Some upheld, recommendations

Summary

C complained about the care and treatment that they received in relation to their mental health from the board over the course of just over a year. C was also concerned about the treatment that they received from a psychiatric consultant including consideration of referring C to a different health board and dealing with complexities in the case, such as C’s parent being employed by the board. We took advice from an independent psychiatric nursing adviser. We found that the overall standard of treatment provided to C was reasonable and did not uphold this complaint.

C was also concerned that the board unreasonably delayed the organisation of community mental health care to them due to concerns over safety and risk. Although C was ultimately referred to the specific community mental health team outwith the area that they had requested from early in the process, we found that the board’s regard for the potential risks of such an arrangement were reasonable and that, overall, there was no unreasonable delay due to the board’s action and that the standard of care provided was reasonable. We did not uphold this complaint.

C was further concerned that the psychiatric consultant did not reasonably record their assessment and reasoning of decisions to hospitalise C, to prescribe medicine to C or to refer C to a psychologist. We found that record keeping over the relevant period had been reasonable and that, taking all of the available evidence, the psychiatric consultant had reasonably recorded their assessments and reasoning regarding C’s treatment. We did not uphold this complaint.

C was concerned about delays in the board responding to complaints about their care and treatment, the board’s inability to explain the reasons for those delays and the board’s failure to provide a copy of a response to an elected representative as C had requested. While the board had accepted some of these failures during their consideration of the complaints submitted or while responding to our enquiries we also concluded that, contrary to the board’s views, the reason for these delays were confusion within the board and a lack of clear responsibility for responding to the complaints. We upheld this complaint.

Recommendations

What we asked the organisation to do in this case:

• Re-iterate their apologies to C for the unreasonable delays in responding to the complaints and their unreasonable failure to provide a copy of their response to their MSP as they had requested. Apologise to C that they did not provide reasonable explanations for the delays in responding to the complaints. 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:

• Establish a clear hierarchy of responsibility for complaint responses and a system of escalation to senior management for circumstances where complaints have not been responded to within three times the length of a timescale in the Complaints Handling Procedure, or Complaints and Feedback Team follow up messages do not result in action to progress matters.

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 adult child (A) had spent time in hospital due to abdominal pain, following which complaints had been raised and promises made that action would be taken to prevent any recurrence. A few years later, A spent time in hospital again as a result of abdominal pain and swelling, bruising to the legs and breathing issues. During the admission, A required cardiopulmonary resuscitation (where the heart and/or breathing is re-started if it stops) and died in hospital. A post-mortem examination established that A had rheumatoid arthritis-related constrictive pericarditis (a condition that causes the flexible sac that surrounds the heart to become stiff, preventing the heart from functioning properly).

C raised a number of concerns regarding the clinical investigations carried out into A’s symptoms, the time taken to reach a diagnosis and the quality of clinical nursing care provided. C complained about the standard of communication from the board’s staff and expressed their concern that the improvements that had been promised previously had not been implemented by the board.

We took advice from an independent nursing adviser. We found that multiple, relevant, investigations were carried out to establish the cause of A’s symptoms, appropriate specialist advice was sought, a reasonable treatment plan was followed and that the true nature of A’s heart condition was not detectable, despite the appropriate investigations having been carried out. Given this, we found that the medical care and treatment provided to A had been of a reasonable standard. We did not uphold this aspect of the complaint.

We found that the board’s monitoring and management of A’s fluid balance and wound care was not of a reasonable standard, and that there were apparent issues in terms of the nursing staff’s engagement with A and their family. We found that the board had failed to provide A with a reasonable standard of nursing care. We upheld this aspect of the complaint.

While we found the board’s communication with C following A’s death was generally reasonable, we found that the board unreasonably failed to apologise to C for not contacting them when A became unresponsive. Given this, and that there were communication failings that the board had accepted, we found that the board had failed to communicate with A’s family appropriately during their admission and following their death. We upheld this aspect of the complaint.

We did not find any evidence that the actions and service improvements promised following C’s earlier complaint were implemented by the board. We also found that if actions were taken, they were not effective, as the board accepted that similar issues had recurred. We found that the evidence the board provided regarding actions taken as a result of their later commitments were from too small a sample of patients and taken over too short a period to adequately demonstrate that issues identified had been addressed. Given this, we found that the board had failed to implement the actions and service improvements promised following C’s earlier complaint. We upheld this aspect of the complaint.

We found that C’s complaint was taken seriously and investigated thoroughly. However, there were delays to starting an investigation into the most recent issues raised by C and to arranging a meeting regarding these. We also found that the board’s communication with regard to the Chief Executive’s attendance at any meeting and how the most recent issues would be taken forward were poor. Given all of the above we found the board failed to handle C’s complaint reasonably. We upheld this aspect of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to A’s family for the issues highlighted. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.
• Apologise to A’s family for failing to contact them when A became unresponsive. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.
• Apologise to A’s family for failing to effectively implement the actions and service improvements promised following C’s original 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 conduct an audit of the relevant ward's current compliance with their obligations to monitor fluid balance and wound condition to ensure that the improvements that have reportedly been made since C’s complaint are reflected in the nursing care currently provided on the ward.
• The board should conduct two audits of the general quality of nursing care in the relevant ward to demonstrate an improvement in standards over the next six months.
• The board should effectively implement the actions and service improvements promised following C’s original complaint and take action to effectively address issues regarding nursing care, communication, attitude and behaviour.

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

Ms C provided her express consent for her pronouns to be used for this publication.

Ms C complained about matters relating to the SPS failing to give Ms C advice and failing to put in place an appropriate procedure for Ms C to obtain certain items. Ms C also complained about the SPS refusing to allow Ms C to wear her own clothing and having the use of certain electrical items. We took independent advice from an adviser who specialises in equal opportunities and diversity.

We found that there were delays in the SPS giving Ms C advice and in putting in place a process to order certain items. We upheld these aspects of Ms C's complaint.

We found it was reasonable that the SPS refused Ms C's request to wear her own clothes and have access to the electrical items. Therefore, we did not uphold these aspects of Ms C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms C for the delays in providing her with advice and putting in place a process for her to order items to support her gender identity. 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:

• All relevant SPS staff should be clear about their obligations to transgender prisoners and their policy on accessing, or facilitating access, to items to support their gender identity.

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.

C's neighbour was granted planning consent for an outbuilding in their garden. C noted that this space was to be used for commercial activities and complained that the council failed to comply with their own adopted and emerging Local Development Plan policies when reaching the decision to approve the application. C did not consider that their concerns in this regard had been addressed in the report of handling.

C raised further concerns as to how the approved development would impact the neighbouring properties and the local area. C contended that the council failed to appropriately notify all of the affected neighbours.

When objecting to the development, and in their subsequent complaint to the council, C noted that approving the application would allow the developer, or future owners of the residential property, to conduct other activities that could be disruptive. C did not consider that the council had taken adequate steps to consider this eventuality, or to limit the activities to those listed by the applicant. C raised a complaint with the council, but did not feel that all of their concerns were addressed.

We took independent advice from a planning specialist. We found that the council were largely able to demonstrate that the planning application had been handled reasonably. Therefore, we did not uphold this complaint. However, the report of handling failed to address C's concerns about the potential for other activities taking place at the site in the future. Whilst we were satisfied that the council were entitled to reach the decision that they had, we were critical of them for failing to demonstrate that this issue had been considered prior to consent being granted and we made a recommendation in this regard. We also found that the council failed to address this, and another issue, in their responses to C's complaint. This was particularly concerning given how central these two issues were to C's complaints about their handling of the planning application. 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 failure 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.

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

• That the council share this decision with their planning staff.

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 various aspects of Social Work Services (SWS) involvement with their children. C complained that SWS failed to invite C to a 72-hour Looked After Child (a looked after child is a child under the care of the council) review. C further complained that at the review, SWS had not given appropriate consideration to the children's care planning, and had failed to correctly follow the Section 25 Children (Scotland) Act 1995 in placing their children with a family member.

We took independent advice from a social work adviser. We found that SWS had made reasonable attempts to contact C to advise them of the review meeting. Therefore, we did not uphold this aspect of the complaint. We found that information presented at the meeting was lacking in respect of the children's own views, and SWS had failed to fully document their discussions with one of C's children. However, we considered that appropriate consideration had been given to care planning for the children. Therefore on balance, we did not uphold this aspect of the complaint but provided feedback to the council about the importance of ensuring accurate recording of social work activities, including seeking views, to inform care planning.

We also found that although C was in disagreement with the placement, and the views of the children themselves had been lacking, C's estranged partner had authority under section 25 of the Children (Scotland) Act 1995 to agree to the voluntary arrangement. We found SWS had followed best practice in ensuring C's estranged partner was appropriately supported in their decision-making regarding the children's care planning, and although there had been a delay in signing the section 25 paperwork, the placement had been valid. Therefore on balance, we did not uphold this aspect of the complaint.

C further complained that SWS had unreasonably presented at their home during COVID-19 restrictions. We found that SWS had failed to follow their own COVID-19 guidance relating to home visits by not exploring the option of a remote meeting with C. We also found SWS had not provided C with a copy of the relevant guidance; had not made enquiries as to the status of C's health; and had not confirmed what PPE would be required to support the visit in advance. We upheld this aspect of C's complaint to the extent that SWS had failed to follow its own guidance, but not to the extent there had been a breach of public health guidance for which this office has no jurisdiction.

C also disagreed with the council's responses to their complaints and the manner in which these had been handled. We did not find any concerns with the manner in which the council had handled C's complaints, all of which were responded to in line with the Model Complaint Handling Procedure and good complaint handling principles.

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:

• Feedback the findings of this investigation to relevant staff for reflection and learning, and to inform future 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 and B complained about the board's handling of reports of alleged elder abuse in relation to a family member (A). They also complained that the board had failed to handle appropriately a referral made to the District Care Panel (DCP) for residential care for A, and had failed to give sufficient consideration to A's circumstances and that they were at risk of harm when rejecting the request. They also complained that following concerns for A's welfare, A had been removed from their place of residence, but the board had failed to properly assess A's care needs or to provide A with a reasonable level of support. In pursuing these matters, C and B said that the board's communication with them had fallen below a reasonable standard.

We took independent advice from a social worker. We found that although the Adult Support and Protection (ASP) investigation was procedurally sound, it had been lacking in quality. The board's analysis of A's circumstances and the Personal Outcome Plans were lacking, and were not persuasive in assessing a care need. As such, we found that the board had failed to safeguard A. We upheld this aspect of the complaint.

We also found that although the DCP handled A's referral for residential care appropriately, the information provided to the DCP was lacking in terms of the quality of the ASP investigation and the robustness of the case presented regarding A's situation. As such there was a failure by the board to prioritise securing urgent short-term accommodation that took account of A's circumstances. We upheld this aspect of the complaint.

We found that following A's removal from their place of residency, the board had followed up with A reasonably. We did not identify any further shortcomings in the board's assessments of A's care or living needs. We did not uphold this aspect of the complaint.

Finally, we found that the board had, at times, failed to respond to C and B's questions and requests for information regarding their concerns about A. We also found that there had been occasions where the board's correspondence with C and B had been unreasonably slow. We therefore upheld this aspect of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C and B for the poor handling of their correspondence. 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, B and A for the issues 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 (i) share this decision notice with the staff involved in A's case with a view to reflecting on how the ASP investigation could have better identified the nature and extent of their situation and pushed for an outcome that would have better protected A; and (ii) use this case as a reflective exercise to consider the effect of undue pressure and trauma on decision-making in ASP cases.
• The board should review how they track and respond to general correspondence to ensure all points are responded to fully and within a reasonable 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, an MSP, complained on behalf of their constituent (A). A had suffered severe pain in the years following a porcine mesh implant (a surgical device, consisting of mesh made of animal tissue, such as intestine or skin, that has been processed and disinfected to be suitable for use implanted into a patient to strengthen a surgical repair) to rebuild their abdominal wall. For a number of years, a pursued treatment for the pain with the board and the possibility of the removal of the porcine mesh. The board's gynaecology department (specialists in the female reproductive system) ultimately advised that they were unaware of any relationship between porcine mesh implants and chronic pain. A was referred to plastic surgery but this was declined on the basis that the plastic surgery department had no additional treatments to offer A.

C asked the board for an independent review of A's case and an assessment for surgery to remove the porcine mesh. The board told C that the gynaecology and plastic surgery departments would review A's case in collaboration. A was ultimately only offered an appointment with gynaecology. Following further consideration, but without a joint appointment for A with the two departments, the board concluded that A was being offered appropriate treatment options and that removal of the porcine mesh would not relieve A's pain. The board advised A to seek a joint gynaecology and plastic surgery referral via their GP.

We took independent advice from a consultant plastic surgeon. While we found that the assessment of A's pain by the board had been reasonable, we concluded that this had not been reasonably explained to A in a single, clear and comprehensive communication that addressed all of the concerns and queries A raised regarding the nature of the mesh used, why this was distinct from the mesh referred to in media reports, why this was unlikely to be contributing significantly to A's pain and why there was no surgical procedure available to remove it. We concluded that it was unreasonable to have promised a joint consultation between gynaecology and plastic surgery and then not carry this out, despite acknowledging that A sought this and having several opportunities to arrange the joint consultation. Given this, we upheld C's complaint that the board had not reasonably assessed or explained the source of A's pain.

However, we concluded that the board's treatment plan for A's pain was reasonable. While the board's decisions on treatment and reasons for these were not well communicated to A, the board reasonably investigated A's condition and reached a reasonable position regarding treatment. Given this, we did not uphold this aspect of C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to A that they unreasonably failed to arrange a joint appointment with the plastic surgery and gynaecology departments, and to explain their conclusions regarding A's pain in a reasonable way. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.
• Arrange and undertake a joint appointment for A with the plastic surgery and gynaecology departments.

In relation to complaints handling, we recommended:

• Staff should handle complaints in line with the Model Complaints Handling Procedure, which includes addressing all the areas the board are responsible for and explaining 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 complained about the care and treatment that they received from Tayside NHS Board following treatment in the A&E of Ninewells Hospital. C attended the A&E after sustaining an injury to the little finger of their right hand caused by a serrated knife. They were diagnosed and treated for mallet finger (a deformity of the finger when the tendon that straightens the finger is damaged at the fingertip), of which treatment involved the application of a splint to the injured finger.

C complained to the board that their injury had failed to heal correctly. C complained that they were not given an x-ray, that the splint was too big and that they were given insufficient information to allow them to care for their injury. C also complained that they had not been provided with a face-to-face physiotherapy appointment timeously.

We took independent advice from an emergency medicine adviser. We found that C's injury was wrongly diagnosed and that, consequently, the application of a splint in C's case was not the appropriate treatment. We found that the A&E should have referred C to a hand surgeon. We upheld this aspect of C's complaint.

We found that it was the responsibility of C's GP practice to arrange a timeous referral to physiotherapy. We, therefore, 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:

• Patients attending the A&E with this type of injury should receive appropriate diagnosis and treatment.
• The board have said that they will ensure C's feedback was used within the A&E to ensure that any ill-fit of splints is explained fully in future as part of the aftercare advice.

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, who suffered with hip problems, was diagnosed with a labrum tear (a condition which occurs due to damage of the soft cartilage that rims the socket portion of the hip joint) and underwent surgery.

C's symptoms failed to resolve following surgery and they were informed during a follow-up consultation that a metal artefact was visible on x-rays of their hip. C complained to the board about the advice to proceed with surgery and the treatment that they received.

C also complained about their concerns regarding their assessment and suitability for surgery to address their symptoms, and that the surgery had been carried out unreasonably.

We took independent advice from an orthopaedic (conditions involving the musculoskeletal system) adviser. With respect to C's complaint about diagnosis and treatment which resulted in the hip surgery being undertaken, we found that C underwent appropriate assessment. We found that the surgery, including relevant complications, was discussed and C had consented to the procedure. On this basis we did not uphold this aspect of the complaint.

With respect to the complaint that the board failed to provide appropriate care and treatment during, and following, the hip surgery, we found that whilst the surgery was performed to a reasonable standard, and subsequent problems investigated reasonably by clinicians, the board failed to comply with the duty of candour when they failed to inform C after the operation about the failure of a metal anchor used in the hip repair. We also identified that the board, in their complaints investigation and response to C, failed to adequately address the issue of the metal artefact in their hip following the operation. 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 meet its duty of candour. 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:

• Discussion by the Orthopaedic Department Clinical Governance meeting of the requirements around Duty of Candour, including reflection on C's case.

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 Greater Glasgow and Clyde NHS Board. C was referred to the Early Pregnancy Unit (EPAS) by a private clinic on two occasions. C complained that EPAS took too long to declare the pregnancy non-continuing, that C was required to attend an unnecessary number of scans and that their care was not escalated to a doctor. C also complained that the advice and care that they received by phone, and the fact that they were contacted and invited to a reassurance scan, was unreasonable. C further complained that EPAS asked them for distressing information rather than gathering this from the private clinic and that EPAS did not gather consent from C for surgical management as they ought to have done. C also complained that the care and treatment that they received as an inpatient was unreasonable.

The board noted that they apologised for the delay in the time C waited to be seen, that during their admission C fainted and was lowered to the floor by a nurse who then called a doctor, that all options were not discussed and that on reflection there was a missed opportunity to obtain a second opinion. The board also noted, however, that this would not have changed C's management plan.

We took independent advice from a consultant obstetrician (the medical specialism for pregnancy, child birth etc) and gynaecologist (medicine of the female genital tract and its disorders). We found that a second opinion should have been sought, which may have allowed miscarriage to be diagnosed earlier. We also found that C should not have had to relay findings or be subjected to repeated examination when diagnosis had already been made by the private clinic and that the necessary documentation ought to have been obtained from the private clinic. We further found that during C's fainting episode, appropriate observations and actions were taken and the faint was well managed.

In light of the above, we found that whilst it was reasonable for EPAS to repeat some scans, a second opinion was not sought when it should have been. If this happened, C's miscarriage could have been diagnosed earlier, and therefore, the care and treatment provided to C was unreasonable. Additionally, the actions of EPAS asking C to relay findings and requiring C to undergo a further scan was unreasonable. We found that C's faint was well managed and the care and treatment provided to C during this time was reasonable.

We also considered the way in which the board handled C's complaint. We found that it does not appear that the board's complaint investigation took account of the clinical notes made by the doctor to ensure a full and accurate response was provided.

We partially upheld C's complaint and made recommendations to the board as a result.

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/informationleaflets.

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

• Patients attending EPAS should not be required to undergo unnecessary scans.

In relation to complaints handling, we recommended:

• When carrying out an investigation, consideration should be given to ensuring the response takes into account any relevant clinical notes so that the complainant receives a full and accurate response.

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.