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Mid Scotland and Fife

  • Report no:
    202105840
  • Date:
    December 2023
  • Body:
    Fife NHS Board
  • Sector:
    Health

The complainant (C) complained to my office about the care and treatment they received from Fife NHS Board (the Board) between April and May 2021. C received Dalteparin injections, a heparin-based treatment, from the Board’s outpatient Deep Vein Thrombosis (DVT) clinic for a superficial vein thrombophlebitis (SVT: inflammation of a vein near the surface of the skin). Around nine days after commencing the injections C reported to the clinic new onset of symptoms of weakness, numbness and difficulty moving their leg. C was admitted to hospital where they received investigations to rule out either peripheral nerve entrapment or a stroke. C’s symptoms continued to worsen including new onset of severe leg pain, and it was later confirmed that C had developed limb ischaemia (inadequate blood supply due to blockage of the blood vessels) due to Heparin Induced Thrombocytopenia (HIT), a serious complication associated with heparin-based products. Although C was transferred to another health board for emergency vascular surgery which saved their leg, they have been left with permanent nerve damage and suffer from chronic pain and reduced mobility.

C complained the delay in treating them for HIT resulted in the permanent harm caused to their leg, and their outcome would have been better had the condition been diagnosed and treated earlier. C also complained that the Board’s handling of their complaint had been unreasonable.

The Board said that C’s presentation of limb ischaemia was unusual, alongside an unusual but not unrecognised, side effect of heparin injections. Ruling out a stroke or spinal problem was the clinical priority. There was a missed opportunity to review C at the DVT clinic in light of the blood tests taken, and there was a failure to consider HIT earlier, timeous screening of which could have prompted an earlier prescription of a different anticoagulant drug to treat or prevent a blood clot. C complained to SPSO about this episode of care and the Board’s handling of their complaint, which they said had failed to recognise the harm caused to them by this incident. When my office contacted the Board about C’s complaint, the Board advised that a decision had been taken to undertake a Local Adverse Event Review (LAER). The complaint was closed by my office as it was considered the outcome of the LAER may resolve C’s remaining concerns. C contacted my office again some months later as they were yet to receive a copy of the LAER report and as the Board were unable to commit to a timescale for its completion. I made enquiries of the Board about the LAER and decided to investigate. The Board subsequently issued the LAER report, 11 months after the decision was made to commence the review process.

I sought independent advice from a Consultant Haematologist (the Adviser). The Adviser told me HIT is an infrequent rather than unusual complication of heparin injections and all patients receiving this treatment should be routinely monitored for this. The DVT clinic appointments were a key opportunity to manage C’s condition before harm had happened, particularly in light of the blood results which were available indicating that C’s platelet count had dropped. HIT is a very difficult condition to treat even when treatment is commenced immediately, however, had action been taken earlier, in their view, it may have significantly changed the outcome for C. It would be usual to treat for HIT urgently until proven otherwise, however, the investigations C received were focused on nerve entrapment or stroke. Had it been the case that C was suffering from a stroke, it would likely have occurred as a consequence of HIT, not as an independent occurrence. The link between HIT and the presence of a stroke had not been made and there was a failure to recognise the need to act on the likely diagnosis of HIT and start treatment straight away.

The Adviser noted the Board’s LAER report did not recognise that the haematology experts, both the DVT clinic and the on-call haematologist, failed to identify the significant change in C’s blood results which had occurred even before C first presented with leg symptoms. It was of significant concern that although junior and general medical staff correctly suspected HIT, they did not then receive appropriate specialist support and advice which meant C was not urgently treated for HIT as they should have been. The Adviser further said that they considered this incident to be a serious adverse event. As C was left with a permanent harm, the incident met the requirements for a category one Significant Adverse Event Review, as set out in guidance issued by Healthcare Improvement Scotland. The grounds on which a LAER or SAER would be commissioned were unclear in the Board’s policy, however, on balance it was unreasonable that this had not been investigated as a SAER.

In light of the evidence I have seen and the advice I have received and considered, I found that:

i. There was a failure to appropriately review and monitor C’s platelet count at the DVT clinic;

ii. There was a failure to appropriately assess and diagnose C for suspicion of HIT; provide appropriate haematology advice to medical staff and review and document C’s response to pain relief; and

iii. the Board’s handling of C’s complaint was unreasonable including their handling of the LAER

As such, I upheld C’s complaints.

 

Redress and Recommendations

The Ombudsman's recommendations are set out below:

What we are asking the Board to do for C:

Complaint number

What we found

What the organisation should do

What we need to see

(a) 
  • The care and treatment provided by the Board to C in April and May 2021 was unreasonable. Specifically, the Board failed to:

i. appropriately review and monitor C’s platelet count at the DVT clinic.

ii. appropriately assess and diagnose C for suspicion of HIT taking into account the timeframe of onset of symptoms or consider the working diagnosis of stroke as a likely manifestation of HIT.

iii. provide appropriate haematology advice to medical staff 

iv. appropriately review and document C’s response to pain relief medication once their pain had escalated.

Apologise to C for the failings identified in this report.

The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.
  • A copy or record of the apology

By: 24 January 2024

 

We are asking the board to improve the way they do things:

Complaint number

What we found

What should change

What we need to see

(a)
  • Under complaint (a) I found that the Board did not appropriately review and monitor C’s blood test results.

Bloods results should be appropriately reviewed and patients receiving heparin injections appropriately monitored. Patients should receive appropriate, timely review if any new onset symptoms are reported.
  • Evidence that the findings of this investigation have been fed back to relevant staff in a supportive way for learning and improvement and to avoid a similar mistake being made again.
  • Evidence that the Board have reviewed the DVT clinic’s management and review of patients receiving heparin injections to ensure blood results are timeously reviewed and acted on appropriately.
  • Confirmation of the action taken and details of any resulting action points or procedural changes.

 

By: 20 March 2024
(a)
  • Under complaint (a) I found that the Board did not

i. appropriately assess and diagnose C for suspicion of HIT taking into account the timeframe of onset of symptoms or consider the working diagnosis of stroke as a likely manifestation of HIT.

ii. provide appropriate haematology advice to medical staff.

Patients presenting symptoms as in C’s case should be appropriately reviewed by general and speciality medical staff with reference to the timeframe of onset of symptoms and likely manifestations of HIT, such as stroke, with treatment commenced as appropriate.
  • Evidence that my findings have been shared with relevant staff in a supportive way for feedback and reflection. Evidence that consideration has been given as to whether guidance is required for the management and treatment of suspected cases of HIT.

 

By: 20 March 2024

 

We are asking the board to improve their complaints handling:

Complaint number

What we found

Outcome needed

What we need to see

(b)
  • I found the Board’s handling of C’s complaint was unreasonable. Specifically the Board failed to consider activating the Duty of Candour process at an appropriate time.

When an incident occurs that falls within the Duty of Candour legislation, the Board’s Duty of Candour processes should be activated without delay and the individual notified within the prescribed timescales.

If there is a delay in notification a full explanation should be provided.

 
  • Evidence that the findings on the Board’s complaint handling have been fed back in a supportive manner to relevant staff and that they have reflected on the findings of this investigation.
  • Evidence that the Board have reviewed their Duty of Candour processes, including timescales for activating the process and notifying the individuals concerned with details of how the guidance, and any changes, will be disseminated to relevant staff.

 

By: 20 March 2024

 
(b)
  • I found that the Board failed to undertake a reasonable adverse event review that identified key learning from C’s complaint.

i. It failed to keep C informed of the process and the reasons for selecting a LAER, rather than SAER.

ii. It failed to identify key learning from the circumstances of C’s complaint.

iii. Significant (rather than a Local) adverse event review should have been held in line with relevant guidance.

 Local and Significant adverse event reviews should be reflective and learning processes that ensure failings are identified and any appropriate learning and improvement taken forward. The Board’s adverse event policy should be consistent with HIS guidance, and the type of investigation undertaken should be appropriate to the level of category identified.
  • Evidence that the Board have reviewed the Adverse Event Policy, the conclusions of the review and any actions taken as a result.

 

By: 17 April 2024

 

Evidence of action already taken

The Board told us they had already taken action to fix the problem. We will ask them for evidence that this has happened: 

Complaint number

What we found

Outcome needed

What we need to see

(b)
  • The Board’s handling of C’s complaint was unreasonable.

The outcome of the local adverse event review had been shared with the key individuals involved for reflection and learning to include improvement in documentation. Teaching sessions were in progress, commencing in July 2022.
  • Evidence that the Board have taken action in relation to this

 

By: 21 February 2024

 

Feedback

Points to note

The Adviser noted that the policy for the management of superficial vein thrombophlebitis does not include information about the monitoring of blood results which should be done for patients being treated with heparin. If this information is included in a separate policy, it is suggested that consideration is given to including a link or reference to the relevant policy that gives such detail, or to include the detail in the SVT policy itself.

Related reading

  • Report no:
    202202065
  • Date:
    August 2023
  • Body:
    Forth Valley NHS Board
  • Sector:
    Health

The complainant (C) complained to my office about the care and treatment provided by the Board. C was admitted to hospital in August 2021 with severe abdominal pain, nausea and vomiting. C underwent a CT scan of the abdomen, which showed localised perforation of the bowel. They were diagnosed with complicated diverticulitis and treated with intravenous (IV) antibiotics and discharged four days after being admitted. C was re-admitted to hospital within a few days and underwent an emergency Hartmann’s procedure in which most of their bowel was removed and a stoma created. C complained that the original decision to discharge them was unreasonable.

At the time of discharge home following their surgery, C was told they would have consultant follow-up in six to eight weeks. They complained that did not happen and they had to chase the Board for an appointment. They developed hernias at the surgery site and complained about the length of time taken to provide them with further treatment. C’s consultant follow-up appointment took place in April 2022, seven months after their discharge. They were advised they may require further surgery in relation to the hernias that had developed. C faced further wait times for scans, and in January 2023 they underwent hernia surgery.

In their complaint, C explained that, following their surgery on 25 August 2021, they were advised that most of their bowel had been removed and that they had been left with a permanent stoma. During my investigation, I sought independent advice from a Consultant Colorectal and General Surgeon (the Adviser). The Adviser explained that, in their experience, it is almost always technically possible to reverse a stoma created during a Hartmann’s procedure such as C had. The Adviser commented that there was no indication of a discussion having taken place with C regarding their stoma being temporary. With C’s agreement, we expanded our investigation to include the complaint that communication with C was unreasonable in relation to the permanence of the stoma.

In responding to the complaint, the Board considered that the decision to discharge C had been reasonable. They acknowledged there had been an unreasonable delay in providing C with a follow-up appointment with a consultant, which they explained had been due to human error. The Board considered that C had been prioritised correctly for their hernia surgery. After we expanded our investigation to include the complaint about communication in relation to the permanence of the stoma, the Board arranged a consultation with C during which the possibility of stoma reversal was discussed.

Having considered the advice received, I found that:

  • The decision to discharge C from hospital in August 2021 was unreasonable and was not supported by evidence of repeat tests and appropriate clinical review.
  • There was an unreasonable delay to C being offered a follow-up appointment post- surgery and a subsequent delay in them receiving hernia repair surgery.
  • The Board failed to communicate reasonably with C regarding the possibility of their stoma being reversible.
  • The Board’s complaint response was unreasonable.

As such, I upheld C's complaints

 

Recommendations

The Ombudsman's recommendations are set out below:

What we are asking the Board to do for C:

Rec number

What we found

What the organisation should do

What we need to see

1

The decision to discharge C from hospital in August 2021 was unreasonable and not supported by evidence of repeat tests and appropriate clinical review, in particular before switching to oral antibiotics.

There was a failure to document the rationale for discharge and complete the safety checklist which could have prompted a better assessment of C’s suitability for discharge.

The discharge summary documentation was not completed timeously, including to C’s GP and there is no evidence that C was provided with appropriate advice on discharge.

There was an unreasonable delay to C being offered a follow-up appointment post-surgery and a subsequent delay in them receiving hernia repair surgery.

The Board failed to communicate reasonably with C regarding the possibility of their stoma being reversible.

The Board’s complaint response was unreasonable

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

Given the delays C has experienced the Board should, as a matter of urgency, provide them with a clear treatment plan and timeline for the follow up assessments required including any future surgical treatment that is decided on following assessment.

A copy of the apology letter.

A copy of the treatment plan.

By: 15 September 2023 

                                                                                                                                                                                             

We are asking the board to improve the way they do things:

Complaint number

What we found

What should change

What we need to see

2

The decision to discharge C from hospital in August 2021 was unreasonable and not supported by evidence of repeat tests and appropriate clinical review, in particular before switching to oral antibiotics.

There was a failure to document the rationale for discharge and complete the safety checklist which could have prompted a better assessment of C’s suitability for discharge.

The discharge summary documentation was not completed timeously, including to C’s GP and there is no evidence that C was provided with appropriate advice on discharge.

Patients’ suitability for discharge should be appropriately assessed and their condition appropriately reviewed, including where appropriate antibiotic therapy regimes, prior to discharge.

The rationale for discharge should be properly documented and any relevant documentation completed (for example, safety checklist) timeously.

Immediate discharge letters should be issued at the time of discharge and patients should receive appropriate advice on discharge which should be documented.

Evidence that the Board have reviewed their management of complicated diverticular disease with specific reference to:

(i) the assessment and clinical review of patients prior to discharge (including decision-making in relation to antibiotic therapy)

(ii) ensuring the rationale for discharge is clearly documented and, where appropriate, the safety checklist is completed, and

(iii) the provision of discharge information to the patient and their GP on discharge. Confirmation of the action taken and details of any resulting action points or procedural changes.

Evidence that this decision and findings have been fed back to relevant staff, in a supportive manner, for reflection and learning.

By: 16 October 2023
3 There was an unreasonable delay to C receiving a follow-up appointment post-surgery and a subsequent delay in them receiving hernia repair surgery.

Patients should receive timely follow up and any subsequent surgery that may be required without delay.

Evidence the Board has in place a robust system to arrange follow-up appointments for emergency admissions that ensures appointments are made and are on the system in a timely manner Evidence that the Board have reviewed their processes for listing patients requiring hernia repair to ensure that cases are expedited appropriately Confirmation of the outcome of the Board’s consideration including any resulting action points.

By: 16 October 2023
4 The Board failed to communicate reasonably with C regarding the possibility of their stoma being reversible. Patients should be fully advised of any potential future treatment options to enable them to make an informed choice without delay.

Evidence that this decision and findings have been fed back to relevant staff, in a supportive manner, for reflection and learning.

By: 16 October 2023

We are asking the Board to improve their complaints handling:

Complaint number

What we found

Outcome needed

What we need to see

5

The Board’s complaint response was unreasonable.

There was a failure to investigate and respond to all the concerns raised by C and provide an appropriate response that recognised the significance of the events for C.

The Board’s complaint handling monitoring, and governance system should ensure that

(i) complaints are properly investigated and responded to in line with the NHS Scotland Model Complaints Handling Procedure.

(ii) failings and good practice are identified, and learning from complaints is used to drive service development and improvement. 

(iii) complaint responses recognise and acknowledge the significance and human impact of the events complained about.

Evidence that the findings on the Board’s complaint handling have been fed back in a supportive manner to relevant staff and that they have reflected on the findings of this investigation. (For example, a copy of a meeting note of summary of a discussion.)

By: 16 October 2023

 

 

Related reading

  • Report no:
    201803897
  • Date:
    January 2020
  • Body:
    Fife NHS Board
  • Sector:
    Health

Summary

Mrs C complained about the care and treatment her mother (Mrs A) received at Victoria Hospital.  Mrs A was admitted to hospital with a suspected infection in her leg, but died shortly afterwards.  Mrs C said that the Board gave contradictory and incomplete replies to her questions about Mrs A's treatment.  In particular, Mrs C believed that Mrs A's existing longstanding health condition, medications and associated immunosuppression had not been properly taken into account during her treatment.  Mrs C was also concerned that medical staff did not communicate reasonably with the family during Mrs A's admission, which meant Mrs A's death had been unexpected and traumatic.  Mrs C noted that the Board had failed to respond comprehensively to the questions she had asked, despite multiple meetings with staff, and a protracted correspondence.  Finally, Mrs C said that Mrs A's death certificate contained errors, and that the Board had not made an adequate effort to correct these. 

We took independent medical advice from a consultant in acute medicine.  We found that there were significant failings on the part of the Board.  The advice noted that there was no record that the most significant drugs Mrs A was receiving were identified by medical staff or taken into account in her treatment.  In addition, although Mrs A had received initial treatment with antibiotics, this had been stopped and there was no detail or reasoning for this recorded in Mrs A's medical records.  Following Mrs A death, the Board did not appear to have properly followed its own procedures for reviewing incidents where a patient had come to harm.  We considered that Mrs A did not receive a reasonable standard of care and treatment and upheld this aspect of Mrs C's complaint. 

We also found that the Board had failed to take reasonable steps to ensure Mrs A's death certificate was accurate.  This included a failure to attempt to correct the death certificate.  We upheld this aspect of Mrs C's complaint. 

In relation to communication with the family, we did not uphold this aspect of Mrs C's complaint.  Although we recognised that the family had found Mrs A's deterioration distressing, the standard of communication between medical staff and the family was reasonable.

Finally, we found that the Board failed to handle Mrs C's complaint reasonably and upheld this aspect of her complaint.

 

Redress and Recommendations

The Ombudsman's recommendations are set out below:

What we are asking the Board to do for Mrs C:

Complaint number

What we found

What the organisation should do

What we need to see
(a), (b) and (d)

The Board failed to provide reasonable care and treatment to Mrs A, the Board failed to provide an accurate death certificate for Mrs A and the Board failed to handle Mrs C's complaint reasonably

Apologise to Mrs C for the failures identified in the report.

 

The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets

A copy of the apology.

 

By:  19 February 2020
(b)

The Board failed to issue an accurate death certificate for Mrs A

Issue an accurate Form 11 (new medical certificate of death), so that the family can provide this to the Vital Events Team at the National Records of Scotland

A copy of the Form 11, with evidence it has been provided to the family

 

By: 5 February 2020

We are asking the Board to improve the way they do things:

Complaint number

What we found

Outcome needed

What we need to see
(a)

The Board appeared to have failed to follow their own guidance on reporting on adverse incidents and holding SAERs

Review this case in light of the relevant guidance on SAERs, to determine why this was not followed

 

A copy of the review

 

By: 19 February 2020
(a) The Board had failed to resolve the questions over staff access to medical records and the decision to stop antibiotic therapy for Mrs A

Staff should have access to medical records and other patient information to ensure that treatment takes account of appropriate information at the appropriate time.

Decisions about care and treatment should be clearly and accurately documented

Evidence of a SAER into Mrs A's care and treatment.  This should include whether Mrs A's rheumatology records were accessed by medical staff and investigate whether staff were able to access rheumatology records.  It should also review the decision to stop Mrs A's antibiotics, to establish why this decision was taken.

A copy of the review report should be provided, including any action plans put in place as a result of it

 

By:  22 April 2020
(b) The Board failed to issue an accurate death certificate for Mrs A The Board should have adequate systems in place to ensure that death certificates are accurate when issued 

The Board should demonstrate they have reflected on the mistakes made in Mrs A's case and report any resulting changes to processes for completing and issuing death certificates

 

By: 4 March 2020

We are asking the Board to improve their complaints handling:

Complaint number What we found Outcome needed What we need to see
(d)

We found the Board's complaint investigation had not answered all the questions raised by Mrs C and had failed to identify and address significant failings on the part of the Board

The Board should ensure complaint investigations conform to the NHS model complaints handling procedures, particularly in relation to time scales.  It should ensure that all the issues raised by complainants are addressed, or explain clearly why it is not appropriate to do so

Evidence that the Board have reviewed the complaint investigation and established why it failed to respond to all the questions raised, or identify significant failures on the part of the Board.  This should include the actions the Board intends to take to improve its complaint handling

 

By:  4 March 2020

Related reading

  • Report no:
    201201639
  • Date:
    May 2013
  • Body:
    Lanarkshire NHS Board
  • Sector:
    Health

Overview
The complainant (Mrs C) raised a number of concerns that sub-standard ultrasound equipment or human error meant that a pregnancy she conceived during her fifth cycle of Intra Uterine Insemination (IUI) treatment was not detected. Mrs C complained that this resulted in the pregnancy being destroyed during the sixth cycle of IUI treatment.

Specific complaints and conclusions
The complaints which have been investigated are that:

  • (a) it was unreasonable that Mrs C's pregnancy was not detected on 30 and 31 August 2011 (not upheld);
  • (b) the scanning equipment used on 30 and 31 August 2011 was not of a reasonable standard (upheld); and
  • (c) it was inappropriate that no record was made of the irregular pain and discomfort Mrs C experienced during the procedure carried out on 1 September 2011 (not upheld).

 

Redress and recommendations
The Ombudsman recommends that Lanarkshire NHS Board:

  • (i) issue a written apology for the failing identified; and
  • (ii) review the IUI recording form to incorporate space for recording symptoms reported by the patient.

 

The Board have accepted the recommendations and will act on them accordingly.

Related reading

  • Report no:
    201104614
  • Date:
    November 2012
  • Body:
    Scottish Prison Service
  • Sector:
    Scottish Government and Devolved Administration

Overview
The complainant, Ms C, who is a prisoner, complained that HMP Cornton Vale were restricting her progression to less secure conditions. Ms C said that when her appeal against her conviction finalised early in 2011, she was told she would begin preparations for progression to less secure conditions but Ms C felt those preparations were not happening appropriately.

Specific complaint and conclusion
The complaint which has been investigated is that HMP Cornton Vale are unreasonably preventing Ms C from progressing to less secure conditions (upheld)

 Redress and recommendations
The Ombudsman recommends that the Scottish Prison Service:

  • (i) review Ms C’s case as a matter of urgency to ensure that appropriate and reasonable steps are being taken to progress Ms C to the National Top End in line with relevant policy; and
  • (ii) undertake a review of practice being applied at HMP Cornton Vale in relation to the progression of those prisoners who do not admit guilt to ensure that staff are managing those cases appropriately and in line with relevant policy.

Related reading

  • Report no:
    201101316
  • Date:
    November 2012
  • Body:
    North Lanarkshire Council
  • Sector:
    Local Government

Overview
The complainant (Mrs C) raised a number of concerns about North Lanarkshire Council (the Council)'s failure to take effective enforcement action against the developer of a number of houses, including the house she owns. In particular, she was concerned that, over a number of years, the Council had failed to ensure that the developer of the site complied with the conditions attached to a planning consent granted in 2002.

Specific complaint and conclusion
The complaint which has been investigated is that the Council failed to take reasonable and timely enforcement action against the developer responsible for building Mrs C's home, to address breaches in planning conditions (upheld).

Redress and recommendations
The Ombudsman recommends that:

  • (i) in the event of the owners of the properties covered by the planning conditions themselves taking forward a scheme to carry out the works required, to upgrade the road under planning conditions 7 and 8 (to ensure the provision of satisfactory vehicular and pedestrian access), the Council meet the reasonable costs associated with the works; and
  • (ii) the Council apologise to Mrs C for the failings identified in their handling of the enforcement action, including their failure to clarify the position with regard to the communal driveway.

 

Ombudsman's Comment
Recommendation (i) cannot be an open ended commitment for the Authority. I consider that the works should be instructed within a period of three years from the date of this report.

Related reading

  • Report no:
    201200068
  • Date:
    October 2012
  • Body:
    A Medical Practice in the Forth Valley NHS Board area
  • Sector:
    Health

Overview
The complainant (Mrs C) raised a number of concerns that her sister, Ms A, reported to her GP practice (the Practice) symptoms of increasing chest, neck and back pain which were not properly investigated. Strong analgesia had little or no effect but the practice continued to issue prescriptions for morphine without physically assessing Ms A. In late December 2011 Ms A was referred to hospital by a GP from NHS 24 where bone cancer was diagnosed. Shortly following the diagnosis, in early January 2012, one of Ms A's vertebra in her neck collapsed and she is now paralysed from the neck down. She has been told that her cancer is terminal and in May 2012 was told that she only has months to live.

Specific complaints and conclusions
The complaints which have been investigated are that the Practice:

  • (a) unreasonably failed to make timely and appropriate investigations to establish the cause of the symptoms reported by Ms A (upheld);
  • (b) unreasonably failed to make any referrals for specialist opinions in view of Ms A's symptoms (upheld); and
  • (c) inappropriately issued prescriptions for morphine without physically assessing Ms A (upheld).

 

Redress and recommendations
The Ombudsman recommends that the Practice:

  • (i) issues a written apology for the failings identified in this report;
  • (ii) carry out a Significant Event Audit (SEA) on this case;
  • (iii) carry out a review of a case note sample to assess the quality of examinations conducted and the information recorded; and
  • (iv) completes the review of how acute prescriptions are issued and put a robust monitoring system in place.

 

The Practice have accepted the recommendations and will act on them accordingly.

Related reading

  • Report no:
    201101643
  • Date:
    September 2012
  • Body:
    Scottish Prison Service
  • Sector:
    Scottish Government and Devolved Administration

Overview
The complainant, Mr C, who was a prisoner, complained about the decision taken by Prison 1 to transfer him to Prison 2. Mr C said the decision was unreasonable because he was about to start medical treatment for his skin condition at Prison 1. Mr C also complained because he said Prison 1 did not explain to him why he was being transferred to Prison 2.

Specific complaints and conclusions
The complaints which have been investigated are that:

  • (a) the decision taken by Prison 1 to transfer Mr C knowing he was about to start medical treatment was unreasonable (upheld); and
  • (b) Prison 1 failed to communicate the reason for the decision to transfer Mr C to Prison 2 and that was inappropriate (upheld).

 

Redress and recommendations
The Ombudsman recommends that the Scottish Prison Service:

  • (i) take steps to put in place a national process for all prison establishments to follow when transferring prisoners to other establishments to ensure the process followed allows for significant and relevant information to be obtained, considered and recorded as part of the decision making process and;
  • (ii) ensure Prison 1 apologise to Mr C for failing to respond to him directly about his complaint.

Related reading

  • Report no:
    201102756
  • Date:
    September 2012
  • Body:
    Forth Valley NHS Board
  • Sector:
    Health

Overview
The complainant, Mr C, raised a number of concerns about the care and treatment given to his father (Mr A) during the final days of his life.

Specific complaints and conclusions
The complaints which have been investigated are that:

  • (a) nursing staff at Bannockburn Hospital (Hospital 1) failed to recognise that Mr A's condition was such that he required appropriate medical assistance (not upheld);
  • (b) two out-of-hours doctors who separately attended Mr A assessed and treated him inappropriately. In particular, they failed to recognise his poor condition and arrange for a transfer to Stirling Royal Infirmary (upheld);
  • (c) the decision making, care and communication of nursing staff in relation to the provision of palliative care for Mr A was inappropriate (upheld);
  • (d) nursing staff inappropriately refused to provide even the most basic of medical records to a medically qualified relative, despite him having Mr C's consent as next of kin with welfare power of attorney (not upheld);
  • (e) a staff nurse refused to allow a medically qualified relative to speak to Mr A's on call consultant and the on call consultant failed to recognise the importance of having this conversation (not upheld);
  • (f) an inappropriate care and treatment plan was agreed between the staff nurse and the on call consultant pending the arrival of an out-of-hours doctor (not upheld);
  • (g) during his stay in Hospital 1, Mr A's consultant failed to make himself available to meet with Mr C, who was next of kin with welfare power of attorney. This was despite Mr C's best efforts (not upheld); and
  • (h) during Mr A's stay in Hospital 1 there was an unacceptable level of care with regard to his possessions, which resulted in the unacceptable loss of his spectacles for some weeks and his hearing aid which was never recovered (not upheld).

 

Redress and recommendations
The Ombudsman recommends that Forth Valley NHS Board:

  • (i) complete a critical incident review regarding this situation, if they have not done so already;
  • (ii) consider the practicality of having routine discussions regarding care escalation for patients admitted to Hospital 1 and other similar units;
  • (iii) consider the means by which it can be ensured that severe illness is promptly recognised in such units, by use of a Scottish Early Warning Score or similar scoring system;
  • (iv) consider a strategy for determining the appropriate limits of care as soon as a patient in Hospital 1 or similar unit becomes acutely unwell and where there has been no anticipatory care discussion;
  • (v) emphasise to staff in Hospital 1 the importance of keeping full and proper records, including notes of conversations and telephone conversations; and
  • (vi) remind Hospital 1 staff of the Do Not Attempt Cardiopulmonary Resuscitation Policy and provide evidence that they have done so.

 

The Board have accepted the recommendations and will act on them accordingly.

Related reading

  • Report no:
    201102194
  • Date:
    July 2012
  • Body:
    South Lanarkshire Council
  • Sector:
    Local Government

Overview
The complainant (Mr C) bought a recently constructed property in a small rural development. He and other residents experienced a problem with low water pressure in the water supply to their homes. He considered that to be as a result of South Lanarkshire Council (the Council) not taking appropriate action when the developer informed them of a change in source of the water supply a year after planning consent was granted.

Specific complaint and conclusion
The complaint which has been investigated is that the Council, in dealing with the planning application for the development, failed to ensure that the developer provided an adequate water supply to the site (upheld).

Redress and recommendations
The Ombudsman recommends that the Council:

  • (i) apologise for their failure to take appropriate action in respect of the letter of 4 September 2006 from the developer; and
  • (ii) consider, in the light of the circumstances detailed in this report, whether they should contribute to the costs incurred in securing a satisfactory water supply.

Related reading

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