Upheld, recommendations

Summary

C complained about the care and treatment provided to their spouse (A). A stayed in critical care wards after surgery and acquired wounds to their back and shoulders. C complained that A’s wounds were not appropriately documented or treated.

In response to C’s complaint, the board acknowledged that documentation of A’s wounds was not started in critical care wards, and A’s wounds were not initially logged on the board’s system for reporting adverse events. The board told us that after C’s complaint, the tissue viability service developed online learning for staff, and developed and promoted a wound management policy. The board apologised that A sustained wounds after surgery.

We took independent advice from a nurse with a specialism in wound care. We agreed that the board did not reasonably document C’s wounds; however, we also found that they did not follow their guidelines in treating A’s wounds. We found that there was a delay in referral to a tissue viability specialist; a lack of skin inspection; inadequate repositioning to prevent pressure damage occurring or deteriorating; and inappropriate wound management. We also found that the board did not provide C with a full and informed complaint response. Therefore, we upheld C’s complaints.

Recommendations

What we asked the organisation to do in this case:

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

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

• Patients should be regularly assessed for tissue damage in line with board procedures. Where tissue damage is found, appropriate treatment including timely escalation to a tissue viability specialist as required should be provided.

In relation to complaints handling, we recommended:

• The board’s complaint handling monitoring and governance system should ensure that complaints are properly investigated and responded to; are accurate; and that failings and good practice are 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 the board failed to carry out a reasonable assessment of their late parent (A) when they were admitted to hospital. They were also unhappy with the decision to discharge A and said that the board failed to communicate adequately with them and their family during the time A spent in the hospital. C complained that the board’s complaint response was not consistent with A’s clinical records.

We took independent advice from a consultant in geriatric and general medicine. We found that while a reasonable assessment of A’s clinical condition was carried out, the assessment of A’s physical condition and the discussion with their family before discharge fell below a reasonable standard, particularly with respect to A’s mobility. We also found that communication with A’s family fell below a level that they could reasonably expect. Finally, we were critical of the board’s complaint response which appeared to be selective in terms of the information provided rather than being objective. Therefore, we upheld C’s complaints.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failings identified and provide an explanation to C about why the discharge document mentioned ‘urosepsis’. 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 gap between a patient’s previous and current abilities should always be assessed and considered when making a decision about discharging the patient. Where a patient’s family is involved in their care at home, they should be involved in discussions about the patient’s discharge and any follow-up care and treatment.
• Complaint responses should be objective, clear, accurate and address the issues raised.

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 and B complained about the support that they had received as foster carers from the partnership. C and B told us that they had been foster carers to two young people for a number of years. Following a significant incident in the fostering placement, social work services had taken the decision to remove both young people from their care. Following the end of the placement, C and B complained to the partnership about the adequacy of support and intervention offered to both them, and the young people, by social work services during the placement, the decision to remove both young people from their care and the lack of transition planning.

In response to C and B's concerns the partnership concluded that a reasonable level of support had been offered to them during the placement. They said that the decision to end the placement had not been taken lightly, and staff had made a professional assessment in the young people’s best interests. They apologised for the delay in convening a disruption meeting, citing a number of mitigating factors, including operational constraints and government restrictions.

We took independent advice from a social worker. We found that, in the weeks prior to the incident, the partnership failed to follow their Placement Support Practice Guidance, specifically a Placement Support meeting was not convened to explore how the placement could be supported and maintained. We found that following the incident, the partnership’s communication and support to the family was not robust or proportionate, and an appropriate debrief had not taken place, including an urgent risk assessment. We found that there was a lack of young people involvement in decisions about their future care planning. The partnership did not complete appropriate transitioning planning or risk assessment to assist the young people, and the foster carers, with the immediate impact of the end of placement, including seeking the young people’s views in respect of their onward communication / contact with their foster carers. We also found that there was an unreasonable delay by the partnership to convene a disruption meeting following the placement ending and inconsistencies in their policies and practice guidance in respect of timescales for a meeting. Therefore, we upheld C and B's complaints.

Recommendations

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

• Where a long-term fostering placement is at risk of breaking down, a Placement Support meeting should be convened as soon as possible to explore how the placement can be supported and maintained.
• Ensure that there is clarity across all of the partnership’s policies and practice guidance in respect of timescales to convene a disruption meeting so that there are no anomalies that remain for practitioners, foster carers and service users. When there are genuine reasons for delay in adhering to these timescales then this should be consistently conveyed to the foster carers and partners to the child/ young person's plan.
• The child / young person’s views should be sought and clearly recorded in decision-making about their care plan.
• Where a long-term fostering placement breaks down, a robust transition plan with input from the foster carers and the children / young people affected should be formulated to assist with the immediate impact of the end of the placement.
• Where a significant incident has occurred in a fostering placement, appropriate support should be offered to the family and a formal debrief meeting facilitated with the family as soon after the event as safe to do so. This should include risk assessment and care planning in light of any risk identified. All views of the incident should be considered and recorded with any immediate and long-term actions being transparent and recorded in case notes.

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 contacted the Scottish Ambulance Service (SAS) when they began experiencing abdominal pain. An ambulance attended but did not take C to hospital. The crew provided advice to contact the service again if their symptoms worsened. C contacted the service again the following day. A telephone assessment was completed but no ambulance was sent. C later made their own way to hospital where they required surgery for a perforated bowel.

C complained that the SAS failed to recognise the seriousness of their symptoms and failed to provide appropriate care and treatment. C said that as a result, they required more extensive surgery than if they had been taken to hospital sooner.

We took independent advice from a paramedic. We found that the ambulance crew had unreasonably failed to carry out an adequate assessment of C. The crew assessed that C had withdrawn consent for further assessment, and did not provide adequate advice on the benefits of assessment or the risks of not completing the assessment. We also found that the telephone assessment the following day was inadequate and was poorly documented. Therefore, we upheld C's complaints.

Recommendations

• What we asked the organisation to do in this case
• Apologise to C for failing to conduct an adequate assessment, failing to recognise the potential seriousness of their symptoms, and failing to provide them with the care that they required. 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:

• Clinical staff are able to recognise symptoms of potentially serious abdominal conditions.
• Clinical staff ensure that benefits of assessment, treatment and transport to hospital, and the risks of declining care, are fully discussed with the patient and recorded.
• Clinical staff reflect on and learn from patient experience to improve future practice.

In relation to complaints handling, we recommended:

• Relevant staff and senior managers are familiar with the Adverse Events Policy, understand the criteria for a Significant Adverse Event Review, and apply it correctly.

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.

Amendment - 27/06/2024

When this complaint was originally published (19/03/2024) we made the following recommendation: "Clinical staff are aware of Kehr’s sign and are able to recognise symptoms of potentially serious abdominal conditions."  This has since been amended to "Clinical staff are able to recognise symptoms of potentially serious abdominal conditions." following receipt of new information.  

Summary

C underwent a coronary artery bypass surgery (a surgical procedure that creates a new path for blood to flow around a blocked or partially blocked artery in the heart). C required three further surgical procedures on their chest wound over a period of seven years after their bypass surgery. C’s chest wound developed a sinus (a track that extends from the surface of an organ to an underlying area) and did not heal properly. C also developed osteomyelitis (a bone infection) in their chest wound. C raised concerns about the care and treatment that they received from the hospital.

We took independent advice from a consultant cardiac surgeon. We found that the clinical treatment provided to C was reasonable. However, we found that the hospital failed to provide timely discharge information after C’s bypass surgery and after C’s surgery over a year later. We also found that the hospital failed to reasonably follow up C after discharge from two of their surgical procedures. Therefore, on balance, we upheld C’s complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the delays in providing timely discharge information and failure to reasonably follow up two of their surgical procedures. 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:

• Discharge letters following surgical procedures should be sent out in a timely manner and clear follow-up arrangements should be given in the discharge letters following surgical procedures.

In relation to complaints handling, we recommended:

• When a complaint involves more than one NHS board, the boards should decide who will lead on the complaint and provide a joint response.

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 a complaint on behalf of their relative (A) who received treatment at hospital. A had previously suffered a stroke (causing left sided weakness) and was admitted after being unwell for a few days. C complained about the nursing care provided to A while they were in hospital.

We took independent advice from a nursing adviser. We found that there were failings in relation to nursing documentation, moving and handling practices, a lack of equipment, and a lack of assessments as to A’s needs. In particular, there was no falls assessment and appropriate action and recording did not take place after A’s fall. In relation to moving and handling, we found that glide sheets should have been utilised and that appropriate equipment should have been available in the ward. The board failed to reasonably record the care that they provided, or carried out appropriate assessments to ensure person-centred care to confirm that A’s needs were met. As such, we upheld this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failings as 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:

• All patients must have a falls risk assessment completed on admission and after a fall a post falls assessment should be completed.
• Every patient should have a person-centred plan of care.
• All patients must have a moving and handling risk assessment undertaken within 24 hours of admission.
• Nursing documentation should be complete and reflect a person's care needs, plan of care, care delivered and evaluation of the care delivered.
• Basic moving and handling equipment should be readily accessible for all patients and staff.
• All patients should have their care needs identified and risk assessments undertaken in order to develop a person-centred plan of care.

In relation to complaints handling, we recommended:

• Complaint investigations should respond to all of the main points raised and identify failings and take learning from what happened.

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 practice prior to their diagnosis of an abdominal cyst, which was surgically removed some years after C first attended the practice with symptoms. C complained that they did not receive a referral for an ultrasound scan until many months after first attending the practice with symptoms. C also complained that four different doctors were involved in their care and that the practice’s complaint handling was unreasonable.

We took independent GP advice. C’s case was complex and challenging due to the nature of C’s cyst, C’s other diagnoses and the timing of C’s consultations during the COVID-19 pandemic. Nevertheless, we found that there was a missed opportunity for the practice to refer C to the colorectal service based on the positive result of a qFIT test (a test to detect blood in the stool) when C first attended the practice with symptoms, based on the National Institute for Health and Care Excellence (NICE) guidance. We found that there was a further missed opportunity for the practice to consider referring C to secondary care based on C’s subsequent positive qFIT test result, which was taken many months after the first positive qFIT test. We also found that there were delays in the practice contacting C after receiving the result of the subsequent qFIT test and when the practice received the result of C’s ultrasound. We found that, given the state of NHS services at the time C attended the practice, there was not likely a significant delay in C receiving a diagnosis or surgery for their cyst. On balance, we upheld C’s complaint about their care and treatment from the practice.

We found that the practice’s complaints handling was unreasonable, because the first complaint response did not address the issues C raised as a complaint. We upheld C’s complaint about the practice’s complaints handling.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failure to action the results of qFIT tests, for the delays and for the unreasonable complaint response. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/meaningful-apologies.

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

• Administrative systems at the practice should support timely actioning of abnormal results.
• Clinical staff should be knowledgeable about the indication and interpretation of qFIT tests, as per NICE guidance.

In relation to complaints handling, we recommended:

• Complaints should be appropriately acknowledged in line with the Model Complaints Handling Procedure for NHS Scotland, and the complaint response should fully address the substantive issues raised in a complaint.

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 practice prior to receiving a diagnosis of a cancerous brain tumour, for which C underwent surgery, radiotherapy and chemotherapy. C had eight consultations at the practice over the course of ten months prior to receiving a referral to the neurology department.

We took independent advice from a GP. We found that there was a missed opportunity for the practice to review C in person and consider an earlier neurological referral on the basis of C’s worsening symptoms. We upheld the complaint. During the course of the investigation, the practice acknowledged these failings and took action to address them.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failure to offer a face-to-face appointment and neurology referrals, and for the practice’s shortcomings in their complaint response. The apology should meet the standards set out in the SPSO guidelines on apology available at http://www.spso.org.uk/meaningful-apologies.

In relation to complaints handling, we recommended:

• The practice’s complaints handling procedure should ensure that complaints are properly investigated and responded to, are accurate and that failings are 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 about the care and treatment that their late parent (A) received from the board following A’s admission to hospital having suffered a stroke. A developed COVID-19 symptoms and this was confirmed by a positive swab. A’s condition deteriorated with them developing COVID-19 pneumonia and they sadly died.

C complained to the board about their parent contracting COVID-19, which they felt must have been hospital acquired as A was shielding prior to admission. C complained that A was unnecessarily transferred between wards which increased the risk of exposure to the virus. C reported concerns that there were known COVID-19 cases in a neighbouring ward and possibly within A’s ward. C was concerned that A wasn’t offered the opportunity of home rehabilitation.

The board’s response stated that national infection prevention and control guidance for COVID-19 was followed at all times. They advised that it wasn’t always possible to accommodate all shielding patients in a single room. They advised that A was transferred between wards according to their care needs. They said that they could not meet A’s rehabilitation needs at home due to capacity issues with their community stroke team.

We took independent clinical advice from a nursing adviser specialising in infection control. We found that A required inpatient care to ensure that they received appropriate investigations and treatment for their suspected stroke. We found that the care provided to A in treatment for their stroke was reasonable and in keeping with their diagnosis.

We found that the board did not comply with relevant guidance on COVID-19 by failing to document the assessment of A’s COVID-19 risk pathway during their admission. We found that there was an unreasonable delay in isolating A from the other patients once A’s diagnosis of COVID-19 was suspected. Given these failings, we upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to triage A’s level of risk, for failure to document A’s shielding status and failure to isolate and follow airborne precautions from the point at which COVID-19 was suspected. 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:

• Feedback the findings of this investigation to relevant staff for reflection and learning, and to inform future practice.
• Medical records should contain all relevant information including the outcomes of assessments and the information required to clarify the decision making regarding the delivery of care.

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 nursing care that their parent (A) received. A had dementia and was admitted following a fall in their care home, remaining in hospital until their death some weeks later. C complained that during A’s admission, A was not treated with dignity, that they were left without food or water, and that they were allowed to aspirate on pureed food because they were not safely positioned in bed.

The board maintained that overall the nursing care was of a reasonable standard, but they accepted that documentation had been poor. They provided us with a detailed action plan which they were implementing in response to the failings that they had identified.

We took independent nursing advice. We found gaps in record-keeping in relation to food and fluid intake. We found that the board had failed to evidence that A was cared for in a dignified and respectful manner. Comfort rounding was not provided as frequently as it should have been, taking into account A’s frailty and general condition. A had pressure ulcers and we found that the board had failed to demonstrate sufficiently frequent skin checks and repositioning. The board also failed to maintain wound charts, recording wound sizes and grade. There was no evidence of oral care having been provided.

We did not find evidence to support the account that A was left to choke on pureed food on the day before they died. The records indicated that A was being checked on regularly that morning, and that A was asleep much of the time and noted to be ‘too drowsy for oral intake’. A was being treated for secretions, which we considered may have accounted for the gurgling sound reported. Although it was not possible to establish precisely what had happened on this date, it was regrettable that this incident caused so much distress to the family, and we noted that the board had apologised for the distress caused.

Taking all of the above into account, we upheld the complaint. We found that the board’s action plan did not adequately address the failings in this case and we therefore made our own recommendations.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C and C’s family for the failings our investigation has found. 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 receive appropriate pressure ulcer care, prevention and grading in line with relevant guidance.
• Records should document what is required to capture that person-centred care has been assessed, planned and the outcome of the plan evaluated.
• Patients should have wound charts completed as appropriate and in line with relevant guidance.
• There should be a discussion with family/carers as appropriate when a patient moves onto a palliative care treatment plan to facilitate understanding and an awareness of what to expect particularly in relation to fluid and nutrition in line with relevant guidance.

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.