Some upheld, recommendations

Summary

C complained about the care and treatment provided to their parent (A) by their GP practice whilst they were resident in a care home. A suffers from dementia and fell in the care home. A was reviewed and treated by several GPs in relation to their pain and urinary infection. C’s complaint is concerning the care and treatment of A, the standard of communication from both the GPs and the partnership, and the partnership’s handling of the complaint.

C said that A had been left for almost two weeks with two broken vertebrae following their fall. C complained that A’s pain was not appropriately managed as they had become 'toxic' from the high levels of morphine in the Butec patches (pain-relief patches) provided and that they continued to suffer urinary infections. C complained that they did not have adequate communication from the GPs about A’s condition and that the record of the discussions that did take place were not accurately documented in the medical notes. C also complained about the communication from the partnership during the investigation of their complaint. C raised concerns about the handling of the complaint, stating it was chaotic and confused and that the partnership did not respond to their further points of concern.

We took independent advice from a GP adviser. We found that A’s pain and urinary infections were appropriately managed and as such, we found that the care and treatment provided was reasonable. We did not uphold this complaint.

With regards to communication from the GPs with C, whilst we noted that there were differing accounts of the same interactions, we found that, overall, communication from the GPs was of a reasonable standard. However, we found that communication from the partnership when C first raised their complaint fell below the expected standard. As such, we upheld this complaint. In addition to this, we upheld C’s complaint about the partnership’s handling of the complaint as we found multiple complaint handling failures, including a failure to address all of C’s concerns and to indicate whether complaints were upheld or not.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to communicate with them reasonably about their complaint and the partnership’s investigation into it. 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 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.
• The partnership should include with their apologies the learning points from the Significant Event Analysis.

In relation to complaints handling, we recommended:

• Staff dealing with complaints should be familiar with the Model Complaints Handling Procedure, understanding the importance of communication and the need to demonstrate thorough investigation of the points raised.
• Staff dealing with complaints should be familiar with the Model Complaints Handling Procedure, understanding the importance of recording consistently whether complaints have been upheld or not, and communicating this to the complainant.

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 by the board to their parent (A), who was admitted to hospital with a suspected liver problem. Ascites (a build-up of fluid in the abdomen) was diagnosed and paracentesis (a drain of the fluid) was performed, during which it was noted that A had accidentally bumped the drain. The following day A reported being in pain and, after a CT scan, it was determined that A was suffering from an un-operable arterial bleed. Shortly thereafter A died.

C complained that A’s consent was not properly obtained, that staff had failed to carry out the drain procedures reasonably, that A’s pain was not managed appropriately, that a CT scan was delayed, that communication from the board had been poor and inconsistent and that the level of review undertaken after the incident was not sufficient.

We took advice from an independent medical adviser in gastroenterology (medicine of the digestive system and its disorders). We found that the timescale for the CT scan was reasonable, that pain medication was appropriate, that the case had ultimately been appropriately reviewed and that the drain procedure appeared to have been carried out by appropriately trained staff under adequate supervision.

However, we found a number of failings. Firstly, the board had obtained verbal consent but failed to adequately record this. Secondly, the board’s complaints response had unreasonably focused on A having bumped the drain as being the cause of the arterial bleed. This was something that could not have been known with any certainty. Additionally, this explanation was not consistent with the post-mortem examination and internal case review, both of which found that the more likely cause of the bleed was as a recognised complication of the drain insertion. Therefore, we upheld these aspects 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 and their families should be given clear, consistent and accurate information about the patient's care and treatment, including any complications. Complaint responses should be accurate, and evidence based.
• In future, the board will get formal written consent from patients for this type of procedure. They will also prepare a consent booklet, which will be reviewed by their gastro clinical governance group and their clinical guidelines group.

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 board on behalf of their partner (A) about the length of time taken to arrange a lumbar puncture test (LP, a procedure used to collect a sample of fluid from the spine) following assessment by a neurologist (specialist of the nerves and the nervous system). C had regularly contacted the board requesting an update on C’s appointment and eventually decided to complain when they were told to ask A’s GP to re-refer them. On complaining, A received their LP appointment. The board advised that the delays had been caused by the Covid-19 pandemic and that A had now been appointed to see a neurology consultant.

We found that the board had separate processes in place for arranging LPs depending on whether a patient was seen by a locum consultant or a member of the board’s own staff. As A was seen by a locum consultant, they were required to be added to an anaesthetist’s (administer of drugs) list which ran every three-four months. Had they been seen by the board’s own staff, they would have arranged the LP test directly without the need to refer them to a separate list. In A’s case, the original anaesthetist’s list that they were appointed to was cancelled, as was the second due to the onset of the pandemic, which meant that A was required to wait 10 months for this test. We upheld this complaint.

C also complained that the board failed to provide pain relief to A while waiting for the LP test. While we considered C’s expectations to be reasonable in respect of the results of the LP test confirming A’s diagnosis and informing decisions about future care and treatment, including management of their pain, we considered that this aspect of their care to remain the responsibility of A’s GP at this time. As such, we did not uphold this part of C’s complaint.

Finally, we found that the board’s complaint handling was unreasonable, particularly in relation to the failure to act on the lack of equivalence in service provision despite this problem being known following the board’s own investigation of C’s complaint. We upheld this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C and A for failing to arrange the LP test reasonably and for failing to reasonably respond 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:

• The board should implement a sustainable model for listing the patients of locum doctors to ensure that they timeously receive LP tests. This should include a contingency plan to prevent long delays for patients when lists are cancelled.

In relation to complaints handling, we recommended:

• The board’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. All staff dealing with complaints should be familiar with the Model Complaints Handling Procedure, understanding the importance of communication and the need to demonstrate thorough investigation and action taken on the points raised.

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 late parent (A) who had a number of medical conditions. During an admission to hospital, A’s condition deteriorated, and they died.

C complained that A’s deterioration was not appropriately managed and that they contracted Listeria Meningitis (a serious disease in which there is inflammation of the membranes of the brain and spinal cord, caused by bacterial infection) and Clostridium Difficile (C-Diff; infection of the large intestine triggered by long term use of antibiotics). C also complained that a medication to treat diarrhoea was inappropriately prescribed because A had a diagnosis of ulcerative colitis. C further complained that staff did not communicate with A’s family that they were suspected of having sepsis. C also raised concerns about the board’s handling of their complaint and the standard of record keeping which was referred to in their complaint response.

The board acknowledged that the medication to treat diarrhoea should not normally be prescribed in patients with ulcerative colitis and that there was no clear record of the discussions that were held with A’s family. The board confirmed that Public Health investigated the source of listeria meningitis and concluded it was not likely a hospital-based transmission.

We took independent medical advice from a consultant gastroenterologist (a doctor specialising in the treatment of conditions affecting the liver, intestine and pancreas). We found that A’s overall care and treatment was reasonable. A was appropriately treated with intravenous steroids and antibiotics and the decision to not provide surgical intervention was reasonable. It was noted that A was at high risk of developing C-Diff given that they had been prescribed a strong immune suppressant. With regards to the listeria meningitis breakout, we found that the board appropriately sought external review and specialist public health and microbiology advice. We also found that the standard of record keeping was reasonable. Therefore, we did not uphold these aspects of the complaint. However, we found that there was insufficient evidence of clear communication with A’s family about their condition and the fact that they had sepsis, and that the board failed to provide a full response to the complaints raised. We upheld these aspects of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to communicate with A’s family that they were suspected of having sepsis and for failing to provide a full response to the complaints raised. 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:

• Staff should understand the importance of, and ensure that they communicate clearly with patients and their families about their condition.

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 failed to respond reasonably to their enquiries. A planning application was submitted by a business located close to C’s home. C contacted the council’s planning service asking a number of questions in relation to the proposed development. There followed a protracted correspondence during which C tried to obtain answers to their questions. The council treated some of C’s questions as objections to the planning application and C was advised that they would receive no response to these points. Some of C’s outstanding questions were eventually answered after C involved their local councillor, but a number remained unanswered.

Generally, we did not consider that C’s enquiries could be viewed as objections to the planning application. We noted the council’s comments about resourcing and the need to focus on core business but found no reasonable explanation as to why the enquiries could not have been dealt with sooner. We considered there to have been a clear and unreasonable delay to their response to C’s enquiries. Therefore, we upheld this part of C’s complaint.

With regard to the procedural aspects of the complaint handling, we found that the council had responded to C’s complaint reasonably. 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 reasonably respond to enquiries made by C regarding the planning process. The apology should meet the standards set out in the SPSO guidelines on apology at www.spso.org.uk/information-leaflets.
• Invite C to submit any outstanding questions they may have with a view to investigating these and providing C with a written response.

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

• The council should review how they handle enquiries from members of the public to ensure that general enquiries are responded to, or that individuals are appropriately signposted to relevant national guidance in good time.

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 medical treatment provided to their late spouse (A) by the board following diagnosis and treatment of upper tract urothelial cancer (a type of kidney cancer). A’s condition deteriorated and they died. C complained that clinicians failed to, amongst other things, communicate with them in a reasonable way about treatment options and take reasonable action in response to A’s clinical condition.

We took independent advice from a urology specialist (concerning the male and female urinary tract, and the male reproductive organs) and a renal specialist (concerning the kidneys). We found that A’s cancer had likely been more aggressive than originally suspected. However, given the information available at the time, the option of treatment offered to A had been a reasonable approach. We also found that the board had failed to adequately document that all treatment options had been discussed with A, and that a specialist renal cancer nurse should have been available to the family sooner. We found that had A’s treatment been carried out sooner (and in line with cancer waiting time standards), it may have improved their health outcomes. For these reasons, we upheld this aspect of C’s complaint.

C also complained that during a hospital admission the board had failed to reasonably manage the removal of A’s nephrostomy tube (a catheter inserted through the skin and into the kidney) causing them to suffer an arterial trauma (or bleed). We found that bleeding is a recognised complication of such a procedure and there was no evidence to indicate any failings in the removal of the tube. We did not uphold this aspect of C’s complaint.

C further complained that when A’s condition deteriorated following dialysis, unit staff advised the family to take A home, or to take them to the emergency department themselves. C also complained that there had been no end-of-life plan in place for A. We found that there was insufficient evidence to determine what advice had initially been offered to the family by unit staff. However, we found that the process around the decision-making to admit A for ward care had been appropriate, and although there had been no end-of-life plan in place, the ‘wait and see’ approach to treatment had been reasonable in this case. Therefore, on balance, 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 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:

• The board should ensure all discussions between patients and clinicians are clearly documented in line with required standards.
• The board should give consideration to the use of specialist renal cancer nurses in supporting patient diagnosis/patient management from an early stage.
• The board should review urgent suspicion of cancer referrals to address treatment waiting times, ensuring that there are appropriate mechanisms in place to monitor progress from diagnosis to definitive treatment.

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 parent (A) lived in a nursing home and had been shielding during the COVD-19 pandemic. A was later admitted to hospital and was placed in a green pathway (a ward for COVID-negative patients) ward in preparation for emergency surgery. Following surgery and a few days in the High Dependency Unit, A was transferred to another ward which C was advised was a red pathway ward (a ward for COVID-positive patients). A was discharged over a week later.

C complained to the board about A’s transfer to a red pathway ward and had not been satisfied with the explanation the board provided. C also complained about the standard of nursing care, the decision to discharge A, and that the board failed to arrange follow-up care for A following their discharge.

We took independent advice from a nurse and a consultant geriatrician (specialist in medicine of the elderly). We found that, while the decision to transfer A to a red pathway ward had been reasonable and appropriate in the specific circumstances, the board had not reasonably explained the decision to C. Therefore, we upheld this part of C’s complaint.

We also found that the standard of nursing care and decision to discharge A was reasonable. The board also made the relevant referrals to the appropriate community services after A’s discharge. Therefore, we did not uphold these aspects of C’s complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for not explaining the rationale behind the transfer of A to a red pathway ward. The apology should meet the standards set out in the SPSO guidelines on apology available at 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 social work failed to reasonably assess A’s needs following a hospital admission, in relation to whether they required 24-hour care, and C’s concerns that social work ignored clinical opinions.

We took independent advice from a social worker. We considered that it was reasonable for social work to have concluded initially that A did not technically meet the criteria for residential care and was functionally fit to be discharged home with a support package. While we noted that the opinions of others were taken into account in arriving at this conclusion, we considered that there was a failure to fully examine the emotional impact on A of potentially being discharged. The council had already acknowledged that there could have been more detailed discussion with A’s GP and further exploration of the views of a specialist nurse from the psychiatry team, which we agreed with. We also considered that some wording used in the social work assessment to describe A’s reactions could have been perceived to lack empathy and compassion. We upheld this complaint.

A suffered a stroke three days after the initial social work assessment was concluded. They were in temporary accommodation at the time, awaiting further assessment. It was subsequently agreed that A required 24-hour care. They remained in the temporary facility until their transfer to a care home, but died a month later. C complained that a delay in social work re-assessing A delayed their transfer to a care home, which meant the transfer took place during lockdown when the family were unable to support A with the move. The council advised that A was re-assessed in a timely manner once a care home vacancy became available. We considered that it was reasonable for the assessment to be updated once a vacancy arose and were satisfied that the delay was due to a lack of available places and not due to a failing on the part of social work. We did not uphold this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to give enough weight to the emotional impact on A of potentially being discharged and for the wording used to describe A’s reactions. 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:

• Appropriate weight should be given to the emotional impact of discharge on clients. Social workers should be aware of the impact of language used and where it may be perceived to lack empathy and compassion.

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 council’s handling of a planning application. Planning consent was approved for a development that was contrary to the Local Development Plan. Whilst C acknowledged that the Planning Committee were entitled to approve the development, they considered that, in doing so, the Committee failed to explain what material considerations had contributed to the decision to go against the Local Development Plan and approve the application. C also complained that a pre-determination hearing should have been held, but was not.

C raised their concerns in a complaint to the council. They said that it took many months of repeated attempts to obtain a response from the council and, when the council did respond, C did not consider that their concerns had been addressed.

We took independent advice from a planning specialist. There was no question that the Planning Committee had the authority to approve developments that were contrary to the Local Development Plan, as long as there were relevant material considerations, or justifiable reasons for doing so. We acknowledged the council’s position that the report of handling for the application set out the material considerations that had to be taken into account when determining the application and that this information was available to the Planning Committee when reaching their decision. However, the report of handling presented the material considerations with reference to the Local Development Plan and explained in detail why the Planning Officer considered the proposed development went against the Local Development Plan and why they recommended the application be refused. We found that there was a clear unexplained “leap” from the Planning Officer’s recommendation to refuse, to the Committee’s decision to approve. We considered that there should have been a clear record of the reasons for approving the planning application in the minutes of the Committee meeting and in the decision notice. We were critical of the council for failing to record the reasoning behind the Planning Committee’s decision. Therefore, we upheld this aspect of C's complaint.

We were satisfied that the decision on whether to hold a pre-determination hearing was a discretionary decision for the council to make. We found no evidence to suggest that their decision not to hold a pre-determination hearing was unreasonable. Therefore, we did not uphold this aspect of C's complaint.

With regard to the council’s handling of C’s complaint, we found that there were excessive delays to the council’s response, despite C chasing them on a number of occasions. We were critical of the council’s delays and their failure to consider C’s correspondence through their complaints procedure. We were also critical of the fact that, when the council issued their response, they failed to address the main points of C’s complaint. We upheld this aspect of C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the poor handling of their complaint and provide a full response to their initial enquiry as to the Planning Committee’s reasons for approving the application contrary to the Planning Officer’s recommendation. 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 council consider how they may take steps to clarify complaints to ensure that they are progressed through the correct channel.
• That the council share this decision with members of the Planning Committee and remind them of the need to properly document the reasons for their decisions.

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, a representative of an organisation that provides support to planning application objectors, complained on behalf of an objecting neighbour (A). C raised a number of concerns about the council’s handling of a retrospective planning application. An unauthorised development had been reported to the council’s planning enforcement team. The retrospective planning application was approved, subject to conditions. C complained that the council failed to reasonably assess the risk of flooding at the site, that they failed to follow correct procedure for the scale of the development and failed to take into account an objection submitted by the Scottish Environment Protection Agency (SEPA).

We reviewed the relevant planning documents and sought independent advice from a planning adviser. We found that there was a failure to seek a flood risk assessment, particularly in light of the concerns raised by SEPA, the fact the development was on a listed flood plain and the Planning Officer had identified a risk of flooding as a reason for recommending refusal of the application. As such, we upheld complaint C’s complaint about the failure to request a flood risk assessment.

In respect of C’s concerns about the council’s consideration of SEPA’s consultation response, we found that the content of SEPA’s response was accurately summarised in the Planning Officer’s report to the Planning Committee. We did not uphold this aspect of C’s complaint.

Our final consideration was whether the council failed to refer the planning application to Scottish Ministers. We concluded that the council should have treated SEPA’s response as an objection to the planning application and that this should have led to the application being referred to Scottish Ministers. We upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to A 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.
• That the council offer to meet with A to discuss ways of establishing to what extent the development may have contributed to an increase in flooding on their property and what action the council can take to mitigate this.

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

• The council should review their standard working practice of not requiring technical assessments in cases where they anticipate refusing an application due to the cost that would be incurred by the applicant.

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.