Page 1

SCOTTISH PUBLIC SERVICES OMBUDSMAN ANNUAL COMPLAINTS REPORT 2012–2013

Learning from complaints

Improving complaints handling

Supporting public service improvement

HEALTH


This is one of a series of reports through which we are aiming to put key messages, information and analysis of complaints about individual sectors into the public domain. We anticipate that Parliamentary committees, government departments, scrutiny bodies, regulators and health boards will find this an effective means of enhancing the learning from our work and identifying issues arising from the complaints we see. Equally, we hope it will prove useful to members of the public who seek more information about the kinds of complaints that are escalated to the SPSO and how we handle them.


CONTENTS

Ombudsman’s Introduction

4

Casework

7

Sharing the Learning

17

Improving Complaints Standards

18

Policy and Engagement

19

Case Studies

22

Health Cases Determined 2012/2013

30


OMBUDSMAN’S INTRODUCTION

Complaints are an essential scrutiny mechanism for ensuring accountability, from board to ward and from support worker to chief executive.

We live in the post Francis era. Following the Francis inquiry into the failings at the Mid Staffordshire NHS Trust, there is rightly a greater awareness than ever before on the importance of using complaints as a driver for improvement. Complaints are an essential scrutiny mechanism for ensuring accountability, from board to ward and from support worker to chief executive. I think we do many things well in the NHS in Scotland. The Patient Rights (Scotland) Act 2011 encourages a culture of person-centredness, transparency and candour. The Scottish Government takes an active interest in complaints and in the lessons from our work. I commend the Health Directorate for their longstanding practice of ensuring that our recommendations are implemented by the health board concerned and also shared nationally. I see a strong commitment from many health boards to improving how their staff handle complaints, and using the learning from them to inform improvements. There are examples of excellent practice, with complaints a standing item in board meeting agendas and the underlying issues and resulting improvements discussed in detail. This positive approach is not consistent, however, and I also see examples of

SPSO ANNUAL COMPLAINTS REPORT 2012 > 2013 HEALTH PAGE 4

defensiveness and a lack of willingness to admit mistakes and to learn from them. So, while some things are being done well, there are areas where they can be done better. Frontline staff are key to our work to improve complaints handling procedures. I endorse the Nursing and Midwifery Council’s response to the Francis report where they state that ‘the vast majority of concerns raised by patients should be resolved at the local level. We strongly support the need for more effective local complaints arrangements and the need to encourage an open, learning and patient-focused culture across all healthcare settings.’ I would like to see staff actively seeking feedback from patients, relatives and carers about the service they provide. Taking time to ask questions such as ‘what could we do to resolve your concerns?’ or ‘what would make your experience better?’ could result in higher numbers of issues being sorted out locally and encourage staff to listen and learn from the experiences. This is very much the ethos of the Patient Rights Act, making openness and feedback about NHS services part of the delivery of care, as well as vehicles for change and improvement.


OMBUDSMAN’S INTRODUCTION

Key trends in our figures We saw a 23.5% increase in the number of health complaints we received in 2012/13 compared with the previous year. Only around 5% of these complaints were about the relatively new area of prison healthcare, so the bulk of this increase cannot be attributed to this expansion of jurisdiction. Research has shown that people can be reluctant to complain about healthcare, and the increase may be a consequence of people seeing more publicity about complaints being taken seriously and leading to action, which has in turn made them feel more comfortable about complaining. It is therefore not possible to use the increase on its own to say whether there has been any change in the underlying quality of care over the last 12 months. What I can say, and I do so emphatically, is that the more feedback that is available from patients, the more the health sector is able to learn. As I have said above, I am fully aware of an increased interest in and engagement with complaints at a senior level. This has been encouraging and we will seek to support this in the next 12 months. When I look at the health complaints we have investigated over the year, it is notable that we continue to find evidence that, in a generally good service, some people are experiencing significant problems. I upheld 52% of health cases investigated in 2012/13. This was a small (4%) decrease compared with the previous year, but still high relative to other sectors. The average is 46%. While some of this high uphold rate can be explained by the fact that I have greater powers in health complaints than in other sectors (i.e. powers to look at professional judgement), the uphold rate in health causes me concern. I am particularly worried when I see cases where failings are obvious and where the internal board investigation found that nothing had gone

wrong. These are complaints that should have been dealt with properly before they reached this office. The increased engagement with complaints that I am seeing in the NHS is, however, giving me some cause for optimism that we can start to reduce the number of obvious cases. It is also notable that in a large number of the cases where I found problems, the upheld aspects were, or included, failings in complaints handling. Those failings should be relatively straightforward to reduce and this report highlights the work we are doing to help support training in complaints handling in the NHS.

Communication I am often asked what the key issue is in health complaints and my response is ‘communication’ – in its widest sense. Better communication between health professionals reduces the potential for clinical errors. Better communication between health professionals and patients and their families and carers minimises misunderstandings and builds trust. And better written communication in complaints letters – jargon-free, empathetic, honest letters that answer all the questions – can resolve problems and provide positive outcomes for complainants and also for the staff involved.

Person-centredness is key to good clinical care and it is also at the heart of good communication.

SPSO ANNUAL COMPLAINTS REPORT 2012 > 2013 HEALTH PAGE 5


OMBUDSMAN’S INTRODUCTION

Changes to the delivery of services There are several areas of significant potential change in the health sector – wider integration of health and social care services, the management of older people in acute settings, the possible introduction of new guidance or legislation in areas such as significant events analysis reporting, no-fault compensation and making an apology without admitting liability. We have outlined in our consultation responses and elsewhere how we see these changes impacting on users of public services. There is a summary of our policy engagement in this report. An important message is that where changes are proposed, the service user’s right to challenge decisions should be considered in advance and complaints systems embedded in policy changes at the formulation stage. To truly put an individual’s needs, for example those of a person who needs a combination of health and social care, at the heart of a process means considering how they will be able to challenge decisions they disagree with or raise concerns about the quality of care received. In Scotland we have an NHS we are proud of. I recognise the commitment, expertise and professionalism that runs through all layers of the health service. Used effectively, complaints enhance accountability and drive improvements in the vital services that the NHS delivers. The SPSO plays an important role in contributing to strengthening processes and cultures that ensure that complaints are valued and lead to these positive outcomes.

Jim Martin Ombudsman

SPSO ANNUAL COMPLAINTS REPORT 2012 > 2013 HEALTH PAGE 6

To truly put an individual’s needs at the heart of a process means considering how they will be able to challenge decisions they disagree with or raise concerns about the quality of care received.


CASEWORK Number of complaints received and dealt with In 2012/13 we received 1,237 complaints about health boards, continuing the trend of the last few years of a rise in the number of complaints received about this sector. This year, we saw a 23.5% increase on the 1,002 complaints we received in 2011/12. Complaints about health boards made up 30% of the total complaints we received at SPSO, an increase on previous years where health complaints have usually made up about 25% of our total workload. The increase in health complaints is significant because we are able to take more of these complaints through to the investigation stage of our process than in any other sector. Given the time and often the high level of professional advice required to deal with health cases, this has implications for our resources. During 2012/13, we dealt with 1,197 health complaints, 28% more than in 2011/12 (in which we dealt with 937 cases). Of this, 4% were about the new area of prisoner health complaints. This came under our jurisdiction in November 2011 as a result of changes brought about by the Scottish Government, though the resulting complaints only began to reach us in numbers in 2012/13. The total number of complaints received and dealt with differs because some cases received in 2011/12 were dealt with in 2012/13.

What we do with complaints At the end of this report, there is a table with the outcomes of all the health complaints we dealt with. Below, we identify some of the key points and what we do at each stage of our process.

Advice All complaints and enquiries come first to our advice team. Their role is to provide information, signposting and support. Much of this work is conducted by telephone and they provide not only advice about our work but also help people find

additional support. They can also make a decision on a complaint if it is clearly a matter that we are not legally able to consider or it has come to us too early. We normally are only able to deal with complaints after they have completed the NHS complaints process. If a complaint comes to us too early (we call these premature complaints) we will let the person know how best to make the complaint to the NHS. We can also give advice about the Patient Advice and Support Service, who are independent of the NHS and the SPSO, and can help people through the complaints process. This year saw a small drop in the number of premature complaints about the health sector, from 31% to 30%. Compared with other sectors, this is a low rate (the overall rate is 40%). All enquiries and the vast majority of premature complaints are dealt with by our advice team. In 2012/13, the team handled 21 enquiries about health services, and 625 complaints, of which 293 were premature. At the next stage in our process, where complaints receive further detailed review, another 63 health cases were found to be premature.

I am very happy that the main part of my case was upheld and that changes will be made to processes within the board so that others may benefit. I am glad to now draw a line under this event. It is a pity so many complaints do have to reach you. Comment from complainant

SPSO ANNUAL COMPLAINTS REPORT 2012 > 2013 HEALTH PAGE 7


CASEWORK

Assessing complaints Last year, 572 health complaints passed from the advice stage to further detailed review. At this stage, we try wherever possible to talk to the complainant to make sure we understand their complaint and what outcome they want. We aim to see if there is a resolution that would be agreeable and acceptable to all parties and in a very small number of cases we were able to achieve this. We also have to assess whether there are reasons we should not take the complaint further. We can only investigate where we have the legal power to do so.

Independent professional advice Our complaints reviewers are helped in their work by being able to call on the services of professional advisers. We have in-house advisers with experience and expertise in the following areas: GP services; nursing; mental health; acute medicine; psychiatry. This means our investigators can discuss issues in detail directly with advisers. We also use an equality and diversity adviser in relevant cases, and through an arrangement with the Parliamentary and Health Service Ombudsman (PHSO) in England we access a wide range of specialist advice on additional clinical disciplines. Over the next year we want to explore whether a Scottish panel of advisers can be set up in place of the PHSO advisers, given the different developments in NHS services in Scotland. We also believe that this could prove a more efficient and cost effective means of obtaining professional advice.

We know it is frustrating for complainants if we can’t resolve a complaint or take it further, so we try to take this decision as quickly as we can. Last year, we decided at this stage that we could not take 187 cases further. In some this was because they were premature, or out of our jurisdiction. In others, the complainant did not provide us with enough information, withdrew the complaint, or wanted an outcome we could not achieve for them. We provide a breakdown of the decisions we made at this stage at the end of this report.

Investigating complaints At the investigation stage, we decide whether the complaint should or should not be upheld. In order to do so, we will consider all the available evidence and, in health cases, most of the complaints require independent professional advice (see left). The advisers will assess the quality of the care provided and whether that was reasonable in all the circumstances. The SPSO remain responsible for the decisions made on each complaint and we are careful to ensure we test the advice we receive and that it is of the highest quality.

Decisions When we investigate, we always issue a written decision. This is an important record and sets out in detail what we have investigated and how. The organisation and the complainant will receive copies. If the complaint is about a family health provider, a copy will also be sent to the relevant board. We know these decisions are often about difficult experiences and in 2012/13 we began moving towards supplementing the written record with a telephone discussion with the people who had made the complaints. This has proved successful and is now part of our regular and increased use of direct contact with complainants.

continued > SPSO ANNUAL COMPLAINTS REPORT 2012 > 2013 HEALTH PAGE 8


CASEWORK

The written record will be in one of two formats. In most case we issue decisions by letter. This letter remains private between ourselves and the parties. In order to ensure learning is shared, we publicly report a summary of the decision to Parliament. In 2012/13 we issued decisions by letter in 351 cases. A further 34 complaints went to our full detailed report stage because they satisfied our public interest criteria. Our public interest criteria can include: > significant personal injustice > systemic failure > significant failures in the local complaints procedure

Across the health sector, we made 557 recommendations in 2012/13. The case studies at the end of this report provide examples of the kinds of recommendations we make. There are many more available in the cases published on our website. We track every recommendation to ensure that the organisation implements it within a specified timescale and provides suitable evidence to show that they have done so effectively. The Scottish Government Health Directorates also check that boards implement SPSO recommendations, and where appropriate share them with other boards, a positive approach that the Ombudsman highlights in his introduction.

> precedent and test cases

Recommendations Where we find that something has gone wrong, we will uphold the complaint and we usually make recommendations for redress and improvement. The main area in which complaints were upheld in 2012/13 was clinical treatment and diagnosis, in which we upheld 70 complaints and partly upheld 63 – a total of 133. This is an increase on the 110 complaints we upheld or partly upheld last year, in proportion to the overall increase in complaints. The next highest area of upheld complaints was communication, staff attitude, dignity and confidentiality. Here we fully upheld eight and partly upheld 13 – a total of 21 complaints, compared to 13 last year.

We have now as a family had time to fully digest the findings and if not completely satisfied with all outcomes we feel there is nothing more that can be done. We are aware there have been recommendations made and … reviews being held by the NHS board that still have to be reported on. … [We feel] that there is always an opportunity for those who share a common interest not to feel that they did anything wrong … or a nonchalance on the part of those involved and a willingness to cover for one another. Comment from complainant

SPSO ANNUAL COMPLAINTS REPORT 2012 > 2013 HEALTH PAGE 9


CASEWORK

Key figures in health complaints 2012/13 > We received

1,237complaints and dealt with 1,197

> The rate of complaints coming to us too early dropped slightly from 31% to

30% compared with last year (the overall rate is 40%)

> The rate of upheld complaints was

52%, down from 56% last year,

but still higher than the overall rate of 46%

> People who received advice, support and signposting:

625

> Number of cases decided following detailed consideration pre-investigation:

187

> Complaints fully investigated

385 with 364* publicly reported

to Parliament

> We made

*

557recommendations for redress and improvement

We publicly report the decisions a minimum of six weeks after sending the decision letter. In a small number of cases we do not put information in the public domain, usually to prevent the possibility of someone being identified.

SPSO ANNUAL COMPLAINTS REPORT 2012 > 2013 HEALTH PAGE 10


CASEWORK

What do people complain about? The top areas complained about remain roughly the same, and are in virtually the same order as last year. The notable exception was the appearance for the first time, at fourth in the list, of prison complaints about healthcare matters. We received 62 complaints about these in the first full year of taking such complaints. We discuss this area later. Top areas of health complaints received 2012/13 GPs and GP practices

215

Hospitals – general medical

161

Complaints increased in most areas during 2012/13, mostly in line with the overall increase. However, the top subject of complaint – clinical treatment and diagnosis – increased by 35% on last year, greater than the general 23.5% increase. Again, this may reflect an increased confidence in questioning the judgment of NHS staff rather than a significant change in quality between 2011/12 and 2012/13 but it is a trend we will watch carefully. The second largest number of complaints received was about communication, staff attitude, dignity, and confidentiality, which increased by 13% and moved up from third place last year. Some subjects of complaint saw large increases compared with the previous year, but these were on such small numbers that it is difficult to identify any emerging trends. The increases include complaints handling (53%); appointments and admissions (31%); and admission/discharge and transfer procedures (61%). Complaints about policy and administration dropped by 27%, and those about GP and dentists lists (usually about removal from the practice list) dropped out of the list of most complained about subjects altogether, being replaced by complaints about appliances, equipment and premises.

Dental & orthodontic services

69

Prison healthcare

62

Hospitals – care of the elderly

58

Hospitals – gynaecology & obstetrics (maternity)

42

Hospitals – psychiatry

40

Hospitals – general surgical

37

Hospitals – accident & emergency

34

NHS boards (including special health boards and NHS 24)

Top subjects of health complaints received 2012/13

26

Clinical treatment/diagnosis

588

Communication, staff attitude, dignity, confidentiality

105

Top subjects of health complaints received 2012/13 Most subject areas saw an increase in cases received, with the biggest increases in the areas that normally feature at the top of the list – clinical treatment and diagnosis; and communication, staff attitude, dignity, and confidentiality. The issues complained about were from across the health spectrum – midwifery care; surgery; end of life care; mental health; late diagnosis or failure to diagnose; complaints handling; being struck off a practice list; nursing care; consent; poor communication with patients, carers and families.

Policy/administration

76

Complaints handling

52

Appointments/admissions

42

Admission, discharge & transfer procedures 21 Record-keeping

11

Appliances, equipment & premises

10

Continuing care

9

Nurses/nursing care

8

Failure to send ambulance/delay in sending ambulance

8

SPSO ANNUAL COMPLAINTS REPORT 2012 > 2013 HEALTH PAGE 11


CASEWORK

Issues in health complaints Older people In January 2013 the Ombudsman spoke to the Health and Sport Committee about his concerns about the care of the elderly. While numbers individually are low, we upheld or partly upheld 23 complaints about the care of older people in hospital during the year. A number of these cases were so significant that we reported them in full. Some of our investigations provide examples of failings we see in hospital care, including a complaint from the wife of an elderly man with dementia, who found his medication lying around his room (case 201004658). This is the first of our case studies, on page 22. Another complaint was about an elderly man with dementia who was left on a hospital trolley for more than 14 hours because there were no spare beds. During this time, his wife had to take care of his personal cleanliness herself (case 201100109). She was not consulted about his care or his discharge from hospital, although she held power of attorney for him. In another case, a woman was admitted to hospital with a urinary infection (case 201200160). When she was eventually discharged home, her husband said she had developed pressure ulcers on her heels. Her medical notes did not identify this, the discharge notes did not point out any wound care issues to community nurses, and she did not appear to have received appropriate care once she was at home. In another example, an elderly woman, who had a large and loving family who wanted to be with her at the end of her life, died in hospital without any of them beside her (case 201100402). She also did not receive the end of life care that they were all entitled to expect she would have. In this last case, I recommended that the board carry out a significant events review of what happened.

Can I thank you again for all your help and understanding, you took a lot of the stress away from me and my family ‌ I appreciate all that you have done to highlight the importance of care and end of life care ‌ the most important part of your life and it should be handled with dignity and respect. Comment from complainant

Vulnerable people Older people are among a wider group of vulnerable individuals about whose treatment we receive complaints. We investigated a complaint from the mother of a young woman with an eating disorder whose eating behaviour started to deteriorate, at the same time as she was having a planned break from treatment, and a change in treatment staff (case 201202231). The young woman lost a lot of weight during the month it took to refer her to a specialist unit. She then had to be hospitalised for re-feeding before she could receive treatment for her eating disorder. We found that the approach that staff in the Child and Adolescent Mental Health Service (CAMHS) were trying to use was not likely to be effective. We also found there was no eating disorder risk assessment – if this had been in place, the deterioration could have been avoided.

continued > SPSO ANNUAL COMPLAINTS REPORT 2012 > 2013 HEALTH PAGE 12


CASEWORK

In another investigation, the wife of a man with severe dementia had welfare power of attorney for him (case 201104449). When he was admitted to a continuing care ward, amongst other things we found that communication with his wife was not of a reasonable standard and did not comply with Adults with Incapacity legislation. This included that a ‘do not attempt to resuscitate’ certificate (which says that a doctor is not required to resuscitate the patient if their heart stops) was signed by medical staff without her input. In a further example of this issue, when a man was admitted to hospital with cancer (case 201103669), the board asked him to consent to certain medical procedures. His wife had both financial and welfare power of attorney for him, and so could normally take decisions about most aspects of his life. She told us that his understanding was limited and he was not able to give informed consent to such procedures. The board said that they did not consider her husband so incapacitated that he could not give consent. Evidence in the medical records, however, suggested that his capacity to do so was compromised. We noted that the doctors should have assessed and documented that capacity, but failed to do so. If they believed that he lacked capacity, then the provisions of the Adults with Incapacity Act should have been used, which would have ensured that his wife was involved, as power of attorney. On the other hand, had the clinicians believed that he had capacity, they should have clearly documented that, which they did not. We said that the board should raise awareness amongst medical and nursing staff of a number of elements of the requirements of the Adults with Incapacity legislation.

The area of mental health treatment is another in which we see the care of potentially vulnerable individuals compromised when things go wrong. In one investigation (case 201005359) a hospital consultant wrote to an accident and emergency department and a GP about a woman (diagnosed with a personality disorder) who frequently turned up at both places. The letters were about managing the woman’s behaviour and were generally reasonable, but in one the consultant had said that threats of suicide should not be tolerated. Good practice guidance says that all such threats should be taken seriously and investigated, so we found this inappropriate. We also found that there was nothing to confirm that the woman’s diagnosis had been discussed with her or that she was made aware of the letters. It is an underpinning principle of mental health care that patients are involved in decisions about their care and treatment, which the woman was not. In another example, a woman with mental health difficulties was referred to a psychiatric hospital because she was struggling to cope with thoughts of self-harm (case 201102541). She was a voluntary inpatient, but during her six weeks in hospital she received poor care, resulting in a further deterioration in her mental health. We found that a number of things had gone wrong, including inappropriate observation levels, problems in communication, and inadequate care and treatment after she took an overdose. We also found that when she expressed a desire to leave she was ‘threatened’ with formal detention. In this case, we made 13 recommendations to the board for improvement.

To read our decisions or search by subject, board or case reference number, visit www.spso.org.uk/our-findings continued > SPSO ANNUAL COMPLAINTS REPORT 2012 > 2013 HEALTH PAGE 13


CASEWORK

Missed or delayed diagnosis We determined 228 complaints about family doctors and made a total of 61 recommendations, including eight where the recommendation referred to carrying out a significant event audit or review. 101 of the complaints we looked at about family doctors were about the clinical treatment of an individual, or about diagnosis. In the latter, people usually bring us a concern that an illness has not been diagnosed appropriately or quickly enough. The complaints are often about very serious or terminal illnesses and it is understandable that people complain about these matters because of the devastation they feel that signs that could have been picked up may have been missed and that as a result someone has needlessly suffered or died. In some cases, it is clear that the original diagnosis was wrong, but this does not necessarily mean that a mistake was made. Some kinds of conditions are very rare or difficult to diagnose. In investigating the complaint, what we do is assess the decisions made based on what was known or should have been known at the time of the consultation or review. In most cases we do not find failings. We usually find that the symptoms reported were appropriately investigated, or the person was referred to hospital as quickly as could be expected under the circumstances at the time. Sometimes, though, we do find that there have been failings, and one example (case 201200068) is about a woman who was eventually diagnosed with terminal bone cancer. She had gone to her doctor with increasingly bad chest, neck and back pain, but the practice had failed to investigate her symptoms properly, or to refer her to hospital quickly enough. In this case, we recommended a significant event audit, completing a review of how they issue acute prescriptions, and putting in place a robust monitoring system.

In another example (case 201202435), a threeyear-old child who had been attending her GP over a number of weeks because of vomiting was eventually found to have a brain tumour that needed immediate surgery. We found that doctors should have followed the national guidelines from the National Institute for Health and Care Excellence, which say that a child with ongoing symptoms but no clear diagnosis should be referred urgently to hospital. As the practice themselves carried out a significant event analysis and took steps to improve their procedures, however, we did not find it necessary to make any recommendations. In a third case, a man had attended his GP practice over a five-year period with continuing stomach problems, and was diagnosed with irritable bowel syndrome (case 201101691). When he registered with a new practice, he was referred to hospital, where Crohn’s disease was diagnosed. The hospital consultant said that this should have been diagnosed much earlier. We found that the first practice should have carried out more investigations of his symptoms and/or referred him to a specialist. We asked them to apologise and to make staff aware of what we had found in our investigation. In a fourth example (case 201200184) a man who had been successfully treated for bone marrow cancer started to complain of breathlessness, weight loss, decreasing energy levels and back pain. His doctor did not make standard observations or arrange for relevant blood tests early enough. When tests were done the results were so worrying that the lab where they were carried out phoned urgently to tell the practice about them. The man was admitted to hospital but died the next day. We found that his symptoms should have triggered a more robust follow-up, and recommended that the GP carried out a significant event audit to be discussed at his next appraisal.

continued > SPSO ANNUAL COMPLAINTS REPORT 2012 > 2013 HEALTH PAGE 14


CASEWORK Another example is described in one of the case studies later in this report, about the care and treatment of a vulnerable man, who committed suicide after years of problems associated with alcohol dependency (case 201005160). In this case failures in communication between the teams involved in his care meant that he was let down by the very system that should have been there to help him. Because the mental health team did not accept a referral and the alcohol problems clinic did not act on a re-referral, he was not followed up by either service.

I am writing to thank you for considering my complaint and investigating it so thoroughly. I am profoundly grateful, as is my husband, for your time, expertise, and effort in response to my complaint. This outcome, from my perspective, will help to restore some of the dignity that was lost for myself and my daughter over this period. Comment from complainant

Communication Communication is frequently a problem in health cases, as the Ombudsman highlights in his introduction. It often appears as a factor in complaints about other elements of health care. Where communication breaks down, as in the case of missed diagnosis, the consequences can be extremely distressing, as the following examples show. In one case, when an 84-year-old woman died in hospital, staff did not communicate properly with her family (case 201102830). She had been taken to hospital as an emergency, and the family were there, but were not told that her condition had deteriorated. When the woman then died, her daughter told us that the family lost the opportunity of being with her at the end of her life, and of saying goodbye. Although we accepted that staff would have been occupied with her mother’s care, this did not justify the lack of communication, and indeed compassion, in telling the family what was happening, explaining how ill their loved one was (thus preparing them for her death), and providing them with a few moments with her before she died. We recommended that the board apologise, and provide us with their plan to ensure that communication with relatives and carers is addressed within the relevant department.

When a man with severe lung disease was admitted to hospital, medical staff decided (as they were entitled to do) that he should not be resuscitated if his heart or breathing stopped, and placed a Do Not Attempt Cardiopulmonary Resuscitation order on his medical notes (case 201202629). When the man later found this out, he was dismayed and said that this was not what he wanted. The board agreed that this should have been discussed with him or his family and agreed to record his wishes on the front of his medical notes. The man asked us to look at the complaint because he was not satisfied that this would stop the same thing happening to someone else. We found that the board had implemented a quality improvement plan, including ensuring that they would communicate this to patients or their relatives in future, and that random audits of case notes would ensure this was being adhered to.

Thank you for taking the time to telephone me to inform me of your decision. I just wanted to thank you for looking into this for me – I can see how thorough it has all been. Even if the outcome had not been in ‘my favour’, I still would want to say ‘thank you’, because you must have put an awful lot of work into all of this. It was kind of you to listen to me, and to understand how it all made me feel, because at the heart of all this … is how awful it all made me feel. I feel like I can put it all behind me now. Comment from complainant

continued > SPSO ANNUAL COMPLAINTS REPORT 2012 > 2013 HEALTH PAGE 15


CASEWORK

Prisoner healthcare By far the main subject of complaints received was, as in mainstream healthcare, clinical treatment and diagnosis. These included cases about how a man’s hand injury was treated; how often dressings on wounds should have been changed; delays in dental treatment; failure to prescribe sleeping medication; and treatment for drug addiction.

We started to receive complaints from prisoners about their healthcare when the Scottish Government transferred the responsibility for prison healthcare to local health boards. It was previously the responsibility of the Scottish Prison Service (SPS), who responded to complaints on behalf of Scottish Ministers. We began to take these complaints more than halfway through the year 2011/12, so 2012/13 is the first year for which we have statistics for a complete twelve-month period. The table below shows the number and subject of prison healthcare complaints received. We are still not seeing as many complaints as we anticipated we would, based on the numbers that Scottish Ministers received before the change. We have raised concerns about the low numbers and published cases about what our complaints show us is the main cause, which is that prisoners have not had proper access to the NHS complaints procedure. Changes have been made to the process and we are continuing to monitor their impact.

Subjects of prison healthcare complaints received 2012/13 Clinical treatment/diagnosis

36

Complaints handling

15

Policy/administration

7

Appointments/admissions (delay, cancellation, waiting lists)

2

Communication, staff attitude, dignity, confidentiality

2

Total Complaints

62

SPSO ANNUAL COMPLAINTS REPORT 2012 > 2013 HEALTH PAGE 16

The second highest subject was complaints handling. As we mention earlier, prisoners told us that they were finding it particularly difficult to get beyond the feedback stage of the NHS process, or to access a complaints form. NHS users are not required to complete a feedback form before accessing the complaints system. In effect, it seemed that those in prison were having to take more steps than they should in order to make a complaint. The Scottish Government guidance ‘Can I help you?’ makes it clear that prisoners should be treated in exactly the same way as those making a complaint about mainstream healthcare – i.e. to complain to the NHS organisation concerned, and then to escalate the complaint to SPSO if they remain dissatisfied. We published a detailed report about this in May 2013 (case 201203514). In 2012/13 we dealt with 50 prison healthcare cases in total. We were not able to investigate many of them for a variety of reasons, including the person having left prison and not having provided an address. More than half of the complaints were premature, in that they had not been through the NHS complaints system, or had not been properly dealt with in that system. We investigated five cases that we did not uphold, and carried forward eight further investigations to 2013/14.


SHARING THE LEARNING

Publishing reports

Annual letters

Each month, we publish reports of as many cases as we can and lay them before Parliament. In 2012/13 we published 330 decision reports about the health sector, making them publicly available to raise awareness and to support learning within and across sectors. In doing this, we are careful to protect the identity of the person who complained and the person about whom the complaint was made. Often complaints are brought to us by family members. There is a very small number of cases where even publishing anonymously would identify an individual, or where for other reasons such as a person’s vulnerability, it would be inappropriate to publish. In these rare circumstances we will exclude a case from publication.

Each year, as an additional tool for learning and improvement, we send each health board their own individual statistics to consider. We publish these annual letters on our website. 2012/13 is the first year in which boards have been required (under the Patient Rights Act) to produce their own annual reports on complaints handling and this will add to their and our understanding of how individual boards deal with complaints and ensure that the learning from them is identified, acted on and publicised.

The bulk of the reports we publish are summary reports of decision letters. These detail the complaint, our decision and whether recommendations were made. We also publish some full investigation reports each month (34 about the health sector in 2012/13) where it is in the public interest that all the detail is in the public domain. All the reports are searchable on our website by organisation, date and outcome and they provide a wealth of information for complainants and organisations. We promote learning from the reports through the Ombudsman’s monthly e-newsletter which highlights themes and issues from our casework. It is sent to 1,800 recipients, including MSPs, scrutiny bodies, service providers, advocacy agencies and the media. Inevitably, given the human interest inherent in health complaints, our investigations about the health sector tend to generate far more media interest than investigations about other sectors.

Working with others As well as publishing reports, we also have memoranda of understanding in place with key regulatory, inspectorate and scrutiny bodies such as the General Medical Council, Mental Welfare Commission for Scotland, Nursing and Midwifery Council and Health Improvement Scotland to help them to use complaints as part of their work. While our role is to seek redress for people at an individual level, if an investigation points to the possibility of a systemic issue, we can and do make broader recommendations as well as publicly alert the appropriate organisation to look into the matter. There can be insight and learning from the different approaches of organisations with different roles and it is essential that we all share information and concerns, within the legal limits under which we operate, especially where there may be any risk to the public. On occasion we may refer a report direct to a regulator if we think it raises an issue that would cause them concern. We also have the power to release details if we think an individual is a risk to the public and can use this if we were concerned about an individual’s fitness to practice. We do not need to wait until an investigation is complete to do this, and can act immediately if we think there might be a danger to patient safety.

Our arrangements with professional bodies, regulators and others are set out in a series of protocols and memoranda of understanding, which are published on our website at www.spso.org.uk/freedom-information/spso-publications-list/about-spso

SPSO ANNUAL COMPLAINTS REPORT 2012 > 2013 HEALTH PAGE 17


IMPROVING COMPLAINTS STANDARDS Can I Help You? Feedback, comments, concerns and complaints In April 2012 the Patient Rights (Scotland) Act 2011 came into force, introducing a package of improvements, including a right for patients to provide feedback and raise complaints. The Scottish Government’s detailed guidance on the NHS complaints handling procedure is outlined in their revised Can I Help You? guidance. Our Complaints Standards Authority (CSA) formed part of the Government’s Complaints Review Group which helped develop the changes to the Can I Help You? document. We fully support the aims of developing a culture that values and listens to the views of patients and other service users to help inform and improve the delivery of health care. The Can I help You? guidance reflects many of the key aims of the CSA’s wider work on complaints across the public sector in Scotland. Introducing this new right for patients means that NHS boards and all NHS service providers have a responsibility to ensure that their staff are competent and confident in dealing with feedback, comments, concerns and complaints in a manner that is person-centred and focused on resolving issues as they arise and getting it right first time. In 2012/13 we worked closely in partnership with NHS Education for Scotland, the national body responsible for educating and training healthcare staff, to achieve the Government’s aims of training all NHS staff in relation to complaints handling and supporting staff to respond to feedback, comments and concerns. Included in this was the development of a two-year plan of training and education and the establishment of a National Steering Group responsible for overseeing and supporting this work.

E-learning modules on feedback, comments, concerns and complaints. During 2012/13, the first phase of the project was to develop e-learning training modules for all NHSScotland staff. These were developed on the basis of SPSO modules provided for other public service sectors. The aim is to provide learning, education and development opportunities to all NHS staff to enable them to respond efficiently

SPSO ANNUAL COMPLAINTS REPORT 2012 > 2013 HEALTH PAGE 18

and effectively to feedback, comments, concerns and complaints. This includes independent contractors – GPs, dentists, pharmacists and optometrists and their staff. The interactive learning modules raise awareness of topics such as the value of apology and of encouraging feedback from patients, their families and carers. They also provide staff with knowledge of the NHS complaints procedure. There is a real emphasis on the importance of frontline staff taking immediate action to resolve problems to avoid these escalating. They focus on person-centred care, with the aim of putting people at the heart of all decisions in health and social care. The free, online resource was launched in May 2013.

We fully support the aims of developing a culture that values and listens to the views of patients and other service users to help inform and improve the delivery of health care. The Can I help You? guidance reflects many of the key aims of the CSA’s wider work on complaints across the public sector in Scotland.


POLICY AND ENGAGEMENT The complaints that people bring us provide a valuable source of information about the direct experiences of those using the health service. As we have said earlier, we put as much of this as possible in the public domain and use recommendations to try to prevent the same problem happening again. We also use our knowledge of complaints systems and people’s experience of such systems when we respond to inquiries and consultations. Sometimes, we are called to give direct evidence. Below is a list of the relevant inquiries, evidence and consultations in 2012/13 to which we responded.

We want to highlight in this report, as we have in our 2012/13 local government complaints report, a repeated theme in our responses. This is the difficulty currently caused by a number of incompatible and overlapping complaints processes in the fields of health and social care. This problem will become critical as, while the move to integrate health and social care is going ahead, complaints processes are being left behind and increasingly reflect a style of provision that no longer exists. To give a practical example, let us consider an older person who has complex needs but who can still remain at home with the right mix of support. A number of bodies will be involved: the local authority has responsibility for assessing needs, a registered care service may provide support and direct assistance and the individual may also require NHS care and support. Organisations already do their best to work together and co-ordinate their efforts and the move to further integration aims to make these processes smoother and more effective. However, what happens if that person is unhappy? At present, and if there are no legislative changes in the near future, the position will look like this:

SPSO health-related responses 2012/13 11 Sept 2012 Scottish Government consultation on the integration of adult health and social care in Scotland 27 Sept 2012 Margaret Mitchell MSP’s consultation on a proposed Apologies Bill 23 Nov 2012 Scottish Government consultation on no-fault compensation for injuries resulting from clinical treatment 8 Jan 2013 Submission to Health and Sport Committee’s Inquiry on the regulation of the care of older people in acute settings 15 Jan 2013 Oral evidence to Health and Sport Committee’s Inquiry on the regulation of the care of older people in acute settings 27 Feb 2013 Healthcare Improvement Scotland’s consultation on building a national approach to learning from adverse events through reporting and review

We post all evidence sessions and consultation responses on our website at: www.spso.org.uk/media-centre/inquiriesand-consultations

Integration of health and social care

> Complaints about NHS services are governed by the Patient Rights Act 2011 and secondary legislation. The person will have a number of options about how to raise concerns and if they wish to complain there will be a simple, single investigation with a response within 20 working days and then the right to bring the complaint to the SPSO. At that point, if relevant, we will be able to directly consider professional judgment because we can look at the clinical decisions made by NHS staff.

continued > SPSO ANNUAL COMPLAINTS REPORT 2012 > 2013 HEALTH PAGE 19


POLICY AND ENGAGEMENT

Š SPCB

> Complaints about a registered care service are governed by the Public Services Reform (Scotland) Act 2010. The person does not need to complain to the organisation first but is encouraged to do so as this may resolve the problem. Complaints are made to the Care Inspectorate and they will assess the complaint against the Care Standards. If the person is unhappy with the work of the Care Inspectorate, they can complain to the SPSO but we will only look at the work of the Care Inspectorate and not the registered care service. > Complaints about local authority social work assessments are governed by the Social Work (Scotland) Act 1968 and Directions issued in 1996. This is a much longer and more complex process than either of the first two and involves complaining to a quasi-independent complaints review committee (CRC). The CRC can look at professional judgment. If the person is unhappy with the CRC they can complain to us. We can comment on maladministration but professional judgment is a matter of discretion and, outside of health complaints, is excluded from our jurisdiction. There are, therefore, three different complaints systems with three different standards for judging complaints. This is clearly not a satisfactory position and will become more

SPSO ANNUAL COMPLAINTS REPORT 2012 > 2013 HEALTH PAGE 20

complex when we are having to work out which part of an integrated service needs to be put through which complaints process because, for example, ultimately something is still a local authority responsibility even if it is being carried out by NHS staff. We have suggested that a possible way forward (one that we think would require minimal legislative intervention) would be for the social work and health complaints procedures to be aligned. This would mean that when complaints come to us we could also look at professional judgment in a social work context. We have also suggested that we and the Care Inspectorate should be given the flexibility to work together on certain complaints. In 2012/13 the Scottish Government set up a short-life working group to look at one aspect of this – the social work complaints process. The working group was encouraged to consider this process in light of the move towards integration. We participated in that working group and anticipate that recommendations will be made in early autumn 2013. We look forward to the outcome of this but remain concerned that any proposed changes to the current system of complaints processes seem to be lagging increasingly behind significant changes in the delivery of services.


POLICY AND ENGAGEMENT

NHS sounding board A sounding board was established in 2012/13 for sharing developments about health matters at SPSO and to provide an opportunity for feedback to help us improve our performance and service. The group comprises senior health professionals, including representatives of chief executives and chairs of boards, a medical director, nursing director, a lead officer on infection control and a patient relations manager. The inaugural meeting was held in March 2013. A separate sounding board to reflect the views of users of our service is being established in 2013/14.

Supporting advice workers and valuing feedback

We also welcome the increasing use of Patient Opinion in Scotland. This independent feedback website enables patients to share their experiences of healthcare services and it states that it exists ‘to help facilitate dialogue between patient and health service providers and to improve services and staff morale.’ More than half of the stories on the website are positive, a third are mixed and a sixth negative. Where things have gone wrong, boards that are signed up to the service have the opportunity to respond and to try to sort out problems straight away, and to direct people to the complaints procedure if appropriate. In the many positive stories on the site, it is heartening to see the evidence of so much that goes right in healthcare delivery in Scotland.

We value the work of Patient Advice and Support Service (PASS) workers in NHS settings. PASS is an independent service providing free, accessible and confidential advice and support to patients, their carers and families about NHS healthcare. The service is provided by the Scottish Citizens Advice Bureau and can be accessed from any bureau in Scotland. PASS promotes an awareness and understanding of the rights and responsibilities of patients, and advises and supports people who wish to give feedback, make comments, raise concerns or make a complaint about treatment and care provided by the NHS in Scotland. We recognise that their workers provide an invaluable service in assisting those who have to make a complaint about what has happened to an NHS patient. We are keen to continue our links with them and, in March 2013, participated in their regional meetings.

SPSO ANNUAL COMPLAINTS REPORT 2012 > 2013 HEALTH PAGE 21


CASE STUDIES This is a selection of case studies from investigations we published about healthcare providers in 2012/13. Some show just how badly things can go wrong when policies are not followed, or complaints are not investigated properly. Others are included to show some of the positive actions that organisations take in response to complaints. To share this good practice, the reports on our website normally highlight where an organisation has taken such action. Still other case studies summarised here are included as examples of where organisations have delivered a service and investigated a complaint properly.

Failures in care of patient with dementia Case 201004658 An elderly man with dementia was admitted to hospital, where his wife felt that he was not properly cared for. She said that staff did not recognise his needs, and did not make sure he took his medication, which she found in the bed and on the floor. She also said he was not kept warm and was not properly fed. Because of this, her husband discharged himself against medical advice and was nursed at home for just over a week, until he died. The medical records showed that there were problems in his care. It appeared that staff did not ensure that he took his medication, and as nutritional records were inadequately completed, there seemed to be no system to make sure he was prompted to eat and drink. His family were not asked about his likes, dislikes and normal behaviours, which would have helped staff understand his needs. We were particularly concerned that this meant his wife lost confidence in the board’s ability to care for her husband and decided he would be better cared for at home. This reflects a lack of basic nursing care. Although we noted that the board had since taken significant steps to support staff in caring for older people and people with dementia, we told them that we expect them to further develop these through the learning from this complaint.

Recommendations The board provide a copy of their implementation plan in relation to Scotland’s National Dementia Strategy, particularly relating to these issues; and provide evidence that future record keeping complies with the Nursing and Midwifery Council’s Standards for Medicine Management.

SPSO ANNUAL COMPLAINTS REPORT 2012 > 2013 HEALTH PAGE 22


CASE STUDIES

Mental health care – failure to co-ordinate support services Case 201005160 This complaint was made on behalf of a man who committed suicide after being seen by health services over a period of time. The man suffered from the effects of long-term alcohol dependency and had attempted suicide before. He attended a mental health inpatient facility, but refused to be admitted to hospital. Staff did not detain him under the relevant legislation, although his family thought they should have done so. Over the following months he had contact with a number of healthcare professionals from mental health and medical services, before he took his own life. Our investigation found that although the man did not meet the criteria for being admitted to hospital, a lack of coordination and communication between healthcare professionals and agencies seriously affected his care. Because of this, we said that the board let him and his family down during an extremely difficult and distressing period. We also noted that, despite the seriousness of the failures between the teams dealing with the man, these were not referred to or addressed when the board made their own critical incident review.

Recommendations The board apologise to the man’s family; and review the coordination of the services to ensure that they address the failures identified in our report.

Complaints handling – prison healthcare Case 201202059 A prisoner complained about the medication decisions taken by his prison health centre. He was not satisfied with the board’s reply and sent a follow-up letter. However, the board sent it back to the health centre, unanswered, and the health centre gave it to him, with a note that advised him to follow the correct complaints process. The man contacted us for help in getting a reply to his follow-up letter as he thought he had been following the process and did not know what to do. Initial complaints to health boards should go through the prison health centre. However, we took the view that follow-up letters may go direct to a board, who may then tell the health centre that they have received the complaint, should they wish to keep staff there informed. It is not appropriate for a complainant to have to try to navigate a complaints system this way. We, therefore, sent the follow-up letter back to the board and asked them to reply directly to the man. We told him that we had closed his complaint while he and the board were dealing with it but that he could come back to us after that if he thought the complaint should be investigated further.

SPSO ANNUAL COMPLAINTS REPORT 2012 > 2013 HEALTH PAGE 23


CASE STUDIES

Incorrect discharge of patient by accident and emergency department Case 201201464 Positive action taken by organisation A 70-year-old man was admitted to a hospital accident and emergency department after losing consciousness at home. A doctor examined him, decided that he had a urinary tract infection and sent him home with antibiotics and painkillers. His family were told that if they were anxious they should bring him straight back. Shortly after returning home, the man became more unwell. His family called an emergency ambulance and he was readmitted. After a scan he was found to have an abdominal aortic aneurysm (a ballooning of part of the large blood vessel in the abdomen), which had ruptured. He died early the next day. The man’s wife complained that staff failed to thoroughly assess and treat her husband, and simply discharged him home. In response to the complaint, among other things, the board said that this type of aneurysm was rare and not easily spotted. Although his wife thought he should have been scanned earlier, they said it was not routine to scan all patients with abdominal pain. The decision on whether to do so would be a matter of clinical judgement, based on the patient’s symptoms and the doctor’s clinical findings. Our investigation found that the man’s symptoms meant that he should have been immediately assessed by a doctor. His medical records did not show a detailed history or examination note, or any obvious attempt to rule out certain, potentially serious, reasons for his condition. Our independent medical adviser said that he should not have been discharged. We noted, however, that the board had learned from the events in this case and had put in place a number of changes so we made no recommendations about the care and treatment provided.

Recommendations The board apologise to the man’s wife for the failures of care and treatment, and for unreasonably discharging her husband from hospital.

Pressure ulcers – failures in nursing care Case 201101660 This complaint was from a man who has been wheelchair-bound for many years, with limited ability to move or to feel any pain or discomfort in the lower half of his body. When he was admitted to hospital, he was dependent on staff for the majority of his daily living needs, including his positioning. After three days in hospital, staff identified that he had a pressure ulcer (pressure sore) which they treated. By the time he was discharged, however, this had developed into a serious ulcer. The man had to endure many months of bed rest and further care before he could be referred to a plastic surgeon to have this repaired. He complained to us that the ulcer developed because he had inadequate care and treatment in the hospital. We found that at first he was correctly noted as being at high risk of this, and was regularly assessed. However, the standard of management later fell below national standards because of a knowledge-skills gap in assessing the condition of the ulcer. We found clear evidence that staff did not identify and grade the seriousness of the wound, or take the most appropriate action.

Recommendations The board ensure their tissue viability training programme provides education and training for the assessment, grading and treatment of pressure ulcers in line with national guidance; and undertake an audit of hospital wards to ensure that pressure ulcer care and management is in line with national guidance.

SPSO ANNUAL COMPLAINTS REPORT 2012 > 2013 HEALTH PAGE 24


CASE STUDIES

Failure to provide interpretation services Case 201104213 A woman, who is hearing-impaired and communicates using British Sign Language (BSL), was admitted to hospital for surgery. During her 12-day stay in hospital, although hospital staff tried to communicate with her, they did not provide a BSL interpreter. This was despite the woman repeatedly pointing to a poster for interpreter services and twice handing staff a BSL interpreter’s card. It was clear from the hospital records that that she felt isolated because of the lack of communication. During our investigation, we took independent advice from our equality and diversity adviser. She said that staff had not taken reasonable and appropriate steps to obtain a BSL interpreter for the woman, which they had a legal duty to do under the Equality Act 2010. As soon as they knew that she needed an interpreter, they should have drawn up a clear plan to coordinate the availability of medical staff with that of a BSL interpreter who was sufficiently trained to be able to communicate complex medical issues. We found that, in failing to obtain a registered BSL interpreter, the board did not follow their informed consent policy. Although we recognise that there is a national and local shortage of such professionals, we took the view that hospital staff did not try hard enough to find an interpreter, and that this was unacceptable.

Recommendations The board consider amending their interpretation and translation policy to highlight their legal obligations, and to make clear that BSL is a registered language; produce further guidance for staff on what to do when a patient says they need a BSL interpreter; consider providing training to staff on deaf culture, language and legal rights; consider seeking input from deaf people to review the effectiveness of the implementation of the Interpretation and Translation Policy; and offer to meet with the woman and a BSL interpreter to answer any questions she has about her treatment and to apologise, explain and feed back how her complaint has helped them to develop their service.

Failure to follow requirements of Adults with Incapacity legislation Case 201005181 Positive action taken by organisation A woman complained about the treatment that her mother, who had dementia, received in hospital. She said that her mother did not have capacity to make decisions about her own healthcare. We found that there was no clear statement about this in the case records. We also found that the board's use of Adults with Incapacity documentation (which is about treating patients who are unable to give consent) was below the standard that could be reasonably expected. We acknowledged that the board had taken action in response to the complaint by compiling a learning plan to increase staff knowledge of the Adults with Incapacity framework, and that they had apologised for these failings. Family members had felt that their mother was over-sedated, and took her home, against medical advice. Her daughter said that the board did not put a discharge plan in place for appropriate medical treatment and support in the community, but we found that it would be unreasonable to criticise this, given the irregular nature of the discharge. Our investigation found that the drugs chosen and used were standard and reasonable but the board failed to involve the family in the decision to prescribe and administer some medication, as they should have done in line with the Adults with Incapacity legislation. However, the board had apologised for the problems and had taken action to try to prevent them from happening again.

SPSO ANNUAL COMPLAINTS REPORT 2012 > 2013 HEALTH PAGE 25


CASE STUDIES

Complaints handling – obtaining witness information Case 201202534 Positive action taken by organisation This complaint was about staff in a hospital where an elderly woman is cared for. Her son told us that when he was visiting, the nurse in charge spoke to him in an inappropriate way. He said that the board did not investigate his complaint properly; they did not ask a witness for information; and there was an unexplained delay in passing information from the ward to their complaints team. We found that the board interviewed the nurse involved as soon as they could after the complaint reached the complaints team. We could reach no conclusion about whether all the correct witnesses were interviewed, as there were differing accounts of who was there during the incident. We upheld the complaint about the investigation, however, as two witness statements were taken after the board replied to the complaint. The board’s policy on complaints handling was that staff should handle a complaint locally as far as possible, and so we found that the delay in passing the complaint from the ward to the complaints team was understandable. We also noted that, as the man and his family had repeatedly expressed concerns about his mother's care, the board had arranged external reviews of her nursing and medical care to try to reassure him.

Recommendations The board remind staff that relevant witnesses to events should be interviewed as soon as possible after the event, and in any case, during the investigation of the complaint; provide specific guidance on obtaining witness information; and review their practice for checking draft letters with the aim of minimising the chance of typing errors.

Material left in wound Case 201202996 Positive action taken by organisation After an operation, a woman was left with packing material in the wound. She told us that when she complained to the board about this, their response was inadequate. They had apologised to her for the failings and explained what they had done to prevent this from happening again. Our investigation found that the board had taken the complaint seriously and had carried out a thorough investigation, including obtaining statements from the relevant staff. They had then reminded staff of their responsibilities and sought information from the packing manufacturers, which led to them use an alternative form of wound packing. We were satisfied that the board's investigation was appropriate, and decided that further consideration of the complaint would be unlikely to achieve any more.

SPSO ANNUAL COMPLAINTS REPORT 2012 > 2013 HEALTH PAGE 26


CASE STUDIES

Insufficient nursing care and failure to discuss decision not to resuscitate Case 201104845 A man was admitted to hospital after a fall. He had fallen twice before and had become increasingly forgetful over a period of seven to ten days. When he was admitted, his level of consciousness was recorded as being normal, but then dropped, and a scan showed that he had bleeding on the brain. Although he made a slight improvement while in hospital, he developed pneumonia and died the next month. His daughter complained about his treatment, and the level of attention paid to his needs while he was in hospital. Although we found that the overall care and treatment provided was reasonable, we also found some serious failings in certain areas. We found that insufficient nursing care was provided during one day, when the man was in a single room, although we noted that the board had taken action to address this. Because there was a lack of written notes, it was not clear whether staff performed certain tasks and, in particular, whether a test to check the man’s ability to swallow was carried out by a suitably qualified member of staff. We were also concerned that the man’s family were not told that staff had decided that doctors were not required to resuscitate him if his heart stopped. This decision was taken without the input of a senior clinician (which is required), and we did not consider that the lead clinician was sufficiently involved in the man’s care overall.

Recommendations The board draw our comments on the use of certain medication to the attention of clinical staff; provide us with details of the outcome of their 'care round' document trial and any changes to their patient monitoring procedures that result from this trial; review the level of involvement of senior clinical staff in patients' treatment; remind staff of the need to discuss 'do not resuscitate' decisions with patients and their families; remind nursing staff that they must keep full and accurate nursing records; and apologise to the man’s family for the failings.

Failure to provide care and treatment – GP practice Case 201202175 Positive action taken by organisation A grandmother complained that reception staff at a GP practice would not allow her granddaughter to see a doctor. The girl’s parents had taken her there because they could not get through on the phone, and they were concerned about their daughter's deteriorating health. When they were told that they could not see a doctor, they took their daughter to hospital where she was diagnosed with meningococcal meningitis (a rare but serious infection of the membranes covering the brain and spinal cord). We found that reception staff failed to deal with this incident appropriately. They should have sought advice from doctors who would then, in all probability, have arranged emergency transport to hospital. We also agreed that they did not handle the complaint well. As a result of this, we upheld the complaint. However, we noted that when the complaint came to the attention of the practice doctors, they took it very seriously. They carried out a significant event analysis and introduced procedural changes and staff training to try and minimise the likelihood of this happening again. On the basis of their actions, and their apology to the family, we did not make any recommendations.

SPSO ANNUAL COMPLAINTS REPORT 2012 > 2013 HEALTH PAGE 27


CASE STUDIES

Failure to assess a patient appropriately – GP practice Case 201102828 A man with cancer had chemotherapy in hospital. A few days after he was discharged, he phoned the practice, asking for a prescription for antibiotics and a telephone consultation. His doctor returned the call and issued the prescription. A few days later, the man’s sister became very concerned about his condition and phoned asking for a home visit. The practice, however, advised her to contact emergency services, so she phoned NHS 24. They arranged for the practice to send a doctor to visit him at home, who arranged an emergency ambulance. The man was admitted to hospital but died several weeks later. His niece complained that he should have been seen by a doctor after her mother called the practice, and that the practice's response to the request for a home visit was unreasonable. We upheld her complaints. We found that, given the seriousness of the man’s illness, he should have had a face-to-face assessment rather than a phone consultation. We found that the problems of communication were compounded by a lack of specific instructions from the practice to contact emergency services. As a result, there was a delay in admitting the man to hospital and, while this may not have affected the outcome, it was clearly distressing to him and his family.

Recommendations The practice reflect on their management of the man’s case particularly in light of the complications of chemotherapy; review their record-keeping for phone consultations; apologise for the failures identified; and review their procedures for house calls.

Failure in complaints handling by health board Case 201102801 A woman took her daughter to a hospital out-of-hours service, and was unhappy with the doctor she saw. When she complained about him, the board responded by simply sending her a letter written by the doctor. The woman was unhappy with this and sent a detailed reply. The chief executive replied addressing her points, based again on information from the doctor. We found the board’s response to the complaint to be a very poor example of complaints handling. It appears that, as the complaint was about the doctor, the board simply used his words to respond, without providing their own analysis or explanation. This was unacceptable, particularly given the tone of the doctor’s first letter that was sent as the initial reply to the complaint. A complaints handling procedure should provide detailed and impartial investigation. The board should have considered her concerns and the doctor’s comments, come to a view on the merits of her complaint, then provided their own response.

Recommendations The board apologise fully for these failures; and provide evidence that they have reviewed their complaints handling procedure to ensure a pro-active approach.

SPSO ANNUAL COMPLAINTS REPORT 2012 > 2013 HEALTH PAGE 28


CASE STUDIES

Failure to obtain proper consent for removal of a tooth – dental practice Case 201200930 This complaint was from a woman who went to her dentist with pain in her lower left five tooth, which she said she specifically pointed out to her dentist. The dentist noted that the lower left seven tooth was moving, with pus coming from one side of it, and extracted it. About twenty minutes after her appointment ended, the woman returned to the practice and complained that the wrong tooth had been extracted. The dentist noted that the lower left five tooth was also mobile and removed it, and wrote in the notes that she had apologised and explained that the lower left seven tooth was not treatable by any means other than extraction. Our investigation found that the notes completed at the time said that the lower left seven tooth was to be extracted, so we could not say for sure whether the wrong tooth was extracted. However, the woman clearly thought that it was the lower left five tooth that was to be removed. We found that the dentist did not obtain consent appropriately and did not communicate effectively. In responding to the complaint, the dental practice had said the dentist was aware of the importance of securing valid consent before treatment and would not have proceeded with the removal of the lower left seven tooth unless she believed her patient understood and agreed to this. We concluded, however, that this was not the case and upheld the complaint.

Recommendations The practice issue a written apology for the failure to obtain consent appropriately for the extraction of the tooth and for failing to communicate effectively with the woman; and make the dentist aware of our findings.

To read our decisions or search by subject, health board or case reference number, visit www.spso.org.uk/our-findings

SPSO ANNUAL COMPLAINTS REPORT 2012 > 2013 HEALTH PAGE 29


SPSO ANNUAL COMPLAINTS REPORT 2012 > 2013 HEALTH PAGE 30

Note: 'No decision reached' includes not duly made, withdrawn and resolved. Totals include complaints about healthcare in prisons.

16

Total contacts

1

Total 16

1

Partly upheld

5

Total 0

0

No decision reached

Fully upheld

1

Not upheld

1

Total 3

0

Outcome not achievable 1

0

No decision reached

Fully upheld

1

Not upheld

Partly upheld

0

Partly upheld

2

Total 0

Premature

Fully upheld

0 1

Outcome not achievable

1

7

Total

No decision reached

4

Premature

0

0

Outcome not achievable

Matter out of jurisdiction (non-discretionary)

3

No decision reached

0

0

Matter out of jurisdiction (non-discretionary)

Matter out of jurisdiction (discretionary)

0

Matter out of jurisdiction (discretionary)

0

0 0

Enquiry

Total

Outcome

Admission, discharge & transfer

Total complaints

Investigation 2

Investigation 1

Early Resolution 2

Early Resolution 1

Advice

Total enquiries

Advice & signposting

Enquiry

Complaint

Stage

Case type 0

Appliances, equipment, premises

9

9

0

0

0

1

0

1

0

0

2

0

0

2

0

0

2

1

0

0

1

0

4

2

0

1

1

0

0

0

2

Appointments/ admissions

44

42

0

0

0

9

1

1

4

3

7

0

0

6

0

1

10

2

3

2

2

1

16

8

0

8

0

0

2

2

5

Clinical treatment/ diagnosis

554

549

27

8

19

203

7

94

54

48

30

1

0

25

1

3

105

40

18

18

6

23

184

96

2

82

1

3

5

5

2

Communication, staff attitude, dignity, confidentiality

103

101

2

0

2

20

0

9

8

3

22

0

0

14

5

3

23

3

7

8

0

5

34

17

0

14

0

3

2

2

0

Complaints by NHS staff

2

2

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

2

2

0

0

0

0

0

0

0

Complaints handling

53

53

0

0

0

10

0

5

3

2

5

0

1

1

1

2

12

10

0

2

0

0

26

15

0

11

0

0

0

0

0

Continuing care

8

8

0

0

0

0

0

0

0

0

2

0

0

0

0

2

2

1

0

1

0

0

4

2

0

1

0

1

0

0

0

Failure/delay in sending ambulance

10

10

1

0

1

2

0

0

2

0

1

0

0

1

0

0

1

1

0

0

0

0

5

5

0

0

0

0

0

0

0

Hotel services (food, laundry)

1

1

0

0

0

0

0

0

0

0

1

0

0

0

1

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

Hygiene, cleanliness & infection control

4

4

0

0

0

2

0

1

1

0

0

0

0

0

0

0

1

0

1

0

0

0

1

0

0

1

0

0

0

0

0

Lists

8

8

0

0

0

1

0

0

1

0

2

0

0

0

0

2

2

0

1

1

0

0

3

3

0

0

0

0

0

0

2

Nurses/nursing care

10

8

1

0

1

3

0

1

2

0

1

0

0

1

0

0

0

0

0

0

0

0

3

2

0

1

0

0

2

2

2

Other

8

6

0

0

0

0

0

0

0

0

1

0

0

1

0

0

1

0

0

0

1

0

4

2

0

2

0

0

2

2

0

Policy/administration

82

82

2

0

2

11

0

5

3

3

8

0

0

4

2

2

16

3

3

2

7

1

45

29

0

16

0

0

0

0

0

Record keeping

9

9

0

0

0

0

0

0

0

0

1

0

0

1

0

0

5

0

1

1

1

2

3

1

1

0

1

0

0

0

1

Out of jurisdiction

21

20

0

0

0

0

0

0

0

0

0

0

0

0

0

0

4

0

0

0

2

2

16

1

0

0

8

7

1

1

7

Subject unknown

276

269

0

0

0

0

0

0

0

0

0

0

0

0

0

0

1

1

0

0

0

0

268

104

1

158

1

4

7

7

21

Total

1,218

1,197

34

9

25

267

8

118

81

60

84

1

1

57

10

15

187

63

34

36

20

34

625

293

4

298

12

18

21

21

STATISTICS Further information about this sector is available on our website at www.spso.org.uk/statistics


SPSO 4 Melville Street Edinburgh EH3 7NS Tel Fax Web CSA

0800 377 7330 0800 377 7331 www.spso.org.uk www.valuingcomplaints.org.uk

SPSO health complaints report 2012 13  
Read more
Read more
Similar to
Popular now
Just for you