Upheld, recommendations

Summary

C, a support and advocacy worker, complained on behalf of their client (A). A had undergone breast surgery to remove nodes and C complained that the board did not adequately assess and manage A's wound when it showed signs of infection. The wound deteriorated and A became critically unwell with sepsis.

The board carried out a Significant Adverse Event Review (SAER), in which A expected greater involvement. C also complained that the SAER failed to identify that the incident met the Duty of Candour threshold and did not address the key issue, which was the inadequate care provided. The board stated the staff involved used their clinical judgement to assess the wound, which did not show signs of infection. However, it was difficult to investigate the adequacy of the wound assessment due to the omission of notes they made. The board acknowledged communication between health care professionals was impeded by a reliance on a paper-based system and the clinical record keeping was inadequate.

The board further advised the SAER was a formal process, which did not allow for A's inclusion and maintained the incident did not meet the Duty of Candour threshold. They considered the SAER to be adequate, as an investigation had taken place that had identified a number of learning points and recommendations.

We took independent clinical advice from a registered nurse specialising in tissue viability. We found the wound assessment to be inadequate, leading to a missed opportunity for appropriate wound management and that those involved in A's care lacked knowledge of current best practice in terms of wound assessment, wound management and antimicrobial stewardship. We also found the SAER to be inadequate as it failed to address the key issues of wound assessment, wound management and antimicrobial stewardship and failed to identify the incident met the Duty of Candour threshold.

As such, we upheld C's complaint.

Recommendations

What we asked the organisation to do in this case:

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

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

• A person centred approach should be adopted.
• For all patients with a wound to have an adequate wound assessment undertaken and documented in a formal wound assessment chart. This should be in line with the following guidance Vale of Leven Inquiry Scottish Government Recommendations 2015NMC: The Code 201Scottish Ropper Ladder for Infected Wounds 2020 and HIS Scottish Wound Assessment and Action Guide 2021.
• A Duty of Candour Investigation to be undertaken, unless there is definitive evidence that the UTI caused the sepsis as wound deterioration is still a strong possibility.
• All staff involved in wound management are competent in appropriate management and familiar with the relevant guidance.
• Pathway to be developed to ensure timely referral to tissue viability specialist for deteriorating or non-healing wounds.
• Recommendations added to the SAER to address learning and improvement around wound assessment, management and antimicrobial stewardship.
• Staff to be reminded of Stage 3 of the Scottish Ropper Ladder for Infected Wounds, and consideration of antibiotics.

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 their late sibling (A) should have been given a telephone or face-to-face consultation with a GP following increasing contact with the practice and an escalation of symptoms relating to chest pain that resulted in A's death from acute myocardial infarction (heart attack). C also complained that the practice's handling of the resulting Significant Adverse Event Review (SAER) was unreasonable.

The practice considered the care and treatment of A to be reasonable. The GP was shielding at home during the COVID-19 pandemic and could not see patients face-to-face. The practice stated it was subject to restrictions imposed by the Scottish Government at the time. The practice also said that A was appropriately triaged and their care managed by a range of healthcare professionals.

We took independent clinical advice from a GP. We found that A should have been offered a telephone consultation with the GP and a face-to-face appointment with the locum GP. We found that A's care was delegated to nursing staff when GP input was required and there was a lack of review between the GP and nursing team when A's symptoms failed to resolve.

We also found that the SAER failed to identify learning points, failings and reflection and did not include the health care professionals involved in A's care.

Therefore, we upheld C's complaints.

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.
• Significant Adverse Event Reviews should be a reflective and learning process that appropriately considers events in sufficient detail, to ensure failings are identified and any appropriate learning and practice improvements.
• When appropriate, patients should be reviewed by a GP either by phone or in person dependant on their symptoms.
• When necessary and required, patients receiving treatment from the nursing team should have their care appropriately reviewed and discussed with a GP.

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 partner (A) about the care and treatment they received from the practice. A was prescribed an anti-inflammatory drug by a rheumatology consultant (specialists in diagnosing and managing chronic inflammatory conditions). The medication was issued on repeat prescription by the practice. C told us that the medication had risks and the practice failed to carry out appropriate medication reviews or update A about the risks. C said A was not aware of the risks of the medication and trusted that it was safe to use long-term. They felt it was unreasonable for the practice to assume A would have read the leaflet with the medication to identify any changes or to know to ask for a medication review.

The practice said that the medication was prescribed by the rheumatology service and would have been monitored by them. The practice highlighted that at the time the medication was prescribed, it was not considered high risk, and that the risks only became known after A had been prescribed the medication for a number of years. The practice noted that A did not proactively contact the practice to review their medication periodically but acknowledged that they did not contact A either.

We took independent advice from a GP. We found that national guidance states that patients should have annual checks when taking medication of this sort. The responsibility for carrying out these checks lies with whoever is issuing the prescription. When discharged from the rheumatology service, the practice should have invited A for a review and arranged appropriate follow-up. The practice should have carried out medication reviews and informed A about the change of risks associated with the medication.

We found that it was unreasonable for the practice not to have carried out medication reviews or informed A about the change in risks. Therefore, we upheld C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to A for failingto alert them to the changes in risks associated with the medication, having a discussion about the risks, and allowing them to make an informed choice on whether or not to continue with the medication; failing to carry out medication reviews annually as they should have done; and failing to invite A to a review of their health when the practice became aware they were discharged from the rheumatology service. 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:

• GPs should recognise that as the prescriber of the medication it is their responsibility to carry out medication reviews on medications provided via repeat prescription. When a GP is alerted to the fact a patient is discharged from a secondary care service due to non-attendance, they should contact the patient to arrange a review and consider appropriate follow-up. Medication reviews should be carried out annually.
• When medication alerts are issued nationally, the practice should identify and review any of their patients to whom such an alert might apply.

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 practice about the care and treatment provided to their relative (A). A began to experience abdominal pain and was reviewed by doctors at the practice a number of times before being admitted to hospital as an emergency. Following discharge, A was seen at the practice again with continuing symptoms and unintended weight loss. They were referred to hospital and again discharged. A colonoscopy performed suggested acute diverticulitis (where small pouches from the wall of the gut become inflamed or infected). A attended the practice again with worsening symptoms and was admitted to the hospital after an urgent request was submitted. A died in hospital a few weeks after.

C was concerned about the standard of care provided to A by the practice. The practice met with A's family. The practice carried out a Significant Event Analysis (SEA). The practice responded to C's complaint and noted their frustration that A had been discharged from the hospital without progress in the management of their condition. However, they did not find that they should or could have done anything differently in A's care.

C submitted a further complaint to the practice after they received a response from the health board regarding the care provided at the hospital. The practice responded confirming that an SEA had been carried out. The doctor who had seen A had discussed the case with colleagues in the practice and with their Educational Supervisor. These discussions had been informal and had not been documented in A's notes.

C was dissatisfied with the complaint responses and brought the complaint to our office. We took independent advice from a GP. We found that most of A's care was of a reasonable standard. However, there was a delay in acting on concerns about A's condition following their second discharge from hospital. Given the significance of the failures identified, we considered that A's care fell below a reasonable standard and upheld this part of C's complaint.

C also complained that the practice failed to reasonably respond to C's concerns. We found that the identified failure should have been communicated to the family, by the practice, during their investigation of the family's complaints. Therefore, we upheld this part of C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to A's family for the failure to act with sufficient urgency following A's discharge. 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 the complaint investigation's failure to identify a failing in A's care. 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 requiring urgent care should be referred to specialists within a reasonable timeframe.
• The practice should ensure relevant staff are aware of the need to document discussions about patient care appropriately, in this case discussions between a trainee doctor and their Educational Supervisor, concerning a patient's care.
• Complaint investigations by the practice should address all relevant issues and should clearly identify and address any failings.

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 partner (A). A had a seizure and was admitted to hospital for further assessment. C reported their concern to staff that A had dislocated their jaw during the seizure, and advised that this had happened to A before.

A underwent x-rays and was referred to oral and maxillofacial surgery (OMFS, specialists in the diagnosis and treatment of diseases affecting the mouth, jaws, face and neck) for review. OMFS concluded that no further treatment was required for A. C continued to report their concern about A's jaw and an urgent referral was made to ear nose and throat (ENT) for further assessment. This was later re-directed on vetting to OMFS, however no follow-up review by OMFS took place by the time of A's discharge some weeks later.

On discharge, C contacted A's GP who arranged for A to be seen by another health board. A was diagnosed as having a dislocated jaw and underwent emergency surgery.

The board said that there had been evidence of dislocation in the right jaw joint. They said that due to A's dementia and reduced mobility, they were unable to fully cooperate during their assessment and would not have been able to manage further x-ray procedures. They noted that A did not appear to be experiencing any pain and appeared to have a good range of movement of their jaw.

We took independent advice from an oral and maxillofacial surgeon. We found that A's initial assessment on arrival at the hospital and the decision to wait until the x-rays had been reported before referring A to OMFS for further assessment was reasonable. However, we found that the assessment of A's jaw by OMFS failed to elicit the clinical features of the dislocation and failed to consider other types of scan after concluding the diagnosis was unclear.

On the matter of the urgent referral to ENT which was later redirected to OMFS, we were critical that no follow-up review by OMFS took place prior to A's discharge. We considered that the board failed to provide A with reasonable care and treatment and upheld C's complaints.

We also noted that, at the point of C complaining to the board, it was known that A had in fact dislocated their jaw during their admission. The board confirmed in their response to our enquiries that no internal processes for reporting or learning or improvement had been followed on becoming aware of this harm. While the board had responded to C's complaint, we were critical that they failed to initiate or follow other processes to record the event, or to elicit learning and improvement outcomes at the point of becoming aware of it. Therefore, we made a recommendation to the board on this matter.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to reasonably assess and diagnose A's dislocated jaw, the referral to ENT being inappropriately accepted, and the unreasonable delay by ENT in reviewing A which did not take place during their admission. 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 findings of this investigation should be fed back to relevant clinical staff in a supportive way for reflection and learning, and to inform future decision making regarding assessment processes.
• Referrals to other specialties for review should be made appropriately and accepted only when it is reasonable to do so. Referrals should be seen within a reasonable timescale.
• When the board becomes aware of a harm through the complaint process, processes should be followed to ensure reporting and learning and improvement takes place. This should be in line with both statutory duties and in keeping with any additional internal processes relevant to the incident type.

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 child (A) was assaulted at school by other pupils. C complained that the council had failed to protect their child, failed to provide appropriate first aid and failed to provide a reasonable level of support to them following the incident. C also complained that the council failed to safeguard A from the bullying they subsequently experienced.

In their response to C’s complaint, the council provided details of the first aid provided and the steps taken to notify C’s spouse of what had happened. They said that the school had introduced a number of measures to help keep child A safe after the incident. The council initially said that C had refused to take part in restorative meetings, which they considered would have helped to resolve matters. After C complained about the council’s response, the council conceded that C had not been invited to a restorative meeting and apologised for this inaccurate information in their response.

We reviewed the council’s actions with reference to the relevant council policies. We considered that the assault had been taken seriously and acted upon swiftly. However, we found that although the council endeavoured to put in place a number of arrangements aimed at keeping A safe, these did not appear to have been fully implemented. We found that certain aspects of the council’s policies were not followed, that the council acknowledged that no restorative meetings took place and that counselling was not available to child A. We found that the council failed to ensure A was sufficiently supported after the incident and we also found shortcomings in the council’s complaints handling. We therefore upheld this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C and C’s family for the reliance on inaccurate information when reaching conclusions in the stage one response, with an acknowledgement of the impact this had on them. 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 the issues highlighted in this decision notice. 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 creating a structured procedure and guidance for dealing with serious unacceptable behaviour and ensuring that the parties involved receive a full suite of support if required.

In relation to complaints handling, we recommended:

• Information contained within complaint responses should be accurate. In terms of good practice, complaint responses should be person-centred and non-confrontational.

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 their council tax account. They had applied for a single person discount and a council tax reduction. C complained that the council failed to manage their account properly, did not communicate with them and issued warning notices for payment while the account was in dispute. C said that the council’s handling of their account amounted to discrimination.

We found that there were significant delays throughout the council’s assessment. However, we noted that this took place during the COVID-19 pandemic when services were disrupted. We found nothing to suggest the council were discriminating against C but considered that their communication was generally poor.

We were satisfied that C’s council tax reduction entitlement was assessed reasonably, but we considered more could have been done to obtain the relevant information for the purposes of assessing C’s application for single person discount. We upheld 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.
• Invite C to provide evidence of the date that they moved into the property and reassess the start date for their single person discount accordingly. The council should confirm to C what type of evidence they would accept as proof of the date of entry.

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 unreasonably assessed that a property was in a safe and lettable condition when they handed the tenancy over, that the council failed to make, or communicate, reasonable arrangements for carrying out repairs, and that the council failed to provide a reasonable response.

In respect to the aspect of the complaint that the council had unreasonably assessed that their property was in a lettable condition when the tenancy was allocated, we found that the capacity of the council’s systems to record safety and quality checks led to the council being unable to evidence that the property met the lettable standard at the time the tenancy was allocated. We therefore upheld this complaint.

C also complained that the council failed to make, or communicate, reasonable arrangements for carrying out repairs. We found that C was put to having to arrange repairs that could have been carried out before the property was let. We also found that the council did not communicate effectively with C when appointments were cancelled or had to be rearranged. We therefore upheld this aspect of the complaint.

C also complained that the council did not provide a reasonable response to their complaints. We found that the responses to the complaints did not address all of the concerns raised and failed to recognise the impact the issues had on C. We therefore also upheld this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to ensure that repairs were carried out to the required standard prior to letting the property, for failing to check that the heating and smoke alarm systems were in full working order, for failing to make or communicate reasonable arrangements for appointments and for failing to provide a reasonable response to their 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:

• Where the council have informed a tenant that they will carry out repair work, officers should keep the tenant updated about any delays.
• The council should have effective systems in place to ensure the Lettable Standard is met and that records are well maintained and easily accessible. Tenants must have a satisfactory provision for heating their property.

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. Responses should address each point of the complaint, providing a clear explanation of what occured and describing action that will be taken where something has gone wrong. The information in responses should be supported by the evidence in the relevant records.
• Complaint responses should recognise the complainant’s experience and demonstrate empathy for their situation.

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 reported concerns to the council’s environmental services department about smoke pollution over a number of years as a result of their neighbour burning bonfires and a wood-burning stove. C was dissatisfied with the lack of action taken by the council and submitted a complaint. C considered that the council’s investigation of their concerns was insufficiently detailed, failed to take account of available evidence, and dismissed factors which C considered important. C also complained that the council’s response contained a number of inaccuracies.

We found that the council did not meet the timescales set out in their complaints procedure. However, the complaint was raised and investigated during the COVID-19 pandemic and C was advised from the outset that timescales were being affected. The council also apologised for this delay. We considered the overall time taken to have been understandable in the circumstances. However, we did note that the council failed to communicate to C that their complaint was being considered at stage 2 of the complaints procedure, despite initially advising that it would be reviewed at stage 1 and that C was not provided with updates when they asked.

It is also clear that there was ongoing communication between C and environmental services throughout the investigation period, correspondence sent and received via a councillor on C's behalf and Freedom of Information requests made. This all contributed to an overall confused chain of correspondence.

Generally, we were satisfied that C’s complaints were taken seriously and an investigation was carried out before the council’s response was issued. However, we found that the investigation sought mainly to respond to the complaint, rather than get to the root cause and attempt to resolve C’s dissatisfaction. The council’s response to C’s complaint reiterated their previously-stated position on whether they considered statutory nuisance had been witnessed. However, C’s complaint referred to the way that the officers had reached their decision, and the lack of objective measurement of the problem or use of official monitoring tools and the apparent disagreement as to which legislation was relevant. We considered that the council’s response should have explained matters such as why the smoke was not considered to be a statutory nuisance, what would be considered a statutory nuisance, why no equipment was deemed necessary to establish that no nuisance existed, and how the officers assess such situations.

We found no evidence that the council’s response to C’s complaint was inaccurate, or that a more detailed investigation would have altered the outcome in terms of the environmental services' assessment of C’s reports.

C also appears to have been given conflicting explanations as to why video evidence was not considered. However, this was clarified in response to our enquiries. We considered that this highlights the importance of collating a single clear explanation before responding to an individual’s enquiry.

Taking all the evidence into account, we found that the council did not reasonably respond to C's complaint. We upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to address some of the issues C raised, that their communication with C regarding the complaints procedure was poor and their general communication was confusing. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.
• Write to C to provide a more comprehensive response to the outstanding issues we have identified in this decision.

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

• The council should consider how they could have better managed correspondence from C to ensure that, where individuals communicate through multiple channels or across multiple departments on the same issue, all points are responded to fully and consistently.

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 adult with autism, was receiving treatment from the Partnership as a new patient after moving into the area and was unhappy with their psychiatrist. C felt that the Partnership did not have appropriate staff who specialised in treating adults with autism.

C complained that the psychiatrist questioned the diagnoses and treatment plan already in place, that the psychiatrist told them that the treatment plan was wrong, that they asked questions in an unstructured way and made unreasonable remarks about C’s personal life. Further, during an online consultation the psychiatrist allowed a second person to be present without having made C aware this would happen and ignored their request for an adjustment to have a doctor of the same gender as them. C also complained that the Partnership accused them of being misogynistic by asking for a same-gender doctor.

The Partnership said that the psychiatrist did agree to provide the prescription C was seeking as C was very fixed on the recommendations made by their previous psychiatrist. The Partnership also said that C was derogatory towards the psychiatrist due to their gender and questioned their ability.

We took independent advice from an adult consultant psychiatrist. We found that the evidence showed that the Partnership provided elements of good care and treatment to C. However, their response to C’s request for a same-gendered doctor was unreasonable, the consultation deviated significantly from recognised good medical practice and it was unreasonable to have an additional person present without C having been told or asked for consent beforehand. In addition, we found that there was no evidence that would support the Partnership’s position that C was derogatory towards the psychiatrist due to their gender, and there was no evidence to suggest C was significantly hostile. Therefore, the Partnership’s assertions about C’s manner were unreasonable. As such, we upheld C's complaints.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failings identified in this 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:

• Complaints should be investigated in line with the Model NHS Complaints Handling Procedure. Particularly they should identify and clarify all points to be investigated at the outset of the investigation, address all of the points raised and be person-centred and non-confrontational.
• New patients should receive initial appointments with clinicians that are conducted reasonably and in line with good practice. Particularly these should ensure questioning and summarisation of clinical information is structured, appreciate the importance of establishing a therapeutic relationship between the clinician and new patient and establish the patient’s expectations from the outset.
• Observations and opinions on a patient’s manner and motivations should be fair, accurate, and evidenced in so far as possible.
• When student or trainee clinicians sit in on appointments for training, the Partnership should introduce the person and explain why they are there, where possible, the patient should be informed in advance of the appointment and the patient's consent should be sought. When a patient does not consent to a trainee/student being present they should leave the appointment.

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.