts should be completed appropriately and consistently. Patients who are experiencing issues with continence should receive appropriate support. Fluid balance charts and care and comfort checklists should be utilised to help support effective management of incontinence.
• The board should communicate with family members regularly and effectively, and the detail of conversations should be recorded. Families, where appropriate, should be involved in the discharge planning process, especially for people with a diagnosis of dementia.

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 child (A) received from a dentist at the dental surgery. C raised a number of concerns, including that the dentist failed to detect decay in A's tooth and provide appropriate treatment for this, and failed to carry out a radiograph (a type of dental x-ray) on A's tooth sooner.

We took independent advice from a dentist. We found that the dentist failed to record the presence of a mark on A's tooth during their third appointment, assess if there had been any deterioration of that mark, carry out further investigations and carry out radiographs at an earlier stage. We also found that the dentist's notes had extremely limited detail added and were below the expected standard. Given the failings in the detection and treatment of the decay in A's tooth and in carrying out a radiograph sooner, we upheld C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to A and C for failing to record the presence of the mark on A's tooth, assess if there had been any deterioration of that mark, carry out further investigations and carry out radiographs 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:

• In cases of this type, dentists should assess if there have been any deterioration of marks on patients' teeth and carry out further investigations, as 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 about the board regarding the care and treatment provided to their late parent (A). Following a diagnosis of bladder cancer, the board identified that A would require heart surgery before they would be fit enough for bladder surgery. They referred A to another health board to provide that surgery, but this took a number of months to arrange and carry out. C told us that, by the time the heart surgery was completed, A's cancer had progressed to a point where treatment was no longer possible.

We took independent advice from an oncology consultant (a doctor who specialises in the diagnosis and treatment of cancer). We found that the board failed to identify radiotherapy as a possible alternative treatment, despite this advice being given by their oncology team. In addition, we found that the board had mishandled the referral to the other health board for heart surgery, failing to ensure that the other board were made aware of the urgency required. Then, when there were inevitable delays in surgery as a result, the board failed to identify that the window for treatment was closing.

For these reasons, we upheld C's complaints.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to provide A with a reasonable standard of cancer treatment. 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:

• A full range of treatment options should be considered when deciding on a treatment plan, and reconsidered if the viability of the original plan changes.
• All referrals made to other boards for treatment should include full details of any time sensitivity around treatment. Where it is unclear if treatment can be provided quickly enough, direct communication should occur between the relevant teams to explore this and alternative treatment options.

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 their parent (A) received from district nurses in relation to the management of sores/ulcers on their legs while resident at a care home. In particular, C complained that district nursing staff had failed to adequately monitor and treat A's sores/ulcers to such an extent that dressings would become saturated in exudate (fluid), requiring care home staff to apply further dressings. C stated that this had led to A developing significant infection requiring admission to hospital, where they died a short time later. C further complained that district nursing staff had failed to identify the deterioration in A's legs and had not alerted A's GP nor made a referral to a specialist tissue viability practitioner (a specialist in aspects of skin and soft tissue wounds including acute surgical wounds, pressure ulcers and all forms of leg ulceration).

In response to C's complaint, the board stated that A had been reviewed frequently by district nursing staff, who had not identified any signs suggesting that A's legs had become infected. The board concluded that district nursing staff had delivered consistent and appropriate care and that referral to a tissue viability specialist had not been indicated.

We took independent advice from a district nursing adviser. We found that there were a number of failings in relation to how A's sores/ulcers had been managed, specifically that wound assessments carried out were incomplete and not carried out at the required frequency and that the wound dressings used were inappropriate, often contradicting the findings of examinations, and contrary to current guidelines. We noted that district nursing staff had failed to carry out baseline observations and tests to check for the presence of infection or sepsis (blood infection) despite noting that A was as “flat” and “lethargic”. We also found that the district nursing staff's record-keeping was poor and not in accordance with relevant professional standards given there was no documented record of interactions with A on certain dates.

For these reasons, we upheld C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to provide A with reasonable care and treatment. 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 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. The board should comply with their complaint handling guidance when investigating and responding to complaints.

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 council failed to reasonably respond to reports of anti-social behaviour that C had made against their neighbours. C felt that the council had not taken their concerns seriously and that they had been passed around between staff members with no one taking a lead role or responsibility for handling their concerns.

We found that the councils procedures and processes for investigating anti-social behaviour were detailed, robust and good practice approaches to handling reports of anti-social behaviour. However, the council failed to provide evidence that these processes had been considered or followed in their handling of C's reports, and made no reference to the specifics of those procedures in their responses to C's complaints or our investigation.

As such, we upheld C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to reasonably investigate and respond to their reports of anti-social behaviour. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.
• Carry out an interview with C under Stage 1 of their process, to ascertain what problems, if any, they are still experiencing, and action those through the remaining stages of the anti-social behaviour procedures, as appropriate.

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

• The council should follow their anti-social behaviour procedures when handling all reports of anti-social behaviour, and clear records should be kept of all steps 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.