Upheld, recommendations

Summary

C complained that the board failed to provide their spouse (A) with reasonable care and treatment during an in-patient admission to hospital for a fractured hip. C who is A’s Power of Attorney also complained that the board failed to communicate adequately with them and A’s family.

We took independent advice from an orthopaedic surgeon (specialist in the treatment of diseases and injuries of the musculoskeletal system) and a registered nurse. We found that the board had failed to provide A with adequate care and treatment, particularly in relation to pressure care management. We found that the board had failed to maintain a reasonable standard of care records. We also found that the board failed to communicate adequately with C and A’s family. Therefore, we upheld C’s complaints. Additionally we found that the board failed to adequately investigate C’s complaint and made a recommendation to address this.

In response to our enquiries during our investigation, the board sent us a detailed list of actions that they have taken to address and learn from the failings we identified. We considered that these were reasonable, but that further learning could be identified.

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.
• Apologise to C for the failings in communication identified by this investigation. 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 the failings in the board’s complaint handling identified by this investigation. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.
• Provide C with a copy of the action plan (redacted to remove any personally identifying or otherwise sensitive details) and an update on the progress of implementation.

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

• All relevant documentation including the nursing notes should be completed in accordance with the relevant policies and guidance.

In relation to complaints handling, we recommended:

• Complaint investigations should be carried out in line with the NHS Model 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 that the medical practice failed to provide their late parent (A) with reasonable care and treatment after A fell and hit their head. A had sustained a subdural haematoma (where blood collects between the skull and the brain). A was cared for in their home and later admitted to hospital. A died a few months after their fall.

We took independent advice on this complaint from a GP. We found that the head injury assessment was unreasonable and not in line with NICE guidance. We were critical that the practice did not acknowledge this failing in their complaint response, the significant adverse event review (SAER) or in response to our enquiries. We found that it was unreasonable that concerns raised by C, after A’s fall, did not prompt further action by the practice. We also noted that the clinical notes did not adequately describe the head injury and there was no evidence that the practice understood the significance of the head injury and communicated that to the medical service they referred A onto. Therefore, we upheld this part of C’s complaint.

C also complained that the practice unreasonably failed to carry out a SAER in line with the relevant Healthcare Improvement Scotland Guidance. We found that the initial SAER was of poor quality. The enhanced SAER was in line with the guidance, but we were again critical of the quality. Therefore, we upheld this part of C’s complaint.

We also found that the practice’s complaint handling did not mirror the current Model Complaints Handling Procedure. Therefore, we made a recommendation to address this.

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 adverse event reviews should be reflective and learning processes that involve the appropriate staff and ensure failings are identified and any appropriate learning and improvement is taken forward in line with relevant guidance.
• When a red flag situation is reported such as a head injury this should be appropriately assessed, including the presence/exclusion of red flags and documented in line with relevant guidance. If further symptoms are reported, all the available information should be considered and action taken as appropriate. Red flag situations such as a head injury should be appropriately reported to other agencies involved in the patient’s care Head Injury: assessment and early management May 2023.

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) who had chronic obstructive pulmonary disease (COPD, a group of lung conditions that cause breathing difficulties). A was admitted to hospital as an emergency with kidney failure, and high blood acid and potassium levels. A died the following day. The cause of death appeared to be a cardiac arrest resulting from high potassium, in the context of coronary artery disease.

C complained that A should not have been stepped down from the critical care unit to a medical ward resulting in a lack of monitoring and timely treatment for A and that A had inappropriately been deemed DNACPR (do not attempt cardiopulmonary resuscitation). C also said that the board’s review into A’s death failed to identify or acknowledge clinically significant evidence and that communication and provision for bereaved families was poor.

We took independent advice from a consultant in acute and general medicine. We found that while it was reasonable for the board to have considered moving A to a general medical ward, an arterial blood gas test conducted prior to the transfer had indicated that A’s condition was deteriorating. This test was not acted upon. We were also critical that the board had missed the significance of these test results during their complaints investigation. Furthermore, while the process for declaring a DNACPR was reasonable, we found that the way in which this had been explained to C had been lacking. We also noted that while the board had confirmed that facilities for bereaved families were available, they were not utilised for A’s relatives on this occasion. Therefore, we upheld all of C’s complaints.

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.
• Apologise to C that the board’s critical care governance review into A’s death unreasonably failed to identify or acknowledge clinically significant evidence. 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 provide reasonable facilities for bereaved families and for failing to provide a reasonable level of communication to the family during A’s admission. 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:

• Adequate procedures should be in place to ensure that all arterial blood gas results are reviewed and acted upon by clinical staff. Appropriate clinical assessment and patient observation should be carried out when a patient is admitted to a ward and the patient should be monitored thereafter. Patient admission documentation should be completed in a timely manner.
• Communication and terminology used when talking to a patient’s family should be clear and easily understood. In relation to a DNACPR decision, the resuscitation process should be clearly explained to patients and, where appropriate, their families with the use of easily understood lay terms and in accordance with NHS Scotland’s Cardiopulmonary resuscitation decisions guidance. Notification of a patient’s death should be delivered in person where possible in an appropriate environment e.g. a relative’s room.
• Critical Care Clinical Governance reviews should be comprehensive, accurate and productive. Where adverse event(s) occur, an adverse event review should be held in line with relevant national guidance to ensure there is appropriate learning and service improvements that enhance patient safety.

In relation to complaints handling, we recommended:

• Complaints should be investigated and responded to in accordance with the Model Complaints Handling Procedures. They should fully investigate and address the issues raised and appropriately identify and action learning.

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 from the board. C attended hospital to have their gall bladder removed by laparoscopic cholecystectomy (keyhole surgery). The surgery was abandoned and C did not understand why. C also complained that communication was unreasonable.

The board advised that C had a high body mass index which made the operation challenging. This was explained at C’s first consultation. Prior to the operation C was referred to the high risk clinic and the risks of the operation were fully discussed with an anaesthetist. The surgeon was also appropriately consulted by email. During the operation, C became wheezy and medication was administered to manage this. When C had stabilised, the operation had to be abandoned because the surgeon was unable to visualise the gall bladder and therefore could not safely complete the surgery laparoscopically.

We took independent advice from a consultant general and colorectal surgeon (specialist in conditions of the colon, rectum or anus). We found that the decision making in surgery was appropriate and that the team had made a reasonable effort to explain why the surgery had been abandoned. However, we found that C could have been referred to weight management services when they were first put on the waiting list for surgery and that the high risk clinic was only six days before the operation, which was not enough time for C to fully consider the risks. We also considered that the surgeon should have been at the high risk clinic to discuss and assess the situation with C and that advice should have been sought from a regional specialist bariatric centre prior to proceeding with surgery. Therefore, we upheld both parts of C’s complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for not cancelling the operation and not recommending non-surgical options. 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 writing to them directly, for not ensuring that they fully understood the risks of surgery and the importance of the liver reducing diet and for not fully discussing non-surgical options. 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:

• Ensure that all clinicians write directly to patients and use ‘plain English’ in these letters.
• That specialist input is sought from a regional bariatric centre/specialist before deciding whether or not to proceed with surgery for a severely obese patient. (especially if the surgery is for a condition which is not life limiting).
• When a concern is raised by the pre-operative assessment clinic regarding a severely obese patient, there should be multi-disciplinary involvement, including the surgeon in the high risk clinic so that the BRAN methodology can be genuinely utilised, including for the “alternatives” and “doing nothing” 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 that they received from the community mental health team, after C was referred due to suicidal ideation. C said that they did not have a reasonable level of contact with the team and had difficulty changing the frequency of a prescription. C also said that the board unreasonably made reference to a historical referral to a befriending service in their complaint response.

We took independent advice from a specialist in adult mental health nursing. We found that the board’s position that prescribing is a matter for C’s GP to be reasonable. However, we found that C did not receive reasonable or adequate contact from the community mental health team and the board failed to follow through on a plan for C to have a face-to-face appointment with a consultant psychiatrist.

We also found that the board failed to follow through with a plan to discuss a referral to a befriending service with the clinical team. The board’s complaint response made reference to a referral submitted several years previously, which we found unreasonable with respect to complaints handling. We upheld C’s complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failings identified by this investigation. 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 community mental health team should have robust administrative systems in place to ensure that planned appointments are arranged as intended and that patients are effectively notified of their personal appointment arrangements in a timely manner.

In relation to complaints handling, we recommended:

• Complaint responses should include information relevant to the events complained about.

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 late sibling (A) received from the practice. A attended the practice with back pain and was given painkillers. Clinical staff noted comments on A’s appearance and demeanour during the appointment. They also noted that they considered A to be drug seeking. A died a few days later.

C complained that the examination was not thorough enough and that clinicians missed the fact that a lung infection was the cause of A’s symptoms. The practice said that they considered the examination to be reasonable, that they felt that A did not present with typical signs of respiratory concern and so auscultation (listening to the lungs) was not indicated. They did not identify anything that could have been done differently.

We took independent clinical advice from an advanced nurse practitioner. We considered that there were enough complicating factors in A’s history and presentation to warrant a more thorough examination of A. Therefore, the examination carried out was unreasonable. We found that the opinion that A was drug-seeking was premature as no differential diagnoses were considered or ruled out. We also noted that an adverse event review was not carried out which we considered to be unreasonable. Therefore, we upheld C’s complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to carry out a reasonable and thorough examination of A when they presented at the practice for a consultation, for failing to consider/rule out differential diagnoses to explain A’s symptoms and for failing to carry out an adverse event review to investigate what happened and promote learning for the staff involved. 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 examined thoroughly. When examination is difficult, and/or it is difficult to obtain a clear history, care should be taken not to reach conclusions prematurely without ruling out differential diagnoses as appropriate.
• When a patient dies shortly after they have been seen at the practice, an adverse event review should be carried out in line with the National Framework for Scotland to ensure that any learning (and good practice) can be identified and acted on.

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 been admitted to hospital before being transferred to a mental health facility. A then developed abdominal symptoms, which required them to be transferred to an acute hospital for treatment. A had been considered for surgery, but this was changed to treatment with medication. A was transferred back to the mental health facility but became unwell again and was taken to A&E. A died from a pulmonary embolism (a blood clot that blocks and stops blood flow to an artery in the lung).

C said that A’s medical and nursing care fell below an acceptable standard which resulted in A’s dignity being compromised, their personal care neglected and A not receiving the medication that they required. C believed that A’s death was caused by a failure to examine A properly or ensure that A received anti-clotting medication. C felt that this resulted in A developing deep vein thrombosis (DVT, a blood clot in a vein) which led directly to their death. C was also unhappy with the board’s response to their complaint. C felt that the board had not represented meetings with the family accurately, and failed to follow up on the actions that they had told the family were being taken, despite acknowledging that there was significant learning to be gained from the family’s experience.

We took independent advice from a registered nurse and a consultant geriatrician (specialist in medicine of the elderly). We found that A’s nursing and medical care had fallen below a reasonable standard. We also found that the board failed to communicate reasonably with C and their family and that they could not provide evidence that they had taken the actions promised to the family following the board’s complaint investigation. In addition, the board’s Significant Adverse Event Review had been delayed, reducing the utility of it to the board. We upheld all of C’s complaints.

Recommendations

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

• All nursing staff on the relevant ward should be compliant with the board’s medicine administration policy.
• An assessment by the medical team of the current rota and continuity of care based on the assurances given to A’s family that staff numbers would improve this.
• Patient documentation completed to an appropriate standard, without sections left blank, this should include admission documents, care rounding charts, person centred care plans and delirium screening.
• The board should develop clear guidance to ensure patients with mental health issues can have timely access to nursing staff trained in mental health care, to reduce the reliance on family members providing care.
• The case should be discussed at the next available morbidity and mortality meeting.
• The medical staff involved should include this case for discussion at their next appraisal.

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 spouse (A) received from Scottish Ambulance Service (SAS). C called for an ambulance after A fell from a height at home. A was assisted to their feet after an initial check and then walked to the ambulance for further checks. After returning to the house, A became pale and reported a brief loss of sight. It was decided A should be transferred to hospital where they were later diagnosed with a broken pelvis.

C said that one of the crew members was rude and dismissive when they had tried to describe the height A had fallen from. C complained that SAS had not fully assessed A, failed to consider the accounts given by eyewitnesses and unreasonably concluded that A could remain at home and take painkillers. A was clear that they did not want to go to hospital, however, C considered the crew failed to recognise A was in shock.

In responding to the complaint, SAS advised that a full assessment had been carried out. It was also noted A did not initially wish to be transferred to hospital and had declined to be immobilised on a spinal board. The response advised of actions for learning and improvement which would be taken with the crew in response to C’s complaint. This included actions in relation to the mechanism of injury (in this case a fall from height), moving and handling, consideration of silver trauma (the impact of trauma on older patients), and communication with patients and relatives.

C was unhappy with this response and brought their complaint to us. We took independent advice from a senior paramedic adviser. We found that SAS failed to undertake a reasonable assessment of A as they did not act in keeping with the Joint Royal College Ambulance Liaison Committee guidance on Spinal and Spinal cord injury. In particular, there was a failure to immobilise A at the scene given the mechanism of injury. We also considered that SAS failed to reasonably document the incident, consider A’s age and the effects of ‘silver trauma’ and to correctly calculate the National Early Warning Score. SAS did not document any discussion about the risks/benefits associated with immobilisation or fully record A’s reported initial refusal to comply with treatment or to be transferred to hospital. Finally, we noted a failure to document a pain score before and after analgesia had been given. Therefore, we upheld C’s complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to A for failing to provide a reasonable standard of care. 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 patient record should be completed in full to reflect the presenting condition/mechanism of injury; the assessment and observations undertaken including NEWS, pain score, the accounts of eye witnesses and consideration of other relevant factors such as age; and the patient’s decision regarding treatment and the information shared to inform this decision.

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 hip replacement surgery within a reasonable period of time. C experienced back and buttock pain for several years due to an existing condition. C started to experience new pain in their right leg. Their GP referred them for an x-ray and made an urgent referral to the orthopaedic department (specialists in the treatment of diseases and injuries of the musculoskeletal system) as C had been off work due to debilitating pain in the hip and was concerned about losing their employment as a result.

C had a consultation with the orthopaedic surgeon and was told that the hip was badly damaged. C was listed as a priority 4 case (a lower priority) for a total hip replacement. C’s condition continued to deteriorate; they were in severe pain and it was affecting their day to day life. C contacted the board to explain the severity of the problems that they were experiencing and they were reviewed in clinic. Shortly afterwards, C underwent surgery privately.

We took independent advice from a trauma and orthopaedic consultant. We found that a number of failings occurred that were not simply as a result of the delays caused by an extensive waiting list. It was unreasonable that C was incorrectly categorised from the outset and that an outdated prioritisation tool was used by the board. It was also unreasonable that the radiological deterioration was not documented and that C’s surgical treatment was not expedited at the further clinic appointment. Therefore, we upheld C’s 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.
• Calculate and reimburse C in relation to their private surgery on production of appropriate receipts. The calculation should be based on what the surgery would have cost the NHS (rather than what it cost C). The payment should be made by the date indicated; if payment is not made by that date, interest should be paid at the standard interest rate applied by the courts from the initial date to the date of payment.

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

• Patients should be given timely, clear and accurate information about their clinical prioritisation and potential waiting times for surgery.
• Patients should receive the appropriate clinical priority level based on assessment and the clinical evidence available.
• Patients who report clinical deterioration during their wait for surgery should be appropriately assessed and reprioritised where this is 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.

This case was reviewed and closed in October 2024. This summary was published prior to review. No changes are required to this summary as the outcome of the review was unchanged from the initial decision from April 2024. 

Summary

C complained on behalf of their parent (A) that the board unreasonably failed to proceed with hip replacement surgery within a reasonable timeframe.

C said that A was referred for physiotherapy before being added to the waiting list for surgery. They complained that this was unreasonable as it was known that it would not help given the extent of deterioration in A’s hip joint. C also complained that several of A’s appointments had been cancelled or postponed, and that the board had failed to act on an urgent referral sent by A’s GP. As it was unclear when A would receive their surgery, they opted to have this carried out privately.

In responding to C’s complaint, the board confirmed that they must take all reasonably practicable steps to ensure that they comply with treatment time guarantees. This includes considering whether to send patients to another care provider if they cannot provide treatment by the patient’s treatment time guarantee. In A’s case, the board noted that A had elected to make their own arrangement for private surgery and, therefore, the NHS offer of treatment was no longer relevant to them.

We took independent medical advice from a consultant orthopaedic surgeon (a specialist in the treatment of diseases and injuries of the musculoskeletal system). At the point of referral to orthopaedics, we found that A was reasonably referred for physiotherapy and added to the waiting list as a routine category patient. At the pre-operative assessment clinic, we found that an x-ray was taken but it had not been reported or reviewed. At this point, A should have been re-prioritised to urgent in keeping with the physical changes that they had reported and the radiological deterioration evident on the x-ray. It was unreasonable not to re-prioritise A at this time. In reference to the urgent referral sent by A’s GP, A continued to be considered as a routine category patient. However, it was clear A’s case had been expedited as they were offered a place on a private sector list for surgery run by the board at the time. The board could not provide evidence to support their decision making. We also found that the board did not meet their legislative requirements when communicating with A about their treatment time guarantee date. On balance, we upheld C’s complaint.

During our investigation, we identified issues with the board’s handling of the complaint. We made a recommendation to the board to support improvement of their complaint handling.

Recommendations

What we asked the organisation to do in this case:

• Apologise to A for not reasonably communicating with A about the breach of their treatment time guarantee date, for not acting on the changes reported by A at the pre-assessment clinic, for not reviewing or reporting the x-ray, for not appropriately reviewing and reprioritising A following the urgent GP referral, and for not documenting the reason for the decision to add A to the private list for surgery. 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 on waiting lists for surgery should be managed in keeping with the relevant policies and guidance, and they should be kept informed about delays particularly when a treatment time guarantee has been breached. The outcome of assessments and test results including x-rays taken at pre-assessment clinics should be timeously reviewed and documented in the medical record. Patients should be appropriately reviewed and reprioritised based on assessment and the clinical evidence available. Decisions made in respect of the patient should be documented by the relevant person in the medical record.

In relation to complaints handling, we recommended:

• 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 The final complaint response should include information about the SPSO, including the timescale for making a complaint, in line with the Model 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.