Not upheld, no recommendations

Summary

C, an MSP, complained on behalf of their constituent (B) about the standard of care B’s late spouse (A) received from their GP practice. A attended an appointment with a GP and received antibiotics and steroids for a possible chest infection. A’s health deteriorated a short time later and they suffered a cardiac arrest at their home. B complained that the practice failed to recognise that A was suffering from a serious cardiac condition.

The practice said that a full examination and history had been taken from A. The GP concluded that the symptoms were from the chest wall rather than originating from the heart, with a suggestion of chest infection and narrowing of the airways. A received steroids and an antibiotic in treatment of a chest infection, and given advice on what to do if their condition worsened. On learning of A’s death, a Significant Event Analysis was carried out by the GP, which identified learning points in relation to arranging ECGs (a test that records the electrical activity of the heart, including the rate and rhythm), and strengthening the advice given to a patient about phoning again should their condition worsen.

We took independent advice from a GP. We found that it was reasonable for the GP to treat A on suspicion of a respiratory infection having taken a history and clinical examination. While A’s oxygen saturation levels were low, this can also be found in cases of acute or chronic lung disease, such as infection. A also displayed symptoms that were not typical of classic heart attack pain. We found that A’s blood pressure and heart rate were both normal which did not suggest a heart attack. We considered that the GP made a careful assessment and reached a reasonable working diagnosis at the time based on the information available and their clinical judgement. Therefore, we did not uphold C’s complaint.

Summary

C complained about arterial surgery. The board accepted that there were issues related to the surgery and communication with C before the procedure.

We took independent advice from a cardiology adviser. We found that there was nothing to suggest that there was poor clinical practice or decision making and found that, overall, the clinical treatment provided to C was reasonable. We did not uphold the complaint.

Summary

C, a support and advice worker, complained on behalf of their client (A). A is a kinship carer to two grandchildren (child B and child D). When child B was born, they stayed with their parent and A at the same address. The following year, child B’s parent left the house and child B remained in A’s care. There was social work involvement during this period, with a section 25 being signed and a noted intention to assess further and refer to the Children’s Reporter. Within a few months, A was granted a residency order conferring parental rights and responsibilities and the council closed the case.

Child D was born and lived with their parent for four years, until they were placed with A under a Compulsory Supervision Order. A received kinship care allowance for child D and also applied for kinship care allowance for child B. This was initially refused, but after A made a complaint to the SPSO, the application was reconsidered. The council backdated the kinship care allowance in respect of child B.

C complained that kinship care allowance was not backdated far enough for child B. The council responded that they had never considered child B to be a “looked after” child and therefore eligible for kinship care allowance. As such there was no reason to backdate further.

We took independent advice from a social work adviser. We found that due to lack of evidence and dispute between parties it was not possible to definitively determine the status of child B in earlier years. On application, the council paid kinship care allowance and backdated to the point at which child D had been placed with A under a Compulsory Supervision Order. We determined that the council had acted reasonably in this matter. We did not uphold the complaint.

Summary

C complained about the care and treatment that they received from the board prior to and during the birth of their child (A). C complained that the midwives were dismissive of their pain levels during labour, failed to properly assess their condition, was wrongly sent home to allow labour to progress, and that staff denied their requests for an epidural. C also complained about the poor communication from the clinical team when they were in theatre for a caesarean section.

The board said that they considered the decision to send C home was made in line with current guidelines but apologised if the reasons for the decision were not communicated at the time. The board explained that C’s request for an epidural was not actioned as labour was progressing rapidly and consideration was being given as to whether an emergency caesarean section was required.

We took independent advice from a midwifery specialist. We found that the midwifery care provided to C was reasonable. We noted that the board apologised for some shortcomings in the care provided and that this was a reasonable response. Overall, we were satisfied that the decisions taken by the midwives were based on a reasonable assessment of C’s presenting condition. In respect of the medical care provided during the birth, we acknowledged that there may have been a lack of clarity around the consent process, however, overall, we did not find any significant shortcomings in the clinical care and treatment provided to C. We did not uphold C’s complaints.

Summary

C complained about the care and treatment that they received from the board’s neurology department. C had been reporting symptoms to the board for several years before obtaining spinal surgery abroad. After surgery, C experienced improvement in their symptoms. C complained that the board did not reasonably investigate or offer treatment for their symptoms.

We took independent advice from a neurologist and neuroradiologist (a specialist in reading medical images of the spine). We found that the board had reasonably investigated C’s symptoms and offered reasonable treatment for C’s symptoms. We found that there was no missed opportunity to identify any physical problem in C’s spine that may have caused C’s symptoms, based on MR (magnetic resonance, a type of medical imaging) images of C’s spine. Therefore, we did not uphold C’s complaint.

Summary

C complained about the care and treatment that their late parent (A) received from the board. C complained that the board failed to reasonably treat an ulcer on A’s toe or manage their related pain. C also complained that A was unreasonably transferred to a nursing home from the ward when they were too frail and unwell to leave the care of the hospital. C advised that the communication with them in relation to A’s transfer was unreasonable, both in the way the matter was discussed with them by the social worker and as the ward failed to explain that their parent was nearing the end of his life. C said that they were only made aware of this by a GP at the nursing home who explained A was receiving end of life care.

The board's response to C’s complaint confirmed that A had received treatment for their toe ulcer during their inpatient admission, with follow-up treatment planned following their discharge to the nursing home.

On the matter of A’s referral to nursing home care, the board advised that this had been discussed with C by phone. The board said that the documentation of the phone call reflected that C was in agreement with the plan, with the purpose of the referral being to arrange long term care for A. Prior to discharge, A was reviewed by a ward doctor and it was determined that they were fit for discharge based on their improving blood results following a recent chest infection and as their observations were stable. The board expressed regret that A returned to hospital 10 days later having deteriorated since leaving hospital.

We took independent advice from a consultant physician and geriatrician. We found that a plan to manage A’s toe ulcer had been put in place and that they advised that A had received pain relief as required. We considered that the plan of care made by the board was reasonable.

In reference to A’s discharge to the nursing home, we found that this had been arranged in discussion with C, noting that A was not suitable for further rehabilitation, and that their cognitive function now prevented them from living safely at home. We considered the plan of care made for A in terms of their long term care needs was reasonable and in keeping with their circumstances. Therefore, we considered that the care and treatment provided by the board to A had been reasonable. We did not uphold the complaint.

Summary

C applied for free school transport for their child (A) when A was about to begin secondary school. The council rejected this application on the grounds that A did not live within the catchment area of the secondary school they had been enrolled in. A had been enrolled at the school automatically and had not obtained a place by placing request (a request that is made when you are not in the school catchment area). C considered that A should have been provided with free school transport because A had not obtained a place at the school by placing request, and therefore the policy on privilege transport (to those who lived out of catchment) should not apply.

We found that the council's communication surrounding this issue could have been better. However, we considered that the policy on both free school transport and privilege transport had been reasonably applied. This was on the basis that regardless of how A came to be provided with a place at the school, the policy was clear regarding allocation of a transport place to those in a school catchment and those who were not. Therefore, we did not uphold C's complaint.

Summary

C complained that the council failed to obtain planning permission for the extension of a playpark. C said the development of the expanded playpark area required planning permission as it was a material change and was also a bad neighbour development.

We found that the council did not misinterpret law or policy and had proper regard for material considerations. Their decision not to take enforcement action in relation to a slide that required planning permission was also legitimate and took account of material considerations. Therefore, we did not uphold C's complaint.

However, we considered that it would have been helpful if the council's planning services had been involved at an earlier stage in the process and not only at the point that residents started raising concerns. This may have helped to identify issues in relation to the height of the slide at an earlier stage. We provided feedback to the council about this.

Summary

C complained about the care and treatment they received by the board. C was pregnant and called triage as they thought their mucus plug (a protective collection of mucus in the cervical canal) had passed and that they noticed green discharge. C was advised to stay at home and call back if they had further concerns. C went to hospital later that day and underwent an emergency caesarean section to deliver their baby (A). A appeared well following birth, but soon deteriorated. A was initially diagnosed with hypoxic ischaemic encephalopathy (a type of brain damage), and then subsequently diagnosed with quadriplegic cerebral palsy (a lifelong condition that affect movement and co-ordination).

C complained to the board about the advice provided not to attend hospital during the initial call to triage, and about the care and treatment during delivery and immediately afterwards. C believed that clinicians delayed in taking appropriate action in response to A's symptoms and considered this may have impacted their health.

In response to the complaint, the board recognised that C's recollection of the call to triage differed from the notes taken but concluded on the basis of the information available, that the assessment and advice was appropriate. The board gave a detailed account of the care and treatment provided to C and A from C's attendance at hospital, through to delivery and in the period following A's birth. The board explained the decision to proceed to an emergency caesarean section and concluded that this was appropriate and timely. The board also concluded that it was impossible to say if the outcome for A would have been different had C attended hospital earlier, and it was unlikely an earlier birth from the time of admission would have altered the outcomes. C was dissatisfied with the board's response and brought their complaints to our office.

We took independent advice from an obstetrician (specialist in pregnancy and childbirth) and from a consultant neonatologist (specialist in the medical care of newborn infants, especially ill or premature newborns). We found that the call to triage and advice given not to attend hospital was reasonable. With respect to the care and treatment during and following delivery of A, we found that whilst there was some information missing regarding the monitoring of A's heart rate, the decision making regarding the timing of proceeding to a caesarean section and the care immediately following birth was reasonable. A was given appropriate care when their health deteriorated following birth and there was no unreasonable delay in admitting them to neonatal intensive care. Therefore, we did not uphold C's complaints.

Summary

C complained about the care and treatment their spouse (A) received from the practice. A had contacted the practice on several occasions with worsening symptoms including headaches, and problems with vision and mobility. C complained that the practice unreasonably failed to undertake tests or act on results, such as when a discrepancy was found in the power of A's legs. C considered the practice unreasonably treated A for anxiety and failed to recognise there was a serious underlying reason for A's symptoms. A was ultimately found to have a brain tumour and died within a few days of receiving this diagnosis.

In responding to C's complaint, the practice provided a letter each from two of the GPs involved in A's care which explained their decision making in respect of the presenting symptoms at the time. The practice also explained they had undertaken a Significant Adverse Event Review (SAER) of A's case for learning and improvement.

We took independent advice on the complaint from a GP. We found that A had initially been treated for labyrinthitis (an inner ear infection) and urinary tract infection which was reasonable and in keeping with the symptoms reported by A at the time. We also found that after A was given a new prescription for glasses, it was appropriate to trial the glasses for improvement of the symptoms of headache and light headedness on standing. In relation to A's upper leg weakness, we found that this can occur for many reasons and, in isolation, would not suggest a more serious underlying cause. Referring to the working diagnosis of anxiety, we considered that this was not unreasonable in the circumstances.

However, the complaint presents a significant learning opportunity, highlighting the need for recognition that symptoms can deteriorate within a short time, and consideration that confused or difficult reporting of symptoms by the patient could in itself be an indicator of an underlying cause. We considered that the practice had provided a reasonable standard of care to A. Therefore, we did not uphold C's complaint but provided the practice with feedback on guidance on conducting adverse event reviews.