Some upheld, recommendations

Summary

C complained about the care and treatment provided to their parent (A). A had presented with foot pain and initially had been thought to have Plantar Fasciitis (an inflammation of the tissue along the bottom of the foot). A later returned to the practice with an infected toe, which failed to respond to antibiotics. A was referred to vascular medicine and later underwent surgery in hospital, but died a few months later. C believed that A should have been referred to vascular medicine sooner, as A was at high risk and displayed symptoms of vascular disease. C was also unhappy with the language used in the complaint response that the family received.

We took independent advice from a general practitioner. We found that A was given a reasonable standard of treatment and care. There was no evidence that symptoms of vascular disease were dismissed or overlooked. We did not uphold this aspect of the complaint. In relation to the language used in the complaint response, we found that the complaint response was inappropriately informal and contained some errors, which added to the family’s distress. We upheld this aspect of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the inappropriate language and incorrect dates in the complaint response. The apology should meet the standards set out in the SPSO guidelines on apology available at HYPERLINK "http://www.spso.org.uk/information-leaflets" www.spso.org.uk/information-leaflets .

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

Summary

C complained that the council had failed to address excessive noise from a recreational area near their home. We found that the council had taken appropriate action in relation to C’s complaints of noise nuisance and did not uphold C’s complaint. However, we did provide the council with feedback on ensuring they carry out visits within a reasonable timeframe where they have agreed to do so, or contact the customer to explain why they are unable to do so.

C also complained about the council’s handling of their complaint. C raised a complaint with the council about the high levels of noise from the recreational area. The council responded on the same day saying that they could not consider noise nuisance under their complaints procedure as the nuisance was not being caused by the council or by any maladministration on behalf of the council. C was advised to engage with the appropriate council service regarding monitoring and establishing the noise nuisance and was signposted to the SPSO if C felt they were not responding to what they considered to be complaints.

We found that the council unreasonably failed to act in line with the Model Complaints Handling Procedure by refusing to further respond to C’s complaint. Therefore, we upheld C’s complaint.

Recommendations

What we asked the organisation to do in this case:

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

In relation to complaints handling, we recommended:

• Complaint investigations should be carried out in line with the Local Authority Model Complaints Handling Procedure.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

Summary

C complained on behalf of a relative (A) who had a learning disability and had been prescribed a special adjusted diet according to the International Dysphagia Diet Standardisation Initiative (IDDSI) guidelines. A had choked on their food and required emergency care. C complained that A’s food, a takeaway meal, had not been suitable for them and had not been prepared in line with their adjusted diet. They considered that this and other failings caused the near fatal choking incident.

We took independent advice from a speech and language therapist. We found that it was reasonable for staff to have obtained a takeaway meal for A and did not uphold this part of C’s complaint. However, we found that staff had failed to follow guidance and ensure that an assessment had been carried out as to whether this meal was safe for A, and that they failed to prepare the meal for A in line with their adjusted diet. Therefore, we upheld these complaints. In addition, we upheld complaints that the partnership had failed to provide A with the correct cutlery and that they failed to appropriately investigate the incident.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C and A for the failings identified in this decision. 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:

• Relevant staff should ensure that for any patient on the International Dysphagia Diet Standardisation Initiative (1) recommendations made by the multidisciplinary professionals are adhered to, (2) that recommendations/guidance issued by the multidisciplinary professionals are clearly understood and followed in relation to a patient’s diet and (3) recommendations/guidance issued by the multidisciplinary professionals are clearly understood and followed in relation to any adaptations that may be needed for the patient when eating.

In relation to complaints handling, we recommended:

• The partnership’s complaint handling monitoring and governance system should ensure that complaints are appropriately investigated and that failings (and good practice) are identified and learning from complaints are used to drive service development and improvement.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

Summary

C complained about the post-operative care and treatment that they received from the board after they suffered a leg and ankle fracture. C said that unreasonable post-operative care led to a poor recovery and the requirement for an additional operation.

We took independent advice from a consultant orthopaedic surgeon (specialists in the treatment of diseases and injuries of the musculoskeletal system). We found that the board failed to report some x-rays and to reasonably explain why further x-rays were taken and who had reviewed them. We also found that there had been an unreasonable delay in carrying out a CT scan and in discussing C’s case at a Morbidity and Mortality meeting. Therefore, we upheld this part of C’s complaint.

C also complained about the board’s handling of their complaint. We found that the board handled C’s complaint reasonably and did not uphold this part of C’s complaint.

Recommendations

What we asked the organisation to do in this case:

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

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

• A patient’s medical records should document the reasons why a scan(s) has been taken and who has reviewed them. The results should be recorded on the hospital’s clinical portal system.
• There should be processes and guidance in place to ensure when it is appropriate to carry out a CT scan.
• Where a patient’s case is appropriate for discussion at a Morbidity and Mortality meeting, this should take place as soon as possible.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

Summary

C complained that the board failed to provide reasonable physiotherapy care and treatment to their child (A) and failed to maintain reasonable clinical records.

We took independent advice from a physiotherapist. We found that some aspects of A’s care were reasonable, particularly in relation to ongoing treatment at school, and the adjusting of equipment and personal care access was in line with normal practice. However, it was unreasonable that no paediatric physiotherapy programme was provided and delegated to school staff initially to support classroom and curriculum access and that clinical notes only mentioned a programme taught to support staff in school following the change in physiotherapist. Therefore, we upheld this part of C’s complaint.

In relation to the clinical records, we found that there were omissions in the completion of documentation and poor physiotherapy clinical record keeping. Therefore, we upheld this part of C’s complaint.

C also complained about the board’s handling of their complaint. We found that the board’s actions in relation to the handling of C’s complaint were reasonable and did not uphold this part of C’s complaint. We also noted that the board had taken learning and improvement action which we welcomed.

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:

• Clinical notes should be comprehensive as set out by the Charted Society of Physiotherapy (CSP)/Health and Care Professional Council (HCPC) standards and include action plans. Senior managers should be aware of their role in relation to monitoring the quality of record keeping (in line with the Records Management Code of Practice).

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

Summary

C complained about the care provided to their adult sibling (A) when they attended A&E following an accident. C also complained that the board failed to reasonably investigate A’s symptoms when they attended hospital with headaches on two further occasions the following year. A was later diagnosed with a brain tumour and C feels that there were missed opportunities in identifying this earlier.

We took independent advice from a consultant emergency physician and a GP. We found that the board undertook appropriate assessments and provided reasonable treatment to A when they attended A&E following their accident. We did not uphold this part of C’s complaint.

In relation to A’s first attendance at hospital the following year, we found that the board failed to investigate A’s symptoms. There were clear flags identified in the GP’s referral letter, indicating further investigations should have been carried out, specifically a head CT scan, and this did not occur. Therefore, we upheld this part of C’s complaint.

In relation to A’s second attendance, we found that the board reasonably investigated A’s symptoms as they presented at the time, with appropriate investigations undertaken and follow-up advice provided. Therefore, we did not uphold this part of C’s complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to undertake reasonable investigations when A attended hospital and for the poor handling of C’s complaint about this matter. 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:

• Junior doctors are aware of the importance of considering relevant clinical information from all available sources to guide clinical assessment. Clear red flags outlined in patient referrals and clinical questions resulting in patient referrals should be clearly documented in patient notes and communicated to senior reviewing clinical staff.

In relation to complaints handling, we recommended:

• Complaint responses should be accurate and based on all of the relevant evidence.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

Summary

C complained about the nursing care and treatment provided to their parent (A) who was admitted to hospital after a fall.

We took independent advice from a registered nurse. We found that there were unreasonable time gaps between care and comfort checks, making it impossible for the board to provide assurance that appropriate checks were completed. We found that the necessary risk assessments and care documentation were not completed to the required standards, with no person-centred care plan in place for A. We also found that the standard of record-keeping was unreasonable. Therefore, we upheld this part of C’s complaint.

C complained that the board had failed to provide them with timely updates on A’s care and treatment. The board accepted that C was not provided with appropriate updates regarding changes to A’s health. We upheld this part of C’s complaint.

C also complained about the board’s communication in response to their complaint. C said that the board had not investigated their concerns about A’s dementia diagnosis and reduced capacity, and had referred in the complaint response to allegations by nursing staff about C’s behaviour which detracted from the complaint. We found that the board had shared the issues for investigation with C, inviting correction. We also found that it was reasonable for the board to take into account the experiences of the relevant nursing staff when responding to concerns C had raised. Therefore, we did not uphold this part of C’s complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the specific communication and process 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:

• Patients should be appropriately assessed by nursing staff, in particular in relation to continence and cognition issues, and nursing care provided in line with the assessments carried out and in a timely manner. Records about a patient’s care and treatment and decisions made should be clearly and accurately documented, in accord with the relevant professional standards and guidelines, and reflect a person-centred approach. Patient records should include clear details explaining why a decision about care and treatment has been made.
• Family members should be communicated with in a timely and appropriate manner.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

Summary

C is the grandparent of A and B, whose parents were separated. C complained about the actions of the council after A and B’s parent (X) submitted an authorised absence request from school to spend some time abroad. C considered that the council failed to check with A and B’s other parent (Y) that they were in agreement with the proposed absence from school and that the council failed to reasonably assess the risks when granting the authorised absence request.

C complained that the council failed to reasonably assess the authorised absence request. We found that the council failed to reasonably assess the authorised absence request as relevant paperwork was not completed or a rationale documented to support their decision. We upheld the complaint.

C also complained that the council unreasonably failed to inform Y of the request. We found that the council reasonably followed their policy in relation to communicating with Y. We did not uphold this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to follow procedure in considering the authorised absence request. The apology should meet the standards set out in the SPSO guidelines on apology available atwww.spso.org.uk/information-leaflets.

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

• When considering authorised absence requests appendix 4 should be completed along with a copy of the pupil’s attendance record.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

Summary

C complained about the social work assessment of their adult child (A). A had fragile-X syndrome (a genetic condition that causes a range of developmental issues), which affected them in a variety of ways. A’s long-standing care worker had retired and A was experiencing difficulties which were putting them and their family at risk. C believed that unreasonable assumptions were made about A’s ability to function independently because of the level of support their family provided for them.

A had been referred for assessment by a psychologist and the partnership's social work department. A was assessed by social workers as not eligible for support. C challenged this, because A’s psychology assessment recommended that they receive support. The partnership refused to alter their decision, saying that the psychology report was inappropriately worded, and that they would seek to have it reworded. C complained to the SPSO that this was unacceptable and that the partnership had failed to handle their complaint properly.

We took independent advice from a registered social worker. We found that the assessment of A by social workers was reasonable. We did not uphold this aspect of the complaint.

Although the partnership wrote to C saying that they would seek to have the wording of A’s psychological assessment reworded or redacted, there was no evidence that they had asked for this. We found that the psychological assessment was inappropriately worded, as A’s eligibility for support could only be assessed by social workers. Social work raised reasonable concerns about this with the psychology team. We found that C’s complaint was handled unreasonably, as the partnership failed to discuss it with C, and consequently did not address all the points of concern C wished to raise. We upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to contact them about their complaint, to clarify the points of concern and the outcomes being sought. The apology should meet thestandards set out in the SPSO guidelines on apology available atwww.spso.org.uk/information-leaflets.

In relation to complaints handling, we recommended:

• Complaint responses should consider and respond fully to the issues raised in accordance with The Model Complaints Handling Procedure. They should consider any relevant national or local guidance in both the investigation and response and identify and action learning.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

Summary

C complained on behalf of a relative (B), about the care and treatment provided by the board to B's late spouse (A).

When A first felt unwell, they visited their GP on three occasions where they were prescribed antibiotics and told they had a chest infection. Following an x-ray, A was prescribed medication to increase the amount of urine produced, with a plan to carry out a follow up x-ray. A visited the GP again with breathlessness and was referred to the hospital where they were admitted and diagnosed with COVID-19. Blood tests showed that A had an infection and a chest x-ray reported fluid on the right side of A’s chest. A was initially treated for infection with COVID-19 and a suspected bacterial infection. A was discharged from hospital with a plan to repeat the x-ray as an outpatient. A few days later, A was readmitted and diagnosed with lung cancer and was showing signs of spinal cancer.

A was further told that there was a cancerous tumour pressing on their lungs. A’s breathing worsened, they had severe weight loss and they were not eating. Only one family member at a time was permitted to visit A. Staff said that more of A's family would be able to visit if their condition deteriorated. A remained in hospital until their death a week later.

In considering C’s complaint, we took independent advice from a consultant in general and respiratory medicine and a senior nurse. We found that the decision to discharge A from hospital was reasonable and did not uphold this aspect of C's complaint. However, we found that it was unreasonable that A's pleural effusion (fluid build up) was not treated on or shortly after admission. Therefore we upheld the complaint that the board unreasonably failed to carry out further investigations whilst A was on the ward.

We also found that A was unreasonably left sitting and sleeping in a chair during their admission, that A’s family were not given any additional time to visit when A was at end of life and that there was a failure by the board to notify A’s family that their condition was rapidly deteriorating. We upheld these aspects of C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the specific failings identified in respect of these complaints. 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:

• Further investigations should be carried out in line with the expected standards for management of pleural effusions in the context of acute admissions.
• In such circumstances, staff should contact the family promptly to inform them of a patient’s deterioration.
• Relevant staff should be aware of changes to guidance.
• The person-centred care plan should be fully completed for each patient and updated with a changing deteriorating picture. When a patient is nursed in a chair it should be clearly documented that this is an informed choice to ensure person centred decision making and regular skin checks completed. Recliner chairs should be obtained promptly where required.

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.