Some upheld, recommendations

Summary

C complained about the university’s handling of an investigation into allegations made against them and their subsequent complaint about the matter. The allegation against C was investigated by the university’s sports association and upheld. The matter was then passed to the university’s student conduct team for consideration as to whether any further sanctions should be applied. C complained about the processes followed by the sports association. C also complained about the processes followed and the delays incurred during the university’s conduct investigation.

We considered C’s complaint that the university’s investigation into the allegations made against C were unreasonable. During our investigation, we found that C had not requested an appeal of the university’s decision. In order for this office to investigate a complaint about an appeal, the student or their representative must first have completed the organisation’s appeals procedure before bringing their complaint to us. As C had not done this, our investigation was limited to considering whether the university had informed C of their right to appeal and provided them with information on how to do so. We found that the university had reasonably informed C of their right to appeal. Therefore, we did not uphold this part of C’s complaint.

We also considered whether the university’s investigation of C’s complaint was unreasonable. We found that it was reasonable for the university not to consider C’s complaint about the sports association. As an autonomous external body, it is not covered by the complaints procedure. In relation to the university’s handling of C’s complaint about the university’s code of student conduct investigation, we found that there were significant delays to the completion of the complaint investigation. We also found that the university did not reasonably provide C with updates regarding the progress of the complaint investigation, with this only being forthcoming in response to the enquiries made by C. Therefore, we upheld this part of C’s complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the unreasonable delays by the university to investigate the 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:

• Complainants should be advised prior to the response deadline if the 20 working day target cannot be met. Information should be given about the reason for the delay and revised anticipated date of completion should be provided.

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 their housing. C had moved into the property because they were downsizing from their previous home. The property they moved into had been purchased by the council from its owner as part of a ‘buy back’ scheme for council properties. C complained of persistent damp and mould within the property that was causing them significant health problems. C was offered alternative properties by the council but C rejected them on the basis that they were unsuitable.

We found that extensive works had been carried out to the property prior to C moving in. We also found that, whilst C disputed the suitability of the alternative properties they were offered, the council had followed the correct procedure in assessing C’s medical needs and the properties offered to C. Therefore, we did not uphold these parts of C’s complaint.

In relation to C’s reports of damp and mould, we found that these issues were investigated. However, the council took an unreasonable length of time to respond, given that they were aware of the health issues being experienced by the family. Therefore, we upheld this part of C’s complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failure to respond timeously to their concerns. 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:

• The council should have effective systems in place to ensure that problems with mould and damp are responded to timeously.

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

Summary

C complained about the care and treatment provided to their adult child (A) in relation to A’s pregnancy. A attended hospital on two occasions over a weekend with no fetal movement. The baby (B)’s heartbeat was considered normal on both occasions and A left the hospital with a plan to return on the Monday. On A’s return to hospital, an intrauterine death (when a child dies in the womb) was diagnosed. A requested to have their waters broken to relieve the pressure that they were experiencing. A ‘s labour was very quick and they delivered B in the toilet of the labour suite at the hospital. They called for a midwife to attend and assist them.

C complained that the hospital did not listen to their concerns for B to be delivered as an emergency. C and A believed that there was too much focus on B’s heartrate and that further investigations, including ultrasound, should have been undertaken. C also complained about the difficult circumstances of B being born in the toilet, and the care provided in the run up to, and following, labour.

In response to the complaint, and following the completion of a Significant Adverse Event Review (SAER), the board found no specific failings of care which led to B’s death. Monitoring of A and B was appropriate, and ultrasound scanning was not available over the weekend. The board noted that A had chosen to return home, rather than be admitted over the weekend which was against medical advice. The board explained that early delivery by caesarean section was not indicated given the clinical picture was reassuring. C and A met with representatives from the board following the complaints response where issues relating to the delivery of B were discussed. The board acknowledged that a midwife should have responded to A’s calls that they were delivering B in the toilet, and acknowledged that A should not have been in a labour ward where they could hear other mothers and healthy babies.

C was dissatisfied with this response and brought their complaint to us. They disputed the accounts of doctors that A was advised about the risks of going home during the weekend and remained of the view that more should have been done for A and B over the weekend.

We took independent advice from a GP who worked as an obstetric and gynaecology registrar (a specialist in pregnancy, childbirth and the female reproductive system) and a registered midwife. We found that appropriate advice was offered to A about the risks of returning home over the weekend, that the level of monitoring and assessment was reasonable and that the assessments were reassuring with respect to the health of A and B. Therefore, we did not uphold this part of C’s complaint.

In relation to the treatment provided to A during labour, we found that care in preparation for delivery of B was reasonable, with appropriate monitoring and pain relief provided. When A rushed to the toilet, given the recent examinations checking the progress of A’s labour, it was reasonable for midwifery staff not to consider A was about to give birth. However, there was a lack of documentation and records at the time of delivery and the immediate period before and after this which prevented our office from drawing conclusions about the level of care provided. Given the board’s acknowledgements that a midwife should have attended immediately to A when they called for help, together with the lack of appropriate record keeping during labour, and the accommodation in the labour suite being inadequately soundproofed, we upheld this part of C’s complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to A for the failures 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 and midwifery staff should keep clear and accurate records, relevant to their practice, in line with the Nursing and Midwifery Council code.

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 was living in a residential unit for young people who are looked after by the council. C complained that the council failed to take appropriate action when they raised safeguarding concerns about the unit manager and failed to investigate a breach of confidentiality when C received abusive messages from a former member of staff. C also complained that the council had failed to keep them informed about decisions made about the future of the residential unit and their complaints had not been handled in accordance with the council’s complaints procedures.

We took independent advice from a children and families social worker. We were satisfied that C had been kept reasonably informed about the position of the future of the unit. Therefore, we did not uphold this part of C’s complaint. However, there were some failings in relation to communication and record-keeping in response to the safeguarding concerns raised. There were also failings in the investigation into abusive messages from a former member of staff and in the complaints handling. Therefore, we upheld these parts 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 the 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:

• Safeguarding concerns should be communicated appropriately and in line with safeguarding guidance and clear and accurate records should be maintained.
• Staff in the unit should be aware of the issues regarding the use of social media highlighted by this case.
• The council should maintain clear and accurate records of discussions and meetings that take place, in line with required standards.

In relation to complaints handling, we recommended:

• Complaint responses should comply with the Model Complaints Handling Procedure and council staff should be familiar with the complaints handling procedure. Complaint investigations should be clearly recorded at each stage and responses provided within 20 working days. If this is not possible, the complainant must be updated on the reason for the delay and provided with a revised timescale.

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

Summary

C’s spouse (A) was admitted to hospital following a stroke. A remained in hospital for several weeks before transferring to another hospital. A later died. C complained to the board about A’s hospital stay and raised concerns about wound management, fall pain management and the identification of hip and shoulder injuries.

The board’s response highlighted several areas for improvement. Firstly, there should have been a referral for A’s wounds, with more robust documentation. Staff training has been conducted to address these issues. Secondly, A fell twice in the ward, prompting a thorough medical review after each fall. Staff training regarding falls has been provided. Thirdly, although A was on regular pain medication, there should have been a pain recording chart in place. Staff will receive training on this aspect. Lastly, A’s hip dislocation likely stemmed from their stroke rather than a fall, with no evidence of shoulder dislocation occurring the ward.

C was dissatisfied with the board’s response and brought their complaint to us. We took independent advice from a nurse with a speciality in wound care and a consultant geriatrician (a specialist in medicine of the elderly). We found that staff failed to follow the board’s policy on wound management. We also found that whilst the medical care of A’s falls was reasonable, the nursing documentation about A’s falls was unreasonable, because documentation was incomplete and at times inaccurate. A’s care plan was also poor, making it difficult to manage A’s pain, and there was a delay in A receiving a medical review over the weekend. Therefore, we upheld these parts of C’s complaint. We found that the board’s explanation of A’s injuries was reasonable. We did not uphold this part of C’s complaint.

We also found that the board’s complaint response did not provide C with a timely, full and informed response to their complaints about the board’s management of A’s wounds and falls. Therefore, we made an additional recommendation to address this.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failures in A’s care. The apology should meet the standards set out in the SPSO guidelines on apology available at http://www.spso.org.uk/meaningful-apologies.

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

• Nursing staff should be competent in the accurate completion of falls documentation.
• Patients should receive appropriate pain management including regular structured assessment of their pain, e.g. through the use of a structured pain assessment tool or chart. This should be documented. Patients should receive appropriate medical review on escalation, and reviews should be carried out promptly.
• Patients should receive care as required and prescribed in care rounding bundles. Those requiring wound care should be appropriately managed in line with local and national guidance on wound management. This should be appropriately documented.

In relation to complaints handling, we recommended:

• The board’s complaint handling monitoring and governance system should ensure that complaints are properly investigated and responded to; are accurate; timely; and that failings and good practice are identified.

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 an advocate for and representative of A. C complained that a social worker acting on behalf of the council failed to timeously apply for state benefits on A’s behalf despite providing an undertaking to do so. C complained that this failure lead to a loss of income for A resulting in rent and council tax arrears and that the council subsequently sought direct deductions from A’s state benefits to pay for these council tax and rent arrears. C further complained that the council failed to adequately communicate with A and their representatives. Finally, C complained that the council failed to adequately investigate or respond to the complaint. The council did not consider that there was any failure to apply for and manage A’s state benefits.

Upon investigation, we found that there was an appointment of a social worker to undertake the application for state benefits on A's behalf. However, we found that there was a delay by the council in submitting an appointee application form. We found that A experienced an actual loss of income as a result. We also found that the council unreasonably sought direct deductions from A’s state benefits for council tax and rent arrears caused by these delays. We therefore upheld these aspects of the complaint.

Whilst we did not uphold the aspect of C’s complaint that the council failed to communicate adequately with A, we found that the council failed to adequately investigate and respond to their complaint. We upheld this aspect of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to A for the delay in progressing A’s application for state benefits and for unreasonably seeking direct deductions from their state benefits to recover rent and council tax arrears. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.
• Either; 1. calculate the amount of Universal Credit (considering each component allowance) and council tax reduction that A lost out on due to their delays and reimburse A for any shortfall of Universal Credit, rent and council tax reduction (taking into account of the discretionary housing payment already made). Or 2. agree a settlement payment with A through their representative C.

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

• Where the council undertakes to apply for benefits on behalf of an individual, this should be progressed promptly in order to ensure that entitlement to benefit is not lost. Deductions from benefits should not normally be sought when arrears have been caused by the council’s inaction.

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 to the council about the way that their child’s school had responded to an incident of bullying in the playground. C also complained about the way this matter had been communicated to them as a parent of some of the children involved.

We found that the council had responded to the incident in keeping with their policies and procedures and we did not uphold this part of C’s complaint.

In relation to the school's communication with C about the incident, we found that there were inconsistencies within the councils own records about the point at which they became aware of C’s child being involved in the incident, and in relation to the school’s position on whether or not there was an area of the playground that was known to be difficult to supervise. Given the discrepancies within the council’s records, we upheld this part of C’s complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C that the complaint response about the playground incident was not supported by the evidence/ the school’s documentation of the incident. 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 responses should be accurate and supported by the evidence. Comments on complaints provided to the SPSO should be consistent with the documentation of the incident being investigated.
• Complaint responses should be accurate and supported by the 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 standard of care and treatment provided to their parent (A) whilst A was in hospital. C's concerns covered A’s medical care, nursing care and physiotherapy care.

C said that A’s myeloma (blood cancer) treatment was delayed by a failure to provide the specialists treating A with blood samples for analysis. Additionally, A was not given an infusion correctly, as nursing staff failed to give A intravenous fluids first to ensure A was hydrated. C felt A’s pain relief was inappropriately managed, with A’s medication being unnecessarily reduced, resulting in A suffering significant and avoidable pain. C also believed that A was injured during a physiotherapy session and that this contributed to A’s decline.

We took independent advice from a registered nurse, a consultant haematologist (specialist in the the diagnosis and treatment of patients who have disorders of the blood and bone marrow) and a chartered physiotherapist. We found that nursing staff had not followed written instructions for the administration of A’s treatment, and A’s records showed that they had consumed only around 15% of the food and water that they should have in the period leading up to the infusion treatment. Nursing staff could not therefore have ascertained that A was properly hydrated. Nursing staff did not appear to have taken all the requested blood samples from A, and they had not taken steps to address A’s pain management. Therefore, we upheld this part of C's complaint.

In relation to A's medical care and treatment, we noted that their condition was progressing rapidly and that they had already had a number of treatments. The decision that A was not suitable for further treatment was not impacted by the missing blood sample and overall, we found that the medical care A received was reasonable. Therefore, we did not uphold this part of C's complaint.

In relation to A's physiotherapy care, we found that there was no evidence within the physiotherapy records that A had sustained an injury. Although there were some unexplained gaps in A’s physiotherapy records, it was clear that the decision to cease physiotherapy treatment was driven by the decision to designate A for palliative care only, rather than active treatment. Therefore, we did not uphold this part of C's complaint.

C also complained about the way that their complaint was handled. We found that the board’s complaint investigation had fallen below a reasonable standard. The evidence showing the failings in A’s nursing care should have been identified by the board’s own investigation. Therefore, we upheld this part of C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to provide A with a reasonable standard of nursing care and for failing to provide C with a reasonable response to their complaint. 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 fluid and nutrition needs should be appropriately monitored. Where there is evidence that fluid and hydration needs are not being met, appropriate action should be taken.
• Patients’ level of pain should be reviewed and where the patient is unable to comply with the administration of pain relief orally, action should be taken to explore alternative means of medication delivery.
• Staff should ensure that written instructions by medical staff and, where appropriate, manufacturer’s guidance is followed when administering infusions and that, where appropriate, the patient is adequately hydrated.

In relation to complaints handling, we recommended:

• The board's complaint handling monitoring, and governance system should ensure that responses are accurate and reflect the information available in the clinical 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 that the board failed to provide reasonable care and treatment to their sibling (A) after they were admitted to hospital. A had a cardiorespiratory arrest (the cessation of effective ventilation and circulation) in the hospital and suffered a brain injury as a result of this.

We took independent advice from a consultant in critical care. We found that the board had provided reasonable care and treatment to A and we did not uphold this aspect of the complaint.

C also complained that the adverse event review that the board subsequently carried out was unreasonable. In relation to this complaint, we found that the board had carried out a level 2 review when a level 1 review should have been carried out. The level 2 review had also been allocated to an inexperienced review team, it reviewed only part of A’s care journey, and it was short and poorly detailed. We also found that the record-keeping on the ward immediately before and after A’s cardiorespiratory arrest was limited and not of the standard expected. Detailed retrospective entries should have been completed shortly after these events occurred, by both medical and nursing staff. We therefore upheld this aspect of the complaint.

We also found that the board’s complaint handling of C’s complaint was unreasonable.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for causing confusion in their responses which related to the new structure that had been put in place. Apologise that part of the complaint handling process was uncoordinated and delayed and that they added to the stress and anxiety the family were feeling at that time. Finally, apologise that they failed to deal with C’s complaints in a timely or satisfactory manner. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.
• Apologise to C that a level 1 review should have been performed in place of the level 2 review and that the level 2 review that was performed was allocated to an inexperienced review team, it reviewed only part of A’s care journey and it was short and poorly detailed. 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:

• For a level 1 review to be carried out.
• Patient records should be accurately completed, signed and dated with the appropriate level of information included, in accordance with the relevant medical and nursing standards.
• Before an adverse event review is carried out, the board should appropriately identify the review level, identify the terms of reference (part of the patient’s care journey to be reviewed) and allocate a suitable staff review team.

In relation to complaints handling, we recommended:

• The board should ensure all complaints are handled in line with the guidance set out in the NHS Model Complaint Handling Procedures, in particular, respond in writing and in a timely manner and address all issues raised that the board is responsible for.

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

Summary

C complained about the care and treatment that they received over a series of interactions with the practice. C believed that their symptoms had not been properly investigated. C subsequently suffered a stroke and felt that the outcome for them could have been better if they had been listened to when they contacted the practice. C also felt that the practice’s complaint handling had been unreasonable, failing to provide C with information that they were entitled to and incorrectly directing them to the local NHS Board as part of the complaints process.

We took independent advice from a GP adviser. We found that some of the assessments of C did fall below a reasonable standard, although it was not possible to conclude that the stroke could have been predicted or prevented. Therefore, we upheld and did not uphold aspects of these complaints around the assessment of C's symptoms over different periods. We also found that the handling of C’s complaint fell below a reasonable standard. We upheld this aspect of the 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:

• Patients should receive appropriate treatment in relation to their presenting symptoms and potential causes considered as appropriate.

In relation to complaints handling, we recommended:

• The practice should provide clear information about their complaints process.

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.