Decision Report 202106540

Summary

C had a history of multiple facial trauma and had undergone various procedures over the last decade in relation to their nose and face. C then received further injury which caused damage to their nose.

C complained that the board refused to perform any further investigations or the reconstructive surgery they considered was required. This was despite numerous GP referrals to the ear, nose and throat (ENT) department. C stated that they continued to suffer ongoing pain and symptoms associated with their facial injuries. C complained that the board were acting on the basis of a psychological assessment from a number of years ago, which suggested investigation and treatment could be damaging to C. C strongly objected to the content of this assessment.

We took independent advice from an ENT surgeon. We found that it was reasonable for the board to take into consideration the psychiatric assessment that warned against unnecessary investigations and treatment unless indicated on objective grounds. However, we considered that given the passage of time since that document was produced, and because C had recently been assaulted potentially causing new injury, it was reasonable for C to be reassessed. Therefore, we upheld C's complaint.

We also noted failings in relation to complaint handling and made a recommendation to address this.

Recommendations

What we asked the organisation to do in this case:

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

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

• Where a significant period of time has elapsed since a patient was clinically assessed and there is evidence that the patient’s clinical situation has changed, the patient should be offered a clinical reassessment.

In relation to complaints handling, we recommended:

• The board's complaint handling monitoring, and governance system should ensure that failings (and good practice) are identified; and that learning from complaints is used to drive service development and improvement. The board should comply with their complaint handling guidance when investigating and responding to complaints.

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.