Health

Summary

C complained that the board failed to provide reasonable personal care and treatment to their sibling (A). A was admitted to hospital to initiate and titrate Clozapine (an antipsychotic drug used to treat schizophrenia and other psychotic disorders). A had a history of diabetes and experienced episodes of incontinence which placed A at greater risk of infection. C complained that the discharge letter did not mention a pressure sore which was treated by A's GP upon discharge. This could have resulted in A’s Clozapine treatment being temporarily suspended.

We took independent advice from a mental health nurse and from a wound-care specialist nurse. We found that A’s feet were examined following concerns raised by C. However, no treatment was prescribed and the doctor's advice about caring for A’s feet was not passed on to C. We found that there was no conclusive evidence to determine whether A had a pressure sore or an ulcer which might have impacted on A’s Clozapine treatment. We also found that it was reasonable for the board to conclude that the wound A had was not a pressure ulcer. However, the board failed to evidence that relevant assessments relating to pressure ulcer risk and skin inspections were carried out. We also found that there was no person centred care plan in place to identify A’s needs in relation to activities of daily living, including personal hygiene. We found that the immediate discharge letter was dated the day after discharge which suggests it was not available to C at the point of discharge, or on the same day, when it should have been. Therefore, we upheld C’s complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the specific personal care and treatment failings. The apology should meet the standards set out in the SPSO guidelines on apology available at HYPERLINK "http://www.spso.org.uk/information-leaflets" www.spso.org.uk/information-leaflets .

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

• Patients should be appropriately assessed and treated by staff. Where clinical needs are identified via assessment, corresponding interventions should be planned and initiated to address the situation and prevent complications arising. Care should be provided in line with the assessments carried out and in a timely manner. Records about a patient's care and treatment and decisions made should be clearly and accurately documented and accord with the relevant professional standards and guidelines and reflect a person-centred approach. Patient's records should include clear details explaining why a decision about care and treatment has been made, and show that this has been communicated appropriately.
• The board should ensure that immediate discharge information reaches the GP as soon as is practicable in every case, ideally on the day of discharge, in order that GPs receive essential information that enables continuity 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 standard of care provided by the board to their parent (A). A had a complex medical history including depression for which they were on three types of anti-depressants. This was noted when A was admitted to hospital but staff failed to provide A with their prescribed medication and inform A and their family that the medication had not been given to them. This led to A’s mental health deteriorating.

We took independent advice from a registered nurse. We found that the board failed to deliver the required service in relation to medicines, maintain adequate recordkeeping, communicate appropriately, recognise the harm done to A and undertake the appropriate review. Therefore, we upheld this part of C’s complaint.

C complained that the board failed to deal with their complaint in a reasonable way. We found that the board’s investigation did not look into an important part of the complaint and that their response did not address the impact on A as a result of the medication being withheld. Therefore, we upheld this part of C’s complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failings identified in this investigation in relation to the standard of medical care and complaint handling. The apology should meet the standards set out in the SPSO guidelines on apology available at HYPERLINK "http://www.spso.org.uk/information-leaflet" www.spso.org.uk/information-leaflet .

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

• Clinical records should appropriately document the action taken to ensure prescribed medication has been reconciled and administered to the patient and medicine reconciliation documentation appropriately completed. Where clinical staff are unable to do so, there should be appropriate communication with the patient and/or their family about this.
• Where an adverse event occurs there should be a thorough review in line with relevant national guidance to ensure that there is appropriate learning and service improvement to enhance patient safety. Where an incident occurs that falls within the Duty of Candour legislation, the board's Duty of Candour processes should be activated without delay.
• Patients admitted to hospital should have their prescribed medicine reconciled without delay and in line with the relevant standards.

In relation to complaints handling, we recommended:

• Complaints should be investigated fully and the complaint response should address all the points raised 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.

Summary

C’s elderly spouse (A) spent approximately ten weeks in hospital. While in hospital, A fell on two occasions. C complained about the medical, nursing and physiotherapy care and treatment provided by the board.

We took independent advice from a consultant geriatrician (specialist in medicine of the elderly). We found that the medical care after A’s falls was reasonable. We found that the board had taken reasonable and proportionate actions to acknowledge, apologise for and support learning and improvement regarding the provision of pain relief and a delay in reviewing an x-ray after A’s first fall. We found that the board did not reasonably handle A’s prescriptions for haloperidol (a sedating medication) or codeine (a type of painkiller). On balance, we upheld this part of C’s complaint.

We took independent advice from a registered nurse. We found that the care and treatment regarding A’s falls was unreasonable, as a mechanical aid should have been used to assist A from the floor, and risk assessments and care plans should have been updated. We found that A should have been more closely supervised prior to their second fall. We also found that the board’s post-fall protocol was not reasonable in its current form. Finally, we found that A’s hygiene needs were not reasonably met in hospital. The board had taken some action to support learning and improvement regarding the management of falls. On balance, we upheld this part of C’s complaint.

We took independent advice from a physiotherapist. We found that the care and treatment provided to A was reasonable, and physiotherapy sessions were appropriate, timely and sufficient, considering A’s clinical presentation. We did not uphold this part of C’s complaint.

Additionally, we found that some points of the board’s complaint response were incomplete and made a recommendation to address this.

Recommendations

What we asked the organisation to do in this case:

• Apologise to A for the failings identified by this investigation. The apology should meet the standards set out in the SPSO guidelines on apology available at http://www.spso.org.uk/meaningful-apologies.

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

• Patients with dementia should receive regular assessments of the benefits of medication, with consideration given to stopping or reducing medication when possible, and patients' families/carers should be informed appropriately.
• Nursing staff should handle falls using safe handling techniques in order to reduce risk to patients and staff. Nursing staff should have access to a reasonable and up-to-date post-falls protocol.
• Nursing staff should ensure patients' physical needs are appropriately assessed and responded to.

In relation to complaints handling, we recommended:

• The quality of the complaint response is very important and should address all the issues raised and demonstrate that each element has been fully and fairly investigated.

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 spouse (A). A had a history or recurring urinary tract infections (UTI's) and was self-catheterising. The board gave A an indwelling (long-term) catheter to be changed every three months. Over the next several months, A attended A&E five times before being admitted and diagnosed with bladder cancer. C complained about the lack of arrangements to change A’s indwelling catheter, that requests for appointments were ignored and that A was only admitted after multiple visits to A&E.

We took independent advice from a consultant urologist (specialist in the male and female urinary tract, and the male reproductive organs), consultant in emergency medicine and a medical director specialising in palliative care. We found that, as the indwelling catheter was a trial, the board should have followed up with A on their progress. There was also unreasonable delays in A being seen by urology and in being advised of their cancer diagnosis. While it was reasonable that A was not admitted by A&E for examination sooner, the board acknowledged that there was a missed opportunity. Therefore, we upheld this part of C's complaint.

C also complained that A’s cancer diagnosis, discharge and care arrangements were not clearly explained. We found that the board made reasonable efforts to explain the cancer diagnosis to C and A. However, they did not reasonably communicate how they might manage once A was discharged home, and about the challenges associated with A reaching end of life. Therefore we upheld this part of C's complaint.

In relation to complaint handling, we found that the information provided to both C and this office was inaccurate in places and incomplete. Therefore, we made a recommendation to improve the board's complaint handling.

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 HYPERLINK "http://www.spso.org.uk/information-leaflets" www.spso.org.uk/information-leaflets .

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

• When a relevant adverse event occurs, the board should carry out a Significant Adverse Event Review (SAER) to investigate the cause and identify any potential learning.
• Patients should receive timely review, follow-up appointments and information based on their clinical needs and presentation and in accordance with relevant guidelines. A's case should be reviewed at the local Morbidity & Mortality meeting with a view to identifying opportunities that were missed to progress A's diagnosis and ways of ensuring similar delays do not affect future patients. The Board should consider whether this case could be used as an opportunity to reflect and improve the interface between the urology and emergency departments in order to minimise the risk of a similar case occurring again.
• Discharge planning should be person-centred and holistic and clear to patients, families and community services. In particular, the palliative care team may support complex discharges but it is the ward team who are best placed to support the patient's discharge. Teams should not just focus on their area of interest e.g. urology but on caring for the whole person. Patients with palliative care needs should be supported within their limited function to live well. Expectation of rehab should be realistic. Staff should explore what is realistic, what the patient and their families' concerns are and also be brave and explore where there are gaps in the system of support, what the best possible mitigation is. There should be thorough documentation of this. Spiritual / other support should be available. They are non-denominational / nonfaith and provide support to patients and families. Learning sessions should occur around recognising a palliative deterioration or the acute deterioration covered by NEWS. Recognising someone heading to the end-of-life phase is essential, as are developing communication skills to support staff to engage with patients and families.

In relation to complaints handling, we recommended:

• Information provided to SPSO and the complainant should be accurate and complete. All relevant records in relation to an SPSO investigation should be provided from the outset of our enquiries.

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 their late partner (A)’s discharge from hospital was unreasonable. A was admitted to hospital with pneumonia and was discharged after ten days. Less than two weeks after discharge, A collapsed and was readmitted to hospital. A died a few days later. C questioned whether A had been fit for discharge. They also raised concerns about not receiving adequate education on the new medications that A was prescribed on discharge.

The board noted that A’s infection had improved with antibiotic therapy and that they had been stable and well enough for discharge home. They explained the rationale for the medications that A had been prescribed and apologised that medical staff did not have a better discussion with them at the time of A’s discharge.

We took independent advice from a consultant in acute and general medicine. We found that A's oxygen levels had been stable and their discharge was clinically reasonable. However, we noted that A's sodium level had been low during their admission but had improved on discharge. We found that no follow-up arrangements were made to ensure that A's sodium level was continuing to improve after their discharge. The working diagnosis on A's readmission was that they had had a seizure due to low sodium which led to hypoxia (deficiency in the amount of oxygen reaching the tissues) and cardiac arrest. It is possible that the fall in A's sodium level could have been detected had there been follow-up to re-check this. Therefore, we upheld C's complaint.

We also noted a discrepancy between the working diagnosis on A’s re-admission and the recorded cause of death on the death certificate. This was not identified by the board. Therefore, C was not provided with a coherent narrative of events surrounding A’s death and 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 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.

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

• There should be robust discharge systems and processes in place, ensuring appropriate communication with patients and carers, and adequate detail in discharge documentation.
• Patients who are discharged with moderately low sodium levels, should be followed up to check that improvement is maintained. There should be clear guidance in place around this, to ensure it happens where indicated.
• The death certification process should be accurate and consistent with the clinical 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 complained that the board failed to reasonably communicate with their family when their parent (A) was admitted to hospital. A was taken to A&E following a fall at home.

A was moved to a ward following an x-ray and medical review showing that A had broken their hip. A underwent an operation later that day and remained in hospital until their discharge nearly seven weeks later. C also complained about the nursing care that A received.

We took independent advice from a nurse. We found that there was a failure to communicate with the family about the consequences of delirium. We also found that there was a failure to ensure A had access to bread/toast and milk. There was a lack of acknowledgement and details regarding A’s lost dentures, a failure to inform A or C that A had developed a hospital acquired pressure ulcer, poor record keeping and a lack of evidence of appropriate nutritional care interventions being followed. Therefore, we upheld C’s complaints.

Recommendations

What we asked the organisation to do in this case:

• Apologise to A and 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 HYPERLINK "http://www.spso.org.uk/information-leaflets" www.spso.org.uk/information-leaflets .

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

• Where appropriate, there should be discussions with family members in relation to diagnosis, treatment and management. An appropriate record of this should also be made.
• Blankets should be available for patients on wards, particularly those that care for elderly, frail patients. When wards run out of blankets, there should be a process in place to obtain replacements without delay.
• Bread and milk should be made available on the ward in line with the Food in Hospitals specification. Toast should be made available to patients where this has been specifically agreed.
• Patients should be changed into nightwear as appropriate or offered a hospital gown where no personal nightwear is available.
• Patients experiencing delirium should be given additional assistance to help secure or monitor their personal possessions and in particular, dentures.
• Staff should be compliant with the Duty of Candour legislation and inform patients/relatives if they come to harm.
• Patient documentation should be completed to an appropriate standard and in line with the required standards of the Nursing and Midwifery Council: The Code in relation to record keeping.
• Patients admitted to hospital should receive appropriate nursing care including appropriate nutritional and fluid intake monitoring and recording. In addition, this should be appropriately documented.

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 adult child (A) received from the practice following their discharge from hospital.

C complained that A had struggled to get an appointment with a GP and that the practice failed to provide a reasonable standard of care in relation to pain management, A’s mental health needs, and follow-up with the health board.

The practice said that they were short-staffed and had been working on an emergency-only basis at the time of the complaint. When A had enquired about seeing a GP, there had been no indication that an emergency appointment was required. A was advised to phone again the next day or to attend A&E.

In respectof A’s pain, the practice said that the discharge medication had been managed in accordance with their policy and in recognition of the nation-wide shortage of the drugs prescribed. A was given an appointment to discuss pain when they reported that the medication was not working and a prescription for nerve pain was given.

In reference to A’s mental health, the practice said that this was discussed during a phone appointment. However, A had breached the practice’s zero tolerance policy during the conversation. A was issued with a warning letter after the incident but was not removed from the practice (as would be policy) in recognition of the mental health difficulties that they were experiencing.

This incident was reviewed as a part of a Significant Event Analysis Review (SEAR) and the practice identified learning to manage this type of occurrence in the future.

In respect of A’s follow-up with the health board, the practice confirmed no post-discharge requests had been made and that it was the responsibility of the hospital to issue clinic appointments.

We took independent advice from a GP. We found that the practice had reasonably managed the discharge prescription for pain medication. While A had been appropriately directed to other services when no appointments were available, we found that the messaging could have been clearer and that reception staff had unreasonably provided advice about pain medication.

We considered A’s appointment with the GP to discuss pain was unreasonable as there was a failure to document any assessment or information to support the nerve pain conclusion reached.

In terms of A’s mental health, we considered that the phone consultation had been reasonably managed, as was the decision to issue a zero tolerance warning letter. The conclusions reached by the SEAR on this matter were also reasonable. We found that the practice’s actions in relation to A’s follow-up with the hospital was reasonable.

On balance, we considered that the care and treatment provided fell below a reasonable standard and we upheld C’s complaint.

Recommendations

What we asked the organisation to do in this case:

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

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

• Advice relating to medical matters should be given by GPs or appropriately qualified members of staff.
• The practice should keep reasonable records of consultations undertaken with patients that clearly record any assessment undertaken and the basis for the diagnosis.

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 spouse (A) when they attended A&E. A had fallen from a height and injured their shoulder. A was x-rayed and diagnosed with a soft tissue injury to the shoulder and a minor head injury. A was discharged home and advised to use regular simple pain relief for the shoulder injury. A was later diagnosed with a rotator cuff injury which required an operation. C said that A should have been correctly diagnosed by the doctor in A&E and that the delay left A in significant pain and distress.

We took independent advice from a consultant in emergency medicine. We found that A should have been reviewed by a senior doctor before discharge. We also found failings in relation to a lack of follow-up and record keeping. Therefore, we upheld C’s complaint.

We also found that C’s complaint was not handled reasonably as there were clear inaccuracies in the board’s complaint response and no reflection on the failings. 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 in this investigation in relation to the standard of care at the A&E and complaint handling. The apology should meet the standards set out in the SPSO guidelines on apology available at  HYPERLINK "http://www.spso.org.uk/information-leaflets" www.spso.org.uk/information-leaflets .

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

• Patients who attend the A&E with a significant soft tissue injury should be provided with a reasonable standard of medical care in relation to the referral process and follow-up.

In relation to complaints handling, we recommended:

• Complaint responses should be clear that failings and their impact are recognised and that any findings from the investigation are supported by the clinical records.

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 is a kidney transplant patient who was suffering from COVID-19 when they were admitted to hospital. C’s COVID-19 worsened and C developed blood clots in their lungs. C was treated with anti-coagulant medication. However, over time C developed a haematoma (a collection of blood) in their right arm and a large haematoma which caused permanent damage to nerves in C’s left thigh. C complained that staff had not been proactive enough in monitoring the effects of the anti-coagulant medication or in managing the blood clots and haematomas. C also complained that a referral to a neurologist should have taken place at the time and would have improved their long term prognosis.

The board explained that the effect of the anti-coagulant was not usually measured, but could be useful in patients with kidney disease. They had therefore monitored as required. Medication was changed due to concerns that the blood clots were getting worse and then stopped in light of the bleed into C’s thigh. A neurology referral was not made, as following discussion with surgical and radiological experts it was determined that supportive therapy was the most suitable management strategy for C’s case.

We took advice from a consultant haematologist and consultant neurologist. We found that C had both blood clots and significant bleeding. Both can be life-threatening, and treating one may make the other worse. We found that the monitoring and management of the anti-coagulant medication and the management of the haematomas and blood clots was reasonable and that it was reasonable not to refer to neurology and not to have considered femoral neuropathy. Therefore, we did not uphold the complaint.

Summary

C complained about the care and treatment provided to their late parent (A). A was admitted to hospital and received treatment for a chest infection and pleural effusion (a build-up of fluid in the chest). A remained in the hospital awaiting discharge arrangements. During a visit to A, C was told that A's bed was needed for a more acute patient and that A would be transferred to a maternity ward as a boarder. C complained that A was not included in this conversation, and that the family felt pressured to accept an unsuitable move. They were concerned that it would negatively impact A’s care and wellbeing due to noise, disruption and the availability of equipment.

The board stated that A had been identified as a patient suitable for boarding and that ward moves are necessary when there is extreme pressure on capacity. The board also considered that the care provided to A was not affected by the move.

We took independent advice from a consultant specialising in acute medicine. We found that A was not considered suitable for boarding under the board's policy. We also found that there had been a failure to conduct and record a full risk assessment, and to record the reasons for this deviation from policy. There was evidence that the move caused A distress leading to a deterioration in their behaviour and acceptance of treatment. Therefore, we upheld this part of C's complaint.

C also complained that the board’s complaint response focussed on allegations of aggressive behaviour from A’s family towards hospital staff. C did not consider that this accurately represented events.

We found evidence of challenging behaviour documented in the available records. However, the board’s complaint response unreasonably focussed on these events, which were not ongoing. Therefore, we considered that the board failed to handle C's complaint reasonably and upheld this part of their complaint.

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 HYPERLINK "http://www.spso.org.uk/information-leaflets" www.spso.org.uk/information-leaflets .

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

• All decisions regarding boarding patients should be made following appropriate clinical considerations and a formal risk assessment. These should be clearly documented. Should a situation arise when a decision is made to deviate from the board's policy due to exceptional pressures, a clear rationale should be documented outlining why the decision has been made and how the risks have been weighed.

In relation to complaints handling, we recommended:

• Complaints should be investigated and responded to in accordance with the NHS 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.