Upheld, recommendations

Summary

C complained about the standard of medical care and treatment provided to their late parent (A) during an admission to Queen Elizabeth University Hospital (QEUH). A was admitted to QEUH with worsening symptoms of a chest infection and a leg ulcer. When A’s condition deteriorated, medical staff decided to transfuse three units of blood. During the transfusion, A went into cardiac arrest and died. C complained that the decision to transfuse A with blood was unreasonable given their condition and symptoms, and that this led directly to their death.

We took independent advice from a consultant geriatrician (a specialist in medicine of the elderly). We found that A should have had a thorough clinical review prior to the transfusion being prescribed. The transfusion monitoring protocol was not followed, and the board acknowledged that this may have led to a delay in recognising A’s deterioration. We also noted that when A’s observations and condition indicated a serious concern, nursing staff should have contacted a senior doctor but instead contacted the most junior doctor on duty. We considered all of this unreasonable. We saw no evidence that the severity of A’s condition, and likely poor prognosis, was actively considered or discussed with them or their family. This would have been good practice.

We noted that after A's death the team appropriately discussed the case with the Procurator Fiscal and the death certificate review team, who stated that they would be content for a death certificate to be issued without the need for a post mortem examination. However, when this was then discussed with A’s family, they remained concerned and said they would like things investigated further. With reference to the relevant guidance, we found that the case should have been referred back to the Procurator Fiscal for further consideration. If the Procurator Fiscal had still considered there was no need to investigate, the medical team should have offered the family the option of a hospital post mortem examination. We upheld this complaint. We were satisfied that the learning already implemented by the board was appropriate and satisfactorily addressed what had gone wrong in A’s care. However, we made further recommendations in relation to the reporting of a death to the Procurator Fiscal.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to advise the Procurator Fiscal of the family’s ongoing concerns regarding A’s death, and for failing to offer a hospital post mortem. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.
• Share this decision notice with the Procurator Fiscal for advice as to whether the board should take any further steps.

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

• Medical staff are clear about the procedures for reporting deaths to the Procurator Fiscal. In particular, in the event that nearest relatives of the deceased are concerned that medical treatment may have contributed to the death of a patient this requires discussion with the Procurator Fiscal, even if initial reporting has already been carried out.

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 attended Aberdeen Royal Infirmary after being referred by their GP for left leg pain and swelling behind the knee. Investigations revealed the presence of a Baker’s cyst (fluid-filled swelling at back of knee) and C was discharged home with no further treatment planned. The pain continued to bother C over the weekend and they sought further medical opinion and returned to the hospital six days later. This time a deep vein thrombosis (DVT, blood clot in a vein) was diagnosed and C was discharged home on blood thinning medication. C believed that the DVT must have been present at their initial presentation to hospital and that action should have been taken at that time to address their symptoms and therefore there was a missed diagnosis.

We took independent advice from two clinical advisers: a consultant radiologist (a doctor who specialises in diagnosing and treating disease and injury through the use of medical imaging techniques such as x-rays and other scans) and a consultant physician. We found that although there was no evidence of a DVT on the original ultrasound scan, staff failed to act in accordance with guidance and arrange a D-dimer test (a blood test that can be used to help rule out the presence of a serious blood clot) and a further ultrasound scan within seven days. Staff gave C advice to seek further medical opinion should their clinical condition deteriorate which C did. There was no delay to the actual diagnosis of DVT and C’s treatment regime would not have altered in the period until the second scan was performed. However, we upheld the complaint on the basis that there was a failure to act in accordance with the guidance.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failure to follow the guidance when a negative scan result was obtained. 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:

• Staff should ensure that they are aware of and follow the guidance concerning negative ultrasound findings for DVT.

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 of their late parent (A) at Falkirk Community Hospital (FCH). A had a cognitive impairment and gained access to washing-up detergent that had been mistakenly left out in the staff kitchen area. A subsequently became unwell and advice was sought from the out-of-hours (OOH) GP service prior to eventual transfer to Forth Valley Royal Hospital (FVRH), where their condition deteriorated and they died the following week. C raised a complaint with the board, seeking answers as to what happened, and the board commissioned a Significant Adverse Event Review (SAER). The board were unable to conclude with any certainty whether detergent was ingested and contributed to A’s death.

C complained to us about inaccuracies and inconsistencies in the SAER and clinical records, and also about timescales surrounding the SAER and complaint processes.

We took independent clinical advice from a nursing adviser and a GP adviser. It was not possible from the evidence available and advice obtained for us to confirm whether A ingested detergent. We found that the SAER was open, transparent and evidence-based. The report acknowledged that there were inconsistencies and inadequacies in the records. However, we considered that the SAER did not adequately probe into the contact with, and actions of, the OOH GP. The initial advice given by the GP was to monitor A, when the observations should have prompted medical review. The GP assumed these observations were incorrect. When the GP later advised transfer to hospital, this was left to nursing staff to arrange and clear advice was not provided surrounding the urgency of the ambulance request. We found that the GP deviated from standard practice and failed to provide appropriate care to A.

While the SAER acknowledged that record-keeping standards were not adhered to, we highlighted a further shortcoming in that the transfer from FCH to FVRH was not formally documented. We found that there was delay in staff completing an incident report following the detergent incident, and a delay in completing the SAER. We also found that there were delays in responding to C’s complaint, and some confusion between the SAER and complaint processes. The board acknowledged these delays and apologised that the complaint process was very protracted at such a distressing time for the family.

We upheld all of C's complaints.

Recommendations

What we asked the organisation to do in this case:

• Apologise to A’s family for the unreasonable delay in completing an incident report, the unreasonable delays in concluding the SAER and responding to the complaint, and the confusion between the two processes, the failure of the SAER to probe sufficiently into the contact with, and actions of, the OOH GP, and the OOH GP’s deviation from standard practice and failure to provide appropriate care to A. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

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

• The board should ensure there are clear mechanisms in place for investigating both significant adverse events and complaints, and clarity between the two processes, with adherence to the board’s SAER policy and Complaints Handling Procedure. The board’s SAER policy should align with Healthcare Improvement Scotland guidance.
• Documentation needs to improve to support safe, effective quality and person-centred care delivery. The board should ensure protocols exist for documentation of handovers and clinical contacts.
• The board should ensure that SAER investigations comprehensively examine contributory factors, and that where possible these are reviewed by someone with knowledge of the relevant speciality, as per Healthcare Improvement Scotland guidance.
• The board should ensure the OOH service has clear protocols in place for escalations to hospital for medical review, including roles and responsibilities in this regard. GPs should act with due care when receiving second hand clinical information.

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

Summary

C complained on behalf of their parent (A) about their care and treatment at University Hospital Ayr. A was admitted to hospital after an episode where they had become unresponsive. C raised concerns that medical staff decided to change A's epilepsy medication without getting specialist input.

We took independent advice from a specialist in geriatric (medicine of the elderly) and general medicine. We found that A had not been properly assessed, that there was no clear reason for changing their epilepsy medication and that there was a lack of communication with their family about the change. We upheld C's complaint. We considered that the board had not appropriately responded to C's complaint, so we also made a complaints handling recommendation to address that.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failings identified in A's care and treatment and for not adequately addressing 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:

• In an emergency setting, patients' medications for specialist conditions should normally only be changed if their diagnosis is clear, the change is unequivocally beneficial and the reasons for the change are discussed with them and/or their families/carers.

In relation to complaints handling, we recommended:

• Complaints should be responded to accurately and as comprehensively as possible, particularly when we have requested that a specific matter is addressed.

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 way that the university handled their complaint.

We found that the university did not communicate clearly with C regarding the procedure being used to investigate their complaint. We also found that the university failed to adhere to their Complaints Handling Procedure (CHP) and the Model Complaints Handling Procedure (MCHP) when determining that all of C’s complaints should not be considered as a complaint under the CHP. As a result of this, C was not kept updated or given a timescale for when the investigation into their complaint was expected to conclude, there was a significant delay of nine months in C receiving a response to their complaint, C was not kept updated with the reasons for the delay in issuing the complaint response and was not provided with a revised timescale. C was also told that they could not approach us to consider their complaint and they were not signposted to this office.

We also found that the university did not respond to the complaints C raised in writing about how the investigation was carried out and that the university’s CHP states that complainants will be expected to complete the appropriate complaint form for complaints considered at investigation stage. This is not a requirement of the MCHP.

Therefore, we upheld C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to communicate clearly with C regarding the procedure being used to investigate their complaint, failing to adhere to their CHP and the MCHP when determining that all of C’s complaints should not be considered as a complaint under the CHP, not keeping C updated or providing a revised timescale for when the investigation into their complaint was expected to conclude, failing to respond to C's written complaints, the significant delay in responding to C's complaint, not keeping C updated regarding the reasons for the delay in issuing the complaint response and not providing them with a timescale for when they could expect a response, telling C that they could not approach this office to consider their complaint and not signposting C to this office in the complaint response. 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 necessary systems should be in place to ensure that complaints are handled in line with the university’s CHP and the MCHP and that all staff responsible for dealing with complaints should be aware of their responsibilities in this respect.
• The university’s CHP should reflect the MCHP.

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 had failed to reasonably maintain and repair their property. We found that there had been delays in carrying out repairs to C’s heating system and windows and that the level of communication about the delays was unreasonable. We also found that C was left without central heating for a period. Therefore, we upheld this complaint.

C also complained that the council failed to maintain an agreed reasonable adjustment that they would not be contacted or visited in the morning. C said that despite complaining to the council about breaches to the agreement, the problem continued. We found that the limited capacity of the council’s systems to record, effectively communicate and implement an agreed adjustment was a significant factor in the council’s failure to provide C with a service in line with the agreed adjustment. Although comments in the council’s complaint files indicated that officers were aware of these issues, it was unclear to what extent, if any, steps were taken to escalate or resolve the issues with the systems. Therefore, we upheld this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the delays in carrying out the repair works and the poor communication in connection with this, and the repeated failure to adhere to the agreed service adjustment. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.
• Once C’s central heating system had been replaced, consider a claim from C for reimbursement of the extra expense they incurred due to the faulty boiler operation.
• Provide C with a schedule for the repair work and temporary rehousing arrangements.

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

• The council should have effective systems in place to ensure that the housing services provided can be adjusted in line with the duty to make reasonable adjustments for disabled customers.
• Where the council have informed a tenant they will carry out repair work, officers should keep the tenant updated about any delays. Tenants must have a satisfactory provision for heating their property.

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 partnership’s handling of a child protection concern relating to their children whereby they were removed from C’s care overnight. The key points to C’s complaint were that the social worker who attended their home did not clearly identify themselves and explain their role, provide adequate information about the options available or their rights, and the children were removed without their consent.

The partnership said they were satisfied that they acted appropriately and within their responsibilities under Section 25 of the Children (Scotland) Act 1995 and that C did not object to the children’s removal.

We reviewed the relevant case records and sought independent social work advice. Our investigation did not find adequate evidence to show that the social worker properly introduced themselves or inform C of their rights. We identified that there was a failure to contact health and education for further information, to contact C the following day, and to interview the children within a reasonable timescale. As such, we concluded the partnership did not follow reasonable process when responding to the child protection concerns raised. Therefore, we upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to follow reasonable process when responding to the child protection concerns raised. 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 partnership should ensure the findings of this investigation have been reflected on and learning is shared with the relevant department.

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 A (an adult who lives as a tenant in supported accommodation provided by the partnership) about the partnership’s communication with A’s welfare guardian (B). A, B and C are siblings.

Following incidents between A and other individuals, B emailed A’s carers to make a suggestion about A’s care. A’s carers responded by email and copied their manager into the email for their information. The care manager subsequently emailed the carers to remark on comments they had made to B but accidently sent a copy to B.

B emailed the care manager shortly after to complain. B considered that the care manager’s email instructed A’s carers to withhold information about A’s care. Neither the care manager, nor the partnership responded to B’s email. C subsequently emailed the partnership to complain on B’s behalf. C reiterated B’s initial complaint. C also complained about the failure to reply to B’s email.

In the partnership’s response, they did not uphold C’s complaint about the contents of the care manager’s email. However, they upheld C’s complaint about the failure to respond to B’s email.

We took independent advice from a social work adviser. We found that the content of the care manager’s email was inappropriate. We considered that the email encouraged A’s carers to reduce the amount of information provided to B specifically to reduce their feedback about A’s care. We also considered that the partnership had failed to adequately investigate B’s and C’s complaint. Therefore, we upheld these complaints.

Recommendations

What we asked the organisation to do in this case:

• Apologise to B and C separately for the care manager’s inappropriate email and for failing to respond to B’s complaint or adequately investigate B’s and C’s complaints. The partnership should also apologise for providing inaccurate information in its previous apology and for suggesting that it was the responsibility of B and C to ensure that they receive responses to issues they raise. The apologies should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.
• The partnership should investigate if any information about A that should have been shared with B has been withheld and, if so, share this with B.

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

• All complaints should be handled in line with the partnership’s complaint handling process.
• Social workers are required to communicate with members of the public in an appropriate, open, accurate and straightforward way.

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 one of their twins (A) at delivery and in the neonatal unit after delivery at Queen Elizabeth University Hospital. C was concerned, in particular, about blood loss at birth, the delay in a blood transfusion being carried out, a delay in blood pressure being taken, record-keeping and communication.

We took independent advice from a consultant obstetrician (a doctor who specialises in pregnancy and childbirth) and a consultant neonatologist (a doctor who specialises in the medical care of newborn infants, especially ill or premature newborns).

We found generally that the evidence in the records showed a safe and appropriate delivery. We found that the blood loss at birth was within the standard parameters for twins delivered by caesarean section, although it is accepted that it was not possible to establish the total blood loss for A. We also found a blood transfusion was carried out within an appropriate timescale. However, A did not have their blood pressure taken until three hours after being admitted to the neonatal unit. We found it would be standard practice for a ventilated and unstable baby on a neonatal unit to take a non-invasive blood pressure reading. The board did not have a policy requiring this. Therefore, we upheld this complaint.

In addition the board accepted their record-keeping during delivery was not of an appropriate standard. They also recognised that communication required to be improved, and they have taken steps to address both of these issues. We identified concerns about record-keeping in the neonatal unit and this has been brought to the board’s attention.

Recommendations

What we asked the organisation to do in this case:

• Apologise to A’s family for the failings this investigation has identified. The apology should meet the standards set out in the SPSO guidelines on apologyavailable 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’s parent (A) had a history of heart problems and suffered a cardiac arrest. Investigations at that time led to a diagnosis of deep vein thrombosis (DVT, a blood clot in a vein). Four years later, A’s heart condition had deteriorated and they were assessed for a possible heart transplant. These investigations indicated severe pulmonary oedema (a condition caused by excess fluid in the lungs) and significant emphysematous changes (emphysema is a condition in which the air sacs of the lungs are damaged and enlarged, causing breathlessness) which meant A was not a suitable candidate for a transplant. The presence of emphysema was previously unknown to A. A died the following year due to heart failure with emphysema listed as a secondary cause. The doctor completing A’s death certificate found mention of mild emphysematous changes in the discharge letter around the time of the diagnosis of DVT. This was the first time A’s family had been made aware of these early findings.

C complained about A’s care and treatment. The board responded that mild emphysema is a very common incidental finding in CT scans of patients, such as A, who are cigarette smokers. The board said the degree of emphysema found was mild and would not have contributed to A’s symptoms or altered the plan for investigation at the time or the care provided to A subsequently. The board gave their view that there was no treatment that could have been offered that would have prevented the progression of the emphysema. The board apologised that they did not provide more information to A about the results of the CT scan at the time and advised that the case had been shared with the cardiology team and the importance of scan results being discussed with patients and recorded in their notes had been reinforced. C was unhappy with this response and brought their complaint to this office.

We took independent medical advice from a consultant in respiratory and general medicine. We found that, although the discharge letter included mention of mild emphysematous changes, emphysema was not included in A’s list of diagnoses and this meant that the board did not reasonably record the findings of the scan in A’s medical records and that a formal diagnosis of emphysema should have been recorded. We also found that A was not reasonably informed of the finding of emphysema or given any of the information recommended in the relevant guidance beyond general smoking cessation advice. While we also noted that stopping smoking was the only effective treatment available for emphysema, what cannot be known is whether a formal diagnosis of emphysema would have had any effect on A’s ability to stop smoking.

We also found that a reduced gas transfer result should have been followed up with a CT scan of A’s lungs. However, this would not have changed A’s treatment or overall outcome.

Overall, despite the board’s failures, C received treatment compliant with relevant guidance and these failures did not materially impact the subsequent progression of the disease or A’s eligibility for a heart transplant. On balance, however, we upheld the complaint that the board’s treatment of A unreasonably failed to take into account the finding of mild emphysematous changes in A’s early scan.

Recommendations

What we asked the organisation to do in this case:

• Apologise to A’s family for the specific failings identified. The apology should make clear mention of each of the failings identified and 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:

• Relevant board staff are aware of the relevant guidance in respect of incidental findings of emphysema on CT scans and of the need to follow up significantly reduced gas transfer results with a CT scan of the lungs.

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.