Upheld, recommendations

Summary

C was sent to hospital by the GP with a diagnosis of severe cellulitis (an infection caused by bacteria getting into the deeper layers of your skin). Prior to being sent to hospital, C received paracetamol, intravenous fluids and intravenous antibiotics. On arrival at hospital, C had a long wait until being treated and C complained that the delay in admission and treatment was unacceptable.

The board apologised that C had to wait in their car and explained that patients were seen on a clinical priority basis. They advised that C's clinical priority was not deemed to be urgent as C had received paracetamol, fluids and antibiotics before arrival.

We took independent advice from an acute and general medicine adviser. We found that at the time, there was no clear system for prioritising patients. However, since then the board have improved their practice. We found that the triage which had been undertaken after admission had not followed guidelines. Additionally, we found that the waiting time to receive antibiotics was longer than the recommended maximum wait between antibiotic doses. As such we upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the delay in admission and treatment, specifically that clinical priority was not appropriately assessed, that the triage decision was not in line with the guidance and that there was a delay in administering medication. 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 triage patients in line with the relevant guidance.

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 during their labour and delivery of their baby (A). In particular, C complained that the standard of care and treatment they received had been unsafe, that there had been a lack of communication in relation to their requested position during labour, the use of forceps and the provision of pain relief. C also complained that they had been unable to give their informed consent for the use of forceps.

The board, when responding to C’s complaint, accepted that some aspects of C’s care did not meet the standard that they would expect in terms of communication and C’s requested positioning throughout the labour and delivery of A. As a result of C’s complaint, the board had shared the complaint with the midwifery staff responsible for C’s care. The board asked them to reflect on C’s experience and consider ways of improving care for the purpose of providing person centred care. The board also accepted that they had failed to arrange C's postnatal review clinical appointment. The board said they had taken action to review and amend the process for appointing consultant led postnatal follow-up. The board indicated that, while the event had not been recorded as an adverse incident and a Datix (an incident/risk management reporting system to collect and manage data on adverse events) had not been submitted, a review had been carried out and action had been taken as a result of that review.

We took independent advice from a consultant obstetrician (a doctor who specialises in care during pregnancy, labour and after birth). We found that during C’s labour there were significant periods of loss of contact (LOC) during the recording of the foetal heart rate. However, we also found that, while labour would have been complicated by the LOC there was no evidence that C or A were put at risk. We also found that the actions of staff during this period were reasonable and proportionate to the needs of C and the clinical circumstances which occurred at the time. We found that safe care and delivery had been provided to C. However, we also found that there had been a material change in C’s birth plan and that there had been a failure to communicate these changes with C.

The board accepted that there was no documentation in the medical records of a discussion with C in line with Royal College of Obstetricians and Gynaecologists guidance on obtaining verbal consent on assisted vaginal births. We found that obtaining consent is an important aspect when providing care and treatment to a patient, and completing the appropriate documentation is a professional standard. The event should have been recorded as an adverse incident and a Datix should have been submitted. We upheld the complaint and provided feedback to the board in relation to the use of the adverse event process and the submission of a Datix.

Recommendations

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

• Patients should receive clear explanations and appropriate information where there are changes to their birth plan. Where discussions have taken place with a patient, this should be documented.
• Staff should be aware of the relevant Royal College of Obstetricians and Gynaecologists (RCOG) guidance on documenting consent.

In relation to complaints handling, we recommended:

• Complaint responses should be informed and accurate and address all aspects of the complaint.

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

Summary

C complained that the council had unreasonably failed to carry out an adequate assessment of their parent (A)'s personal care needs and made an unreasonable decision that A did not meet the criteria for free personal care funding.

We found that the council's records did not evidence that thorough assessments of A's needs were carried out. There was no evidence that A's needs had changed, or that they no longer met the criteria for free personal care funding when the funding stopped. Although there was some evidence that A's needs were considered when the decision to stop funding was challenged, there was no evidence of an adequate assessment. Therefore we upheld C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to complete an adequate assessment of A's needs, for failing to work in partnership with A and their family and for stopping free personal care funding. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.
• Provide financial redress for an amount equal to the payment of free personal care funding that A should have received between the dates specified in our decision notice.

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

• Assessments and reviews should be fully and accurately recorded within a reasonable timeframe.
• Funding decisions should be based on robust assessments that are completed and recorded in accordance with council procedures.

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 reports they made about their neighbours' antisocial behaviour. They reported a number of incidents to the Police and to the council's Antisocial Behaviour and Private Sector Services teams. Although C's reports were investigated, they were dissatisfied with the action that was taken by the council. C complained that the council failed on multiple occasions to respond to their contacts or took an unreasonable length of time to respond. C submitted a formal complaint to the council. Again, they considered that the council took an unreasonable length of time to respond to their concerns and inappropriately assigned an individual who was involved in the matters they complained about to conduct the investigation.

We found that although the council communicated clearly and regularly with C regarding their ongoing reports of antisocial behaviour, more could have been done to explain their assessment of the situation and the reasons why no formal action was being taken. We found that the council failed to follow their complaints handling procedure. There were delays in responding to C's complaint and it would have been better practice for the complaint to be investigated by someone with no involvement. On balance, 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.

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

• Staff should handle complaints in line with the Model Complaints Handling Procedure, ensuring that wherever possible the complaint is investigated by someone not involved in the complaint.
• The council should ensure that when customer contact is escalated to a formal complaint, it is dealt with under the complaints handling procedure.

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

Summary

C complained that the council failed to respond appropriately to concerns they raised about their child (A) who had cancer. C was separated from A's other parent (B) and, at the time A became ill, both C and B shared A's care on an equal basis and had Parental Responsibilities and Rights in relation to A. C was concerned about aspects of A's care and quality of life during their illness. C raised concerns that B repeatedly acted against medical advice, and acted aggressively and was abusive to C and C's partner while A was present. C complained about the way social workers and A's Named Person (a central point of contact if a child, young person or their parent(s) want information or advice) dealt with their concerns. C complained that during A's illness council staff acted unprofessionally and did not take their repeated requests for help seriously.

We took independent advice from a social worker. We found that the council should have more fully investigated the concerns C raised about A's welfare. In particular, they should have made contact with a relevant health professional involved in A's care to clarify whether they shared C's concerns. The council had a statutory duty to make enquiries in connection with A's welfare, to satisfy themselves that A was not at risk. We found that the council failed to meet their statutory obligations in this regard. Therefore, we upheld this part of C's complaint.

C complained about the council's complaint handling. We recognised this was a difficult and complex complaint for the council to investigate, but we were critical of a number of aspects of the complaint handling. We recognised that the complaint investigation spanned some of the COVID-19-related lockdowns, when services were adversely impacted. However, we found that the council not only failed to meet the relevant timescales in accordance with their complaints handling procedure, they also failed to keep C updated regarding progress. We were critical of the complaint being passed back to the team manager to finalise the response when the senior manager investigating the complaint retired; the team manager was not sufficiently senior to deal with the complaint and they were cited in the complaint themselves. We also found that there was a lack of depth in the investigation. We considered the complaint handling was unreasonable and upheld this part of C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failings identified in our investigation. The apology should recognise the impact of these failings on C, C's wider family, and on A. 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:

• Council staff are clear about their obligations and act within the relevant statutory framework. Parents with parental responsibilities and rights are treated equally by council staff. In particular, where parents present differing accounts of significant events which cannot be reconciled, relevant independent third parties should be contacted for verification, both parents should be involved in planning for meetings such as TATC, the child's views should be sought in relation to matters affecting them.
• The council should consider putting in place a system for auditing records of child protection concerns reported to a school or noted by a school.

In relation to complaints handling, we recommended:

• Complaints are investigated in line with the Model Complaints Handling Procedure. Complainants are kept updated regularly. Complex stage 2 complaints are investigated by a senior manager. Complaints should not be investigated by staff cited within the complaint.

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

Summary

C complained about the care provided to their elderly parent (A). A had to remain in bed to allow several pressure sores to be treated. To assist with moving A out of bed and changing A's position, a manual handling assessment was requested. C felt that there was an unreasonable delay in conducting this assessment and that when it was carried out, the equipment was provided too slowly and was not fit for purpose.

The partnership responded to C but denied acting unreasonably, or that there had been an undue delay. C responded to this challenging the accuracy of the partnership's response. The partnership issued a second response which acknowledged the first response had been inaccurate. However, they maintained that staff had acted reasonably, and that A had not been put at risk by the handling equipment used to move them.

We found that there had been a delay in providing a manual handling assessment caused by the referral not being initially received, which was compounded by staff absence on leave. However the partnership were able to demonstrate they had already addressed this through the recruitment of additional staff. We also found that the partnership's procedures required them to review the suitability of manual handling equipment after it was delivered to the patient, as well as ensure care staff were competent at using the equipment properly. This was not done, and we found it was unreasonable for the partnership not to have followed their own procedures. We also found that it was unreasonable for the partnership to have issued a stage 2 complaint response which was inaccurate, as their follow-up response acknowledged that it had not reflected the partnership's electronic records accurately. Therefore, we upheld C's complaints.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failings identified in this report. 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 about the care and treatment they received from the board in relation to an incident of extravasation (the leakage into surrounding tissue of medication administered intravenously) of chemotherapy into their arm. C told us that following the incident, their arm became painful and swollen and that they were left with loss of function in their hand and arm, despite being referred to the board's orthopaedic, plastic surgery and physiotherapy departments for further treatment. C considered that the aftercare they had received had been unreasonable and that there had been a lack of diagnosis in relation to the injury to their arm. C also complained about the attitude of nursing staff after the incident, which they felt lacked compassion.

The board told us that extravasation is a known risk of chemotherapy treatment but that once the extravasation was noticed, chemotherapy treatment was stopped immediately and that attempts were made to aspirate the fluid from C's arm. The board also noted that C was reviewed by an on-call plastic surgeon, all in accordance with their extravasation policy. The board acknowledged that, while C was subsequently seen by specialist in orthopaedics and physiotherapy, their recovery appeared to be slower than would normally be expected and that the long term implications were unclear.

We took independent advice from an oncologist and a nurse. We found that the board's response to the extravasation incident, both immediately and in the months that followed, was in keeping with their extravasation policy and established good practice. However, on review of the available documentation, there was no evidence to show that nursing staff had completed the necessary hourly checks of C's peripheral vascular cannula (through which the chemotherapy was administered) or that the extravasation incident had been discovered as a result of monitoring by nursing staff. This was unreasonable and contrary to professional nursing standards in relation to record-keeping. For this specific reason, we upheld C's complaint. However, there was no evidence within C's clinical records to confirm that the attitude of nursing staff had been poor.

We also found failings in the board's handling of C's complaint and made recommendations under our powers to monitor and promote best practice in relation to complaints handling.

Recommendations

What we asked the organisation to do in this case:

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

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

• All relevant staff should be trained in and be aware of the relevant guidance in relation to PVC insertion, monitoring, maintenance and removal; and the completion of the relevant PVC monitoring documentation (this should include reference to the NMC Code Section 10). There should be a reliable method of ensuring that a PVC chart/aide memoire/policy/guideline is included in each patient's record as required. Relevant documentation should where appropriate be marked “N/A” if the sections are not required, so it is apparent that they have not just been missed.

In relation to complaints handling, we recommended:

• The board should comply with their complaint handling guidance when investigating and responding to complaints.

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 practice's care and treatment of their parent (A) who died as a result of sepsis several days after being admitted to hospital. According to the death certificate, one of the underlying causes of A's death from sepsis was an infected grade four sacral ulcer (an injury that breaks down the skin and underlying tissue, grade 4 is the most severe type) that had been there for several months.

C complained that in the period preceding admission to hospital, GPs from the practice never assessed A's sacral ulcer, despite C's requests for them to do so. C complained about a house visit consultation carried out by a GP (GP1) when the family suspected A may have sepsis. They complained about GP1's decision to prescribe oral antibiotics even though A was known to have swallowing problems. C also complained about the GP's refusal to assess the ulcer visually and their decision not to arrange admission to hospital. C also complained about a telephone consultation a few days later, in which a GP (GP 2) declined to carry out a house visit and arranged admission to hospital on a non-urgent basis.

We took independent advice from a GP. We accepted GP1's clinical assessment that oral antibiotics were appropriate. However, we were critical of GP1's failure to record observations during the house visit, noting that in the absence of these records it was not possible to establish the basis on which GP1 concluded A did not have sepsis. We found it unreasonable that GP2 declined to carry out a house visit or arrange urgent admission to hospital, even though this may not have changed the ultimate outcome for A. We found there were omissions in the records in relation to anticipatory care/palliative care planning. There was also a lack of recorded discussions with A's family. Taking all of this into account we upheld C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to A's family in writing for each of the failings identified in our investigation. 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 take and record observations where appropriate. GPs should review a grade 4 ulcer if requested to do so, with District Nursing support as required. GPs should carefully consider house visit requests where concerns about sepsis are raised. GPs should ensure record-keeping meets a reasonable standard. Where appropriate, anticipatory care plans/palliative care plans should be in place, documented and discussed with relevant parties. GPs should ensure patient records contain summaries of discussions with key family members and other health care 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 that their spouse (A) was not properly assessed by Scottish Ambulance Service (SAS) paramedics and should have been conveyed to hospital, as they had a high temperature, was struggling to breathe, had a fever, a cough and a NEWS2 score of 5 (the system used to identify acutely ill patients). C felt paramedics dismissed A's high temperature due to the temperature in the room and that A should have been given oxygen. C also complained about SAS's handling of their complaint. SAS considered the assessment by paramedics was reasonable.

We took independent clinical advice from a paramedic. We found that while it was reasonable that paramedics did not administer oxygen, the paramedics did not follow the advice provided in the SAS Clinical Guidance for COVID-19 v5.0 guidelines, as A met the criteria for a referral to the Covid Hub and this was not considered by paramedics. We found paramedics did not appear to have considered or acted on warning signs for sepsis and there was no documented rationale for the decision to downgrade the NEWS2 score. We also found that the initial investigation and complaint response was lacking in detail and explanation.

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. The apology should meet the standards set out in the SPSO guidelines on apology.

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

• Patients presenting symptoms should be appropriately assessed, taking into account relevant SAS guidance. The presence of warning flags for sepsis, including NEWS2 scoring, should be appropriately assessed and acted on taking into account relevant guidance. If a decision is made not to act on warning flags or NEWS2 scoring in accordance with relevant guidance the reasoning for this should be recorded in the clinical documentation.

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 late parent (A) was referred by their GP to the board's ear, nose and throat (ENT) department on urgent suspicion of cancer. A's referral was originally vetted and agreed as urgent. In response to the COVID-19 pandemic, significant operational changes were made by the board resulting in A's referral being re-vetted and downgraded to routine the following month. Due to worsening of their symptoms, A contacted the board and it was agreed that A required further investigation by barium swallow (a test to look at the outline of any part of the digestive system). However, as an aerosol generating procedure, these procedures had been suspended by the board and A did not undergo the test until six month's after their initial GP referral. Following the barium swallow and further investigations, A was diagnosed with oesophageal cancer.

C complained that the care and treatment provided by the board to A had been unreasonable, noting the delays in investigating A's primary symptom of dysphagia (interference with the swallowing mechanism). C also considered A's age had negatively impacted the decision-making in respect of the investigations and treatment options they were offered, and they advised that A had not known until a month after their barium swallow that cancer had even been considered as the likely cause of their symptoms.

We took independent advice from a consultant ENT surgeon. We found that the referral to ENT should not have been downgraded to routine when it was re-vetted given A's symptom of dysphagia. On being seen at the ENT clinic, it was reasonable to refer A for a barium swallow at this stage but only if it had been done urgently. In A's case, the time between the request being made and their appointment was four months, which we considered was unreasonable in light of oesophageal cancer being recorded as a possible differential diagnosis on the referral form. We did not find that A's age had negatively affected the treatment options available to them. On the matter of when A became aware of their diagnosis or knowing that they were being investigated for cancer, we could not find any evidence to reasonably determine what was known or understood by A about the cause of their symptoms at the time. On balance, we upheld C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the delays in investigating and treating A's symptoms. 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:

• Evidence that the findings of this investigation have been fed back to relevant clinical staff in a supportive way for reflection and learning, and to inform future decision making regarding vetting processes.
• Patients referred with urgent suspicion of cancer symptoms should be appropriately assessed, taking into account relevant guidance.

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.