Upheld, recommendations

Summary

C complained that the board failed to adequately investigate and/or treat their late spouse (A)'s condition by failing to follow up their appointment at a gynaecological clinic.

A experienced abdominal pain and heavy menstrual bleeding. A's GP referred them to a gynaecology clinic. A attended the clinic and was referred for a scan. A was then discharged back into the care of their GP. A year later, A's GP referred them to gynaecology under a suspicion of cancer. A was subsequently diagnosed with endometrial cancer (a type of cancer that begins in the uterus). A was given various cancer treatments but later died.

C complained to the board about A's care and treatment. The board acknowledged that A's care was not to the standard it should have been. They accepted that the gynaecology clinic had failed to follow local treatment guidance in A's case. They apologised for this. C remained unhappy and asked us to investigate. C was concerned that the board had failed to adequately explain events.

We took independent advice from a gynaecologist. We found that the board had failed to follow their local clinical guidance in A's case. We welcomed the board's acknowledgement of this failing and their apology. However, given the significance of the failings identified we made additional recommendations for action by the board.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failure to follow the relevant clinical guidelines in A's case. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

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

• Where local guidance varies from national guidance there should be appropriate review to ensure the variation has been adequately documented and controlled and diagnostic criteria and terminology is clear and appropriate. In undertaking the review we would encourage the board to consider our comments on the simplification of the local guidance and structure of its flowchart.
• Patients with heavy menstrual bleeding should receive appropriate care and treatment in line with the relevant clinical 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 asked a doctor at the practice to complete a DVLA medical examination. The doctor advised C that they did not have capacity to assist C and directed them to a private firm who could help.

C made a complaint to the practice about the decision and availability of doctors at the practice. In their response, the practice asked C to apologise for insulting staff or they would be removed from the practice. C was subsequently removed from the practice list. C made a further complaint to the practice regarding the decision to remove them from the practice list. The practice responded to the complaint, explaining the rationale for removing C. C was dissatisfied with the responses provided by the practice to their complaints.

We found that, whilst C's complaint was likely to have been difficult for staff to learn about, the practice's response was poor. Demanding C apologise was not an appropriate manner in which to try and establish an understanding or re-build trust between a complainant and members of staff. Therefore, we upheld this part of C's complaint.

We also found that it was not reasonable for the practice to have treated C's complaint as having caused an irretrievable breakdown of the relationship between C and the practice. The practice did not follow the appropriate process should they have wished to warn C about the appropriateness of the complaint. Therefore, we found it was unreasonable for the practice to remove C from the practice list and upheld this part of C's complaint.

The practice apologised to C.  While we acknowledge that an apology was given, that apology did not, in our view, meet the SPSO guidelines on apology, as was required by our recommendation.  In this respect it only partially met the recommendation.

Our office tried to engage constructively with the practice over a considerable period of time about giving a further apology, recognising that the original circumstances giving rise to the complaint, were rooted in an already difficult relationship with the C. The practice did not issue any further apology to C. The Ombudsman considered the extent to which it would be in C’s and in the public’s interest to escalate the matter and apply her statutory powers as set out in our Support and Intervention Policy. Having had regard to the length of time which had passed, the fact there had been partial compliance, and changes there had been at the practice in the meantime, the Ombudsman determined that a further apology, even were it to be issued by the practice, would no longer be meaningful, so would not be in either the C’s, or the public’s, interests to pursue.

The Ombudsman has communicated with the practice to communicate her disappointment about the practice’s failure to engage meaningfully with her office and their poor attitude, and to confirm additional steps her office will take when considering complaints received about the practice in the future

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to focus their response on the issue of C's complaint and in responding in an inappropriate manner. 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 failures identified and the decision to remove them from the practice list. 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:

• Complaint responses focus on issues of complaint raised by complainants. Staff should be familiar with the practice's complaints handling procedure and reflect on appropriate approaches to communicating with service users, highlighting communication it deems to be offensive or inappropriate and how to resolve complaints in an effective manner.
• Staff should be familiar with the practice's complaints handling procedure and reflect on appropriate approaches to communicating with service users and how to resolve 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.

This decision was originally published on 16 August 2023. On the 24 July 2024, we added the following information: 

"The practice apologised to C.  While we acknowledge that an apology was given, that apology did not, in our view, meet the SPSO guidelines on apology, as was required by our recommendation.  In this respect it only partially met the recommendation.

Our office tried to engage constructively with the practice over a considerable period of time about giving a further apology, recognising that the original circumstances giving rise to the complaint, were rooted in an already difficult relationship with the C. The practice did not issue any further apology to C. The Ombudsman considered the extent to which it would be in C’s and in the public’s interest to escalate the matter and apply her statutory powers as set out in our Support and Intervention Policy. Having had regard to the length of time which had passed, the fact there had been partial compliance, and changes there had been at the practice in the meantime, the Ombudsman determined that a further apology, even were it to be issued by the practice, would no longer be meaningful, so would not be in either the C’s, or the public’s, interests to pursue.

The Ombudsman has communicated with the practice to communicate her disappointment about the practice’s failure to engage meaningfully with her office and their poor attitude, and to confirm additional steps her office will take when considering complaints received about the practice in the future."

Summary

C complained about the care and treatment provided to their relative (A) by the practice.

A attended the practice frequently within a year and was later diagnosed with an aggressive form of cancer. A died shortly after. C believed that A's concerns were not properly taken into account when they attended the practice and that A should have been referred sooner for investigations. The practice provided a detailed reply to C, stating their view that A's concerns had been investigated appropriately, and that there had been no indication for a cancer referral.

We took independent advice from a GP. We found that there was no reason to suspect cancer as a possible cause of A's symptoms. However, as symptoms persisted, an urgent cancer referral should have been considered. We found that it was highly unlikely, given the aggressive nature of A's cancer, that the delay in A's diagnosis had any impact on the outcome of A's disease. Although A's initial treatment was reasonable, we found that there were failings in care in that the practice should have made an urgent referral for A sooner. We therefore upheld this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C, and A's immediate family, for the failure to make a referral for A in line with the Scottish Government guidelines. 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 practice should be familiar with the Scottish Suspected Cancer Referral Guidelines and refer patients for specialist assessment in accordance with the guidelines.

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) by the board. A had dementia and was experiencing worsening delirium following a urinary tract infection. A was admitted to hospital by an out-of-hours doctor who visited A at home. C's sibling accompanied A in the ambulance but was told that they were unable to stay with A in hospital due to COVID-19 visiting restrictions. A was transferred to a side ward and later that evening, fell from the bed. A had a head laceration and complained of right hip pain. A head CT and hip x-ray were undertaken which confirmed a right hip fracture. A was transferred to an orthopaedic ward (specialists in the treatment of diseases and injuries of the musculoskeletal system) but it was decided A would not survive an operation due to the fall and hip fracture trauma. A died a few days later.

We took independent advice from a consultant geriatrician (a specialist in the care of older adults) and a senior nurse in falls prevention.

We found that a reasonable level of information from A's family was recorded and taken into account by medical staff, that the assessment of A's delirium was reasonable and that it is common practice for a doctor to try and speak directly with a patient with significant dementia or delirium to allow them to assess the individual's capacity. We also found that it was reasonable to transfer A to a side room, that the action taken by medical staff following the fall was reasonable, as was the communication with the family. Furthermore, that the pain relief was reasonable and was a priority of staff who saw A.

However, we found that there were a number of failings in the nursing care and treatment provided to A. We found that it was unreasonable that no family members were allowed to stay with A, that there was a lack of information documented in the nursing records and a lack of completed paperwork in relation to assessments that should have been carried out on A. Whilst nursing staff's immediate attendance and commencement of the post fall assessment and escalation tool was reasonable, we also found that there was a delay in contacting the family and failure to use a straight lift. Therefore, we upheld this part of C's complaint.

C also complained that the board failed to carry out a reasonable investigation into A's fall in hospital. We found that a serious adverse event review (SAER) should have been carried out instead of a local adverse event review (LAER). Therefore, we upheld this part of C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the specific failings identified in respect of the complaint. 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:

• Family members should be communicated with in a timely manner, particularly after a patient has fallen whilst in hospital, and the detail of conversations should be recorded. Relevant staff should be aware of the requirements for the assessment for potential fracture, safe manual handling for possible fracture including using flat lift equipment.
• Patients' nursing care should be clearly and accurately recorded including any conversations with family members. Entries should be legible, signed and dated.
• Adverse events should be reviewed and reported in line with relevant guidance and in a way that fully reflects the patient journey and outcome with appropriate regard to learning and improvement and communication with the family throughout the process.
• Assessments such as mobility; bedrail and TIME assessments should be completed appropriately and consistently and recorded in the nursing records.
• Relevant staff should be aware of changes to 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 City of Edinburgh Council’s administration of their council tax account. C complained that the council issued reminders for council tax arrears and threats of legal action when they had paid their council tax in accordance with a payment arrangement. C also complained that the council failed to respond to the their complaint in accordance with their Complaints Handling Procedure (CHP).

The council apologised for delay in responding to C’s complaint. They said that a council tax payment reminder had been sent to C as they had made a payment without using their reference number. This had meant that the payment hadn’t been allocated to C’s account.

C remained unhappy and asked us to investigate. C complained that the council had failed to respond to their correspondence and had failed to take the fact that they are a vulnerable person into account.

We found that the council had repeatedly failed to engage with C’s correspondence over a significant period of time. We found serious and repeated failures by the council to adhere to their CHP. We considered that the council acted without any consideration or accommodation of C’s vulnerability. Therefore, we upheld C’s complaints.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failings identified in the administration of C’s council tax and in the handling of 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:

• Enquiries about council tax payments, especially where the council is claiming no payment has been made and the customer is stating the contrary, should be dealt with and responded to promptly.

In relation to complaints handling, we recommended:

• The necessary systems and procedures should be in place to ensure that complaints are handled in line with the council’s complaints policy and procedure and that all staff are aware of the complaints handling policy and procedure.

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

Summary

C complained about Fife council's handling of a complaint that they made regarding an incident involving their child (A) at their school.

C said that A was a victim of sexual assault and harassment during a playground game in which another child forced A to kiss them, touched A inappropriately and encouraged other children to chase and catch A. C said that, as a result of this, A felt unsafe and was unable to return to the school.

C complained that the council’s staff failed to carry out a reasonable investigation, including that A’s teacher’s account of events was accepted without any further scrutiny.

We found that the council’s initial investigation of concerns raised verbally by C was reasonable and highlighted the school staff’s conclusion at that time that this had been a matter that could be dealt with in the classroom. When new information became available indicating that the events may have been more serious, the council left the investigation to the police. Following completion of the police’s investigation, the council issued their response to the complaint, which reflected the situation as they understood it.

However, C’s complaint clearly included mention of their concern that a few weeks before the specific incident complained of they had reported to the teacher that a similar incident had occurred. Due to the lack of records available of the council’s investigation it is unclear whether, or to what extent, that these concerns were taken into account or investigated. These concerns were not responded to by the council. It is unclear, therefore, whether the council reasonably considered the implications of the teacher having been aware of potentially inappropriate behaviour taking place among the children for a few weeks before the reports that led to action being taken. These implications may have included what weight the school and council gave to the teacher’s statements, whether evidence or corroboration should have been sought for when the teacher or other staff first became aware of the children’s actions in the playground, and whether the outcome of the investigations would have been the same. Therefore, we upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for their failure to investigate and respond to C’s concern that they had reported to the teacher. 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:

• Complaints are properly investigated and responded to in line with the Model Complaints Handling Procedure for Local Authorities.

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 planning department with respect to a section 75 agreement (a contract that is entered into between a landowner and a planning authority). In particular, C complained that the council had failed to adhere to a clause of the section 75 agreement requiring them to adopt open space and woodland areas within, and bordering the housing development on which C lives. C noted that some of the land in question had now been sold to a property developer. C believed that the council’s inaction could result in development adversely affecting C and other residents’ properties and a failure to maintain the playpark and communal spaces. Additionally, C was dissatisfied with the council’s response to their complaint due to missed timescales, and the response having been issued by an officer closely involved in the matters complained about.

We took independent advice from a planning adviser. We found that many of the significant events related to this complaint were now historic. In particular, the fifth clause of the section 75 agreement required prior action be taken, adoption of the land by the council, before occupation of a number of homes in a phased development. However, a number of years previously the council had failed to monitor and discharge this condition allowing occupation. While in theory enforcement action remained a possibility at the council’s discretion, due to the passage of time the owner of the land likely now had deemed planning permission. On this basis, we upheld C’s complaints about these matters. We also upheld C’s complaint that the complaint had not been handled in line with the council’s complaints handling procedure.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing in their duty to ensure that all the conditions and schedules of the decision notice and the Section 75 Agreement were discharged. Apologise for failings in relation to enforcement action which due to the passage of time and failings outlined appeared to no longer be a reasonable option available to the council. Additionally, apologise for the failings in complaint handling. 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 as a condition of planning permission being granted, the council and the developer have entered into a Section 75 Agreement, the said Agreement and the conditions attached there too require to be monitored by the council to ensure that they are complied with and discharged. The council should therefore ensure that they have a systematic and robust system of monitoring in place.

In relation to complaints handling, we recommended:

• The council should ensure that they comply with the process and time limits set out in the complaint handling procedure. Where the council are unable to meet their time limits for responding to a complainant they should notify the complainant and explain the reasons why. The council should also ensure that their final response to a complaint signposts to this office in line with their 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 provide support to them and their child (A), who had a severe and debilitating mental illness, and that the council unreasonably failed to respond to all of their concerns.

We took independent advice from a social work adviser. In relation to the council’s failure to provide support to C and A, we found that there were unreasonable delays by the council at each stage of this case. We found that there appeared to be a lack of appropriate management oversight of the case, and a lack of follow up to ensure the best possible outcome for A was met. We also found that the overall communication with C was poor.

In relation to the council’s failure to respond to all of C’s concerns, we found that the actions which the allocated social worker said that they would undertake to progress the case had led C not to make a complaint. We found that the council’s complaint response lacked detail and clarity as to what went wrong and how this could have been avoided. In particular there should have been a clearer acknowledgement and explanation as to why their own guidelines on timescales were not adhered to. We also found that the council failed to fully acknowledge the impact on C, A and their family from those delays and that if the council considered it was not possible or appropriate to issue a joint response on behalf of the council and other partnership organisations, the reason(s) why should have been explained to C and C should have been signposted accordingly. Therefore, we upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failings in providing support to C and 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:

• Complaint responses should be informed and accurate. The council’s complaint handling monitoring and governance system should ensure that failings (and good practice) are identified and that learning from complaints is used to drive service development and improvement. The council should ensure that they carry out a robust investigation of a complaint when things go wrong. This should include examining the management and decision-making processes of a case to ensure that they have an understanding of all aspects of a case.
• Contact and referrals to social work services should be handled in a timely way and, where appropriate, allocated to a social worker without delay. Children and Young Persons’ assessments should be completed wherever possible in accordance with the timescales set out in the council’s policy. Where this timescale cannot be met, the reasons for this should be fully documented and there should be regular and proactive communication throughout the process.

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 South Lanarkshire Health and Social Care Partnership's handling of supported living arrangements for their adult child (A) with severe learning difficulties and significant support needs.

The partnership approved an assessment of A’s needs that included supporting them to move into their own tenancy with one-to-one support. It was noted that, long-term, the preferred option would be for A to move into a shared tenancy. C said that they worked with A’s care provider to find a suitable two-bedroom (to accommodate care staff) tenancy for A. The partnership were advised that this work progressed to the point where the care providers were looking to purchase a property for A to live in, and they told C a three-bedroom property should be the focus of the property search to achieve the ultimate aim of A securing a shared tenancy with room for another individual and care staff.

We took independent advice from a social work adviser. We found that the partnership’s assessment of A and C’s needs was reasonable. We were satisfied that the partnership’s reasoning was clear and appropriate in determining that a shared tenancy was the preferred long-term option for A, that the benefits of this (if delivered appropriately) were agreed by all involved, and that the partnership’s communication with C and other involved parties was clear and frequent throughout. We did not find that A’s assessed needs changed following the reassessment. However, it was decided at that point that the focus had to switch from providing A with a single tenancy to a shared tenancy. This decision was in line with the agreed long-term plan for A but was also, as the partnership described it, a material change from the initial proposal. It was also a change made without any prior preparation by the partnership in terms of finding a suitable joint tenant or three-bedroom property. We found that this caused an unreasonable delay to A being able to move towards independent living given plans were already advanced to secure a single tenancy that would have met A’s assessed needs. With this in mind, on balance, we upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C that the partnership’s decision caused an unreasonable delay to A’s move to independent living. 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 partnership review their handling of A’s case with a view to identifying how they may better investigate the viability of all options for independent living and progress these before reaching decisions that effectively reduce those to a single option.

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 presented to the medical practice with nausea and weight loss. Following blood tests, a significant drop in haemoglobin levels was noted and anaemia (deficiency of healthy red blood cells in blood) was diagnosed. C complained that they were not referred on to secondary care for admission or investigation at this point. A few days later, C collapsed and suffered internal bleeding as a result of a large gastric ulcer (a perforation or hole in the lining of the small intestine, lower oesophagus or stomach).

The practice advised that C was a new patient to the practice and had recently been in hospital with acute kidney injury. On first presentation they had a urine infection, which was treated with antibiotics. Following the blood test results, examinations were carried out to check for internal bleeding. No signs of bleeding had been found but C had a bladder full of urine and their catheter was bypassing. The doctor referred to district nursing for a catheter change and a repeat blood test. This was to check whether C was experiencing further kidney injury. There were no obvious signs of dyspepsia (a condition where digestion is impaired) as no heart burn was recorded.

We took independent medical advice from a GP adviser. We found that it would have been appropriate to make an urgent cancer referral based on the symptoms, but that it was reasonable not to have suspected a gastric ulcer. We also found that there was no record that the causes of the anaemia had been fully explored or that a treatment plan and safety netting advice had been considered or communicated.

We upheld the complaint as we considered that although many of the actions had been reasonable, it did not appear that a cancer referral, a treatment plan or safety netting had been properly considered, recorded or communicated. We did not consider that this had changed C’s outcome and acknowledged that the practice had taken steps to learn from the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for not fully exploring C’s symptom history and medication, for not communicating a treatment plan and for not providing worsening advice in case of deterioration. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflet.

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

• The practice should consider scheduling regular peer reviews to ensure that consultations are fully recorded including treatment plan and safety netting advice. Staff should be aware of NICE Guidelines and Scottish Referral Pathways for suspected cancer.

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.