Some upheld, recommendations

Summary

C complained that the board failed to provide their late spouse (A) with reasonable care and treatment during three attendances at A&E and an admission to hospital.

The board said that A complained of pain in their right forearm causing them sleep disturbance. However, there was no indication that imaging scans were required as an emergency. A was already under the care of orthopaedics (specialists in the treatment of diseases and injuries of the musculoskeletal system) which was appropriate for the muscle injury A had. Therefore, the assessments, plan, and discharge of A at the first two attendances in the emergency department were appropriate on the basis of what was known at the time. During the third attendance at the emergency department, the board said that investigations indicated that A had a raised marker for infection and inflammation which could have been an indication of underlying condition or malignancy. At this point it was identified that an MRI scan should be carried out, but there was no indication that this was required as an emergency. A was admitted to hospital for further investigations.

We took independent advice from a consultant in emergency medicine. We found that appropriate and timely emergency care was provided to A on each of their attendances at A&E. We also noted that a clinical significant event review was carried out. The issues were fully explored and the board had appropriately reviewed and reflected on learning. We considered that A received reasonable care and treatment at A&E and as an inpatient. Therefore, we did not uphold this part of C's complaint.

C also complained about the board's handling of their complaint. C said that the board did not contact them during their complaint investigation. They also highlighted that the board did not address all their concerns. We found that the board failed to address and respond to a significant part of the complaint raised by C until prompted to do so by this office. 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 handle their complaint reasonably. 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:

• The board's complaints handling system and their investigation should ensure that failings (and good practice) are identified, and enable learning from complaints to inform service development and improvement. Complaints should be properly assessed in line with the Model Complaints Handling Procedure and all points of complaint should be identified and agreed before the complaint investigation begins.

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, an MSP, complained on behalf of their constituent (B) about the care and treatment of their adult child (A). A had awoken with a cut and bruised face and no memory of how the injuries had been sustained. A attended a minor injuries unit before being sent by taxi to A&E for further assessment. A was assessed and discharged without further treatment or follow-up. A few months later, A died suddenly.

B believed that A had suffered a seizure on both occasions and that A's assessment had been inadequate. B felt staff had failed to consider whether A had suffered a seizure nor had they considered prescribing medication which could have prevented further seizures. B was also unhappy with the way their complaint was handled.

We took independent advice from a consultant in emergency medicine. We found that the examination of A was thorough. However, given the uncertainty over the cause of A's injuries and the symptoms they described, further investigation should have been carried out. We did not find that A's death could have been predicted, or that there was any definitive evidence that A had suffered a seizure. However, given that further investigations were justified and were not carried out, we found that the standard of care provided to A was unreasonable and that the cause of A's injuries was not adequately investigated or followed up. Therefore, we upheld these parts of C's complaint.

In relation to complaint handling, we found the board's investigation to be reasonable. We did not uphold this aspect of C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to B 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:

• The board should share this decision with the departments involved for discussion at a team review with a view to identifying any points of learning and improvement.
• The emergency department should review their practices regarding the assessment of causes of head/facial injury and subsequent investigation of underlying conditions.

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 neighbour was granted planning permission for the construction of an outbuilding in their garden. C complained that the council’s handling of the planning application was unreasonable. C complained that their objections had not been set out in full in the Report of Handling and that the report did not include an assessment of the impact of the proposed development on C’s garden.

The build site was on sloping ground and C complained that the change in land height on the build site had not been mentioned. They also complained that the Report of Handling did not accurately summarise the scale of the proposed development or its proximity to C’s garden.

We took independent advice from a planning adviser. We found that although the Report of Handling did not include reference to the assessment of the impact of the proposed development on sunlight in C’s garden, the council had been able to demonstrate that this formed part of their assessment. We found that there was a reasonable consideration of the impact of the build on the existing house, the surrounding area, and the amenity of C’s property.

Although we were critical of aspects of the council’s handling of the application, we did not consider the shortcomings sufficient to lead to a finding that the handling was unreasonable. We found no evidence that any material considerations which might have led to the refusal of the application were overlooked. Therefore, we did not uphold the complaint but we did provide feedback on matters the council could have dealt with better.

In relation to complaint handling, we found that the council failed to identify and respond to the key concerns raised by C. Therefore, we upheld this aspect of C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to investigate their complaint to a reasonable standard. 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 .

In relation to complaints handling, we recommended:

• Complaint handlers should identify the key aspects of complaints and ensure complaint responses address these matters, in line with the 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 about the care and treatment that they received from the board. C was diagnosed with an ovarian cyst and admitted to hospital for a laparoscopy (a surgical procedure that allows a surgeon to access the inside of the abdomen and pelvis through a small hole in the skin) to remove the cyst. During the procedure, no cyst was found. However, an unusual mass was identified but not removed. An MRI scan was arranged to further investigate the findings of the laparoscopy.

C was discharged from hospital but became unwell. C attended the A&E with severe vomiting and diarrhoea and was admitted to hospital that same day.

An MRI scan was carried out and the results indicated that the previously identified mass was a haematoma (a collection of blood) and C was discharged home with antibiotics.

C became unwell again and attended a hospital in England where they were diagnosed with Clostridium Difficile Infection (CDI, a bacterial infection of the large intestine, a common healthcare associated infection). A CT scan also identified a cyst.

C commented that clinicians were surprised that C had not been screened for CDI when they previously attended hospital, having presented with diarrhoea several days after a laparoscopy. The clinicians also reportedly questioned why C’s haematoma was not removed when it was diagnosed given the likelihood of infection.

C complained that the board misdiagnosed their haematoma and failed to screen them for CDI, resulting in unnecessary complications and illness.

The board, in their response to C’s complaint, explained that there was no clinical indication that C was experiencing ongoing diarrhoea, and were satisfied that they did not therefore screen for CDI. The board said that having reviewed the care provided to C during their admission, they were satisfied that, whilst C suffered complications, the care provided was appropriate and reasonable

We took independent advice from a general surgeon adviser. We found that C presented with a history of diarrhoea prior to admission and that this was not identified or flagged to relevant clinicians on their admission to hospital. Given C's history prior to admission, C should have been screened for CDI and therefore, we upheld this aspect of the complaint.

With respect to the C’s diagnosis and treatment, we found that the conservative management plan which was adopted was reasonable in the circumstances. Whilst we identified some aspects of the clinical review undertaken of C’s condition which could have been better, they did not negatively impact on C’s outcome and we did not uphold 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:

• That the board ensure that they implement, or have implemented, all of the recommendations of the Guidance on Prevention and Control of Clostridium difficile Infection (CDI) in health and social care settings in Scotland.
• That the board review their practices and ensure that all staff are operating in line with the Guidance on Prevention and Control of Clostridium difficile Infection (CDI) in health and social care settings in Scotland.

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 way that the council had handled a planning application related to a development of new homes adjacent to their home. In particular, C expressed concern about the position and proximity of one of the plots to their home and the detriment this would cause in terms of overshadowing and loss of daylight.

On first receiving C’s complaint, we considered that the council’s complaint response had not fully addressed the issues C had raised, and we therefore asked the council to write to C again at stage two of their complaint handling procedure. As C remained unhappy with the council’s response on the matters of overshadowing, and on their conservatory and kitchen/diner not being considered as habitable rooms when determining any loss of amenity, they returned their complaint to us for further review.

We took independent advice from a planning adviser. We found that the council had managed the planning application in keeping with the relevant guidance and we did not uphold this aspect of C’s complaint. However, we provided feedback to the council on the way in which the impact on amenity had been recorded in the Report of Handling, and in relation to retention of records, particularly when known objections had been raised. On the matter of complaint handling, we found that the council had unreasonably failed to respond to C’s original complaint on the planning application and we therefore, upheld this aspect of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to fully address the complaint of overshadowing in their complaint response, and of not ensuring the investigation was undertaken by someone with no prior involvement in the circumstances being complained about. 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:

• The council should comply with their complaint handling procedure and ensure matters complained about are fully responded to.

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 their spouse (A) about the care and treatment that they received from the board.

A initially presented with a locally advanced cancer which at the time of presentation had already spread to their lymph nodes. A underwent treatment, however, went on to develop progressive disease in their lymph nodes and also evidence of spread to the bone. While further treatment was given, A's general condition deteriorated and after a number of admissions to hospital, A died of a progressive cancer.

C raised concerns that the board had failed to provide reasonable, timely and appropriate medical care and treatment to A during their admission to the treatment centre.

We took independent advice from an oncologist adviser (cancer specialist).

We found that the treatment A had received conformed to current guidelines from the European Urology Association and Medical Oncology Associations, and overall, we found that the management of A’s care was reasonable and that there were no significant failings in relation to the care and treatment given to A. However, we found that, while there was little, if no, evidence that earlier CT scans would have influenced the final outcome, given the circumstances of A's case, the CT scans carried out could have been done sooner.

With regard to C's concerns about the way that A's prognosis was communicated to them, while we found that overall the communication had been reasonable, we acknowledged that the method of communicating A's diagnosis to them had not met their needs and we provided feedback to the board about this.

While we found that the majority of the care and treatment given to A was reasonable, given that the CT scans could have been done sooner, on balance, we upheld this complaint.

C also raised concern about the medical care and treatment given to A during their admission to hosptial. In particular, that there had been clinical failures to pay attention to which medications had previously failed, which led to the same medications being prescribed to A again. Also, that there had been an unnecessary delay in moving A to the hospice.

We took advice from an independent oncology adviser. We found that A had been treated with appropriate anti-cancer therapies and symptoms relieving treatments, that the choice of antibiotics had been reasonable and that there had been no unreasonable delay in transferring A to the hospice.

We considered that the overall care and treatment provided to A was reasonable. As such, we did not uphold this complaint.

C also complained that the nursing care and treatment given to A in the hosptial had been unreasonable. We took independent advice from a nursing adviser. We found that a number of aspects of the nursing care and treatment given to A had been reasonable and that, in particular, the nursing care provided for A had been delivered in a person centred way. However, we considered that it would have been reasonable to expect that a skin assessment to establish the extent of any skin damage would have been carried out and documented prior to A's move to the hospice, especially given that A was a high risk patient at end of life care. We considered that this aspect of A's nursing care was unreasonable and therefore on balance we upheld this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failings identified in this case. 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:

• In patients presenting with significant symptoms, the need for an urgent referral for a CT scan should be considered.
• Pressure area care should be given in line with National Institute for Health and Care Excellence (NICE) Clinical guidance CG179.

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 their spouse (A) regarding the care and treatment A received from the board. A has serious health issues and has had multiple surgeries over a number of years.

Following a scan of A’s abdomen, it was identified that they had staples attached to their bladder. A considered that these had been left behind following surgery to remove their J-pouch (a pouch made from part of the small intestine and attached to the anal canal to form a pathway for the passage of stool). C complained that A experienced recurring infections and other complications as a result of the staples being left in their abdomen. A said that these had a detrimental impact on their long-term health.

We took independent advice from a general and colorectal surgeon (specialist in conditions in the colon, rectum or anus). While it was not possible to establish exactly which operation the staples came from, we considered that the staples were a likely source of A's infections. We found that the staples were clearly visible on previous scans but that these had not been reported on by radiology and therefore the clinical team did not consider these when they were assessing A’s likely source of infection and future treatment. Therefore, we upheld this aspect of C's complaint.

C also complained about the handling of their complaint. Whilst we found that there were some delays to the board’s investigation, we recognised that many years had passed between the events complained about and the complaint being submitted to the board. This meant that some issues were reasonably time-barred and some parts of the investigation were delayed due to difficulties sourcing the records and staff comments. Overall, we were satisfied that communication was generally reasonable with C and A, and that the board’s complaints procedure was followed appropriately. Therefore, we did not uphold this aspect of C’s complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the issues highlighted 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:

• The board should provide us with an update as to any procedural changes that have been made to ensure patients’ individual needs are considered when handling a complaint.
• The board should share this decision with their radiologists as a reminder of the importance of fully reporting on scans to reduce the chances of important omissions.
• The board should share this decision with their surgical team with a view to ensuring that the origin of infection is included when considering treatment of chronic infection.

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 their spouse (A) received over a number of years by the board.

C submitted a complaint to the board expressing A’s concern that they did not take reasonable care when carrying out two surgeries. C and A were dissatisfied with the board’s investigation and response to their complaint.

A underwent surgery in their abdomen in an attempt to resolve recurring infections and said they suffered significant pain afterwards. We took independent advice from a general and colorectal surgeon (a surgeon who specialises in conditions in the colon, rectum or anus). We were satisfied that this surgery did not cause the pain that A had linked to the procedure. However, we were critical of the board for failing to recognise that scans taken prior to the surgery had shown evidence of staples in A’s abdomen from previous surgeries. We found that the staples were a likely source of A’s infections and that this should have been identified prior to the surgery taking place. Had it been identified, A’s management plan may have been different. Therefore, we upheld this aspect of C’s complaint.

A also underwent a procedure on their reproductive organs. C complained that the procedure that was carried out, as described in the record of the operation, was not the one to which A had consented. We found that it had not been possible to complete the planned procedure due to an issue in the affected area, which had not been apparent until the procedure began. Whilst we were critical of the way that the procedure was described in the records, we found that the procedure itself was reasonable and appropriate in the circumstances. Therefore, we did not uphold this aspect of C’s complaint.

C and A complained that despite the board’s complaints procedure stating that complaints could be submitted in writing, in person, or over the telephone, the board insisted that A’s complaint was submitted in writing. A explained that they found it difficult to put their complaint in writing and had specifically requested a meeting with the board to discuss their concerns. This request was denied. We found that although there were reasonable reasons for asking A to submit the complaint in writing, these were not explained clearly by the board, and A was given no explanation as to why their request for a meeting was refused. We were critical of the board’s communication with C and A regarding the complaint, and of delays in the early stages of the board’s investigation. Therefore, we upheld this aspect of C’s complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the issues highlighted 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:

• The board should share this decision with the clinical staff involved in A’s treatment with a view to identifying ways of avoiding similar issues in the future.

In relation to complaints handling, we recommended:

• The board should provide us with an update as to any procedural changes that have been made to ensure patients’ individual needs are considered when they make a complaint.

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 raised a complaint on behalf of their advocacy partner (A). Following A’s arrest, C complained that A’s child (B) had been removed by social work services (SWS) from A’s care and placed with their non-custodial parent (D) without legal authority, against B’s express wishes and without taking account of A’s views. C also raised concerns that during B’s residency with D, SWS had not appropriately facilitated contact between A and B, had unreasonably requested A complete a parenting assessment and had failed to reasonably respond to A’s further concerns about B’s welfare.

In their response, the council explained that D had enacted their parental rights and responsibilities (PRR) and assumed care of B when A had been arrested which they had helped support. They said that a range of professionals had been actively involved and utilised different approaches in obtaining B’s views. They noted that contact between A and B had not been straightforward, and that the regularity of contact had been disrupted by decisions of both A and B. They said that the requirement that A complete a parenting assessment had been reasonable given the longstanding issues of concern and more recent issues involving A and that the concerns A had raised about B’s welfare while in D’s care had been treated seriously and resulted in prompt attention.

We took independent advice from two social work advisers. We found that there was a lack of recording of the discussions and the process by which the decision was taken to place B in D’s care and that there was a failure to convene a formal interagency referral discussion (IRD) to plan the approach on a multi-agency basis to assess the suitability of D as alternative care for B. We upheld the complaint as a result of the failings identified.

We found that once B had moved to D’s care, their conflicting and changing views should have prompted a referral to independent advocacy sooner. However, the council had taken reasonable steps to ensure B’s views were appropriately sought and taken regular account of. Therefore, on balance, we did not uphold this aspect of the complaint.

We also found that once B had moved to D’s care, SWS’ approach to facilitating contact between A and B had been in line with national guidance and social work practice at that time, that SWS were justified in their decision to request that A complete a parenting assessment given the long-standing concerns regarding A’s parenting capacity and history caring for B and that SWS had responded reasonably to the welfare concerns A had raised. We did not uphold these aspects of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to A, Band C for the failings identified. Theapology should meet the standards set out in the SPSO guidelines on apologyavailable at www.spso.org.uk/information-leaflets.

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

• Ensure the findings of this investigation have been reflected on, and learning is shared, with the relevant department and externally with Police partners to ensure effective future practice.
• In child protection matters, it is important that all multi-agency decisions and discussions with those affected, and their views, are clearly recorded.

Summary

C complained on behalf of their client (A) about Fife Health and Care Partnership's (HSCP) assessment of A’s needs and the level of support being provided by the HSCP. A is registered blind and has a number of other health conditions, including diabetic neuropathy (nerve damage) requiring A to use a wheelchair.

C complained to the HSCP that support previously available for C to access the community or go shopping had been withdrawn. C also believed that the HSCP operated a blanket policy not to fund services to support service users to access the community or go shopping.

In response to the complaint, the HSCP said that the arrangement to go shopping was via an unregistered cleaner and that the Care Inspectorate identified issues with this, and the worker was removed. They explained that a worker taking A shopping was not deemed as critical care criteria, that they could not offer funding for it and that alternative options were not taken up by A.

We took independent advice from an adult social work adviser. We found that, whilst there was evidence that the HSCP undertook an assessment of A’s needs, the assessment was unclear about what needs were assessed as being critical and substantial, and therefore eligible for funding. We also found that the Assessment and Support Plan failed to offer sufficient detail about the discussions with and options available to A with respect to the support available. We upheld the complaint that the assessment of A’s care plan was unreasonable.

With respect to complaints made about the operation of a blanket policy, it was noted that a number of statements and comments in A’s case notes and assessments gave the impression that this may be the case. However, whilst we found failings with respect to the assessments in this case, there was no evidence available which demonstrated that the HSCP operated a blanket policy not to fund access to social supports or the community. We did not therefore uphold this aspect of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to A via their representative C for the failings. 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:

• Reflect on this decision, and the relevant Assessment and Support Plan, in this case and ensure that assessments are clear with respect to the needs of the individual and the assessment of needs according to the relevant eligibility criteria for support.

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.