Upheld, recommendations

Summary

C complained about the orthodontic care (dentistry dealing with the prevention and correction of irregular teeth) provided to their child (A), particularly that A's treatment had been unreasonably discontinued. The dental practice's decision to discontinue was based on a failure to comply with the requirements of the orthodontic treatment. C complained that the orthodontist had not raised any significant concerns previously, and that there had been a lengthy period without review due to Covid-19 restrictions.

We took independent clinical advice from an orthodontic adviser. We found that the records evidenced only intermittent or periodic poor oral hygiene, as opposed to the consistently poor oral hygiene noted by the orthodontist. We also found that there was evidence of valid clinical grounds to support the stoppage of A’s treatment. However, we also found that there were significant failings regarding the way the decision was communicated.

At the last appointment A attended, the records give the expectation that treatment was continuing. C tried to contact the orthodontic practice following this appointment to find out when the next review appointment would take place. When they did not receive a reply they submitted a complaint, the response to which communicated the decision to discontinue treatment. This was several months after A had last been seen. The orthodontist failed to clarify in the response why they had not replied to C’s communication after the last appointment, and it was not made clear specifically when it had been decided A’s treatment should be discontinued. We found that the orthodontist’s actions were not compliant with General Dental Council standards for communicating with patients. We found that the orthodontist’s decision to discontinue A’s treatment was unreasonable, particularly in relation to the way it was communicated. As such, we upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C and 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:

• Communication with patients and/or their guardians should be carried out and documented in line with the relevant standards (Standards for the Dental Team, GDC).
• The orthodontist needs to ensure that complaints are handled in line with the NHS Complaints Handling Policy. This requires a response to be issued within twenty working days of receipt of a complaint, addressing all the issues raised and showing that they have been fully and fairly investigated.

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 a delay in diagnosing their late partner's (A) oesophageal cancer. The board had already acknowledged that A’s cancer could have been diagnosed sooner and apologised for failing to fully investigate their symptoms. However, C did not consider that the board had provided a satisfactory explanation as to why A’s cancer was not diagnosed at an earlier stage.

We took independent advice from an Ear, Nose and Throat (ENT) consultant. We found that initial examinations had identified a lesion in A’s throat, but that this was not found on a subsequent examination (a microlaryngoscopy - an examination of the throat with magnification). The board, therefore, did not arrange any further ENT follow-up. We noted C’s history and presenting symptoms and considered that there were multiple red flags for cancer. We found that further radiological investigations should have been ordered and that it was unreasonable for investigations to have stopped at that point. We upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to conduct further investigations. 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 their adult child's (A) treatment in the months prior to their death. A completed suicide soon after they had been assessed by nurses from the Crisis Assessment and Treatment Service (CATS) and Specialist Drug and Alcohol Service (SDAS). C complained that the risk to A’s life wasn’t properly assessed, and that the family weren’t appropriately involved. C also complained that board staff failed to take follow-up action when A had communicated suicidal thoughts in previous months, and that there was no follow-up plan in place following discharge from a hospital admission.

We took independent advice from a mental health nurse and a psychiatrist. We found that the assessment prior to A’s death did not explain how it was concluded that there was no immediate risk when A was exhibiting a number of risk factors. There was no evidence of these risk factors being effectively weighed against protective factors, and no evidence of hospital admission having been considered and ruled out. There was also no evidence of C and A's sibling (B) having been appropriately involved in the assessment. We found that the post-assessment care plan was not sufficiently robust, and that the notes were not clear as to the level of the family’s agreement with this. B contacted CATS out of hours service post-assessment to express concern about A and complained that no help was provided. We found that there was an unreasonable failure to arrange a follow-up telephone consultation.

With regards to a lack of follow-up further to A’s previous report of suicidal thoughts, the board said that they could find no record of this having been reported to them. We found that there was evidence in the GP record of the GP having contacted SDAS about this. We found that there was a failure to record or act upon this communication from the GP. It was noted that this may not have had a material impact on the eventual outcome, as A was later admitted for assessment and stabilisation, though, we found that there was an unreasonable delay in A receiving any follow-up following their discharge from this admission. The board had already acknowledged this and taken steps to address it.

C also complained about a reduction in dosage of A’s anti-psychotic medication during the aforementioned admission. We found that A was appropriately involved in this, but that there was no evidence of proactive involvement of family members in these discussions. We also found that there was a lack of clarity surrounding the prescribing of Pregabalin (an anticonvulsant and nerve-pain relief drug). The board had already undertaken to establish good practice guidelines to ensure medication safety in polypharmacy (the simultaneous use of multiple medicines by a patient). The board also acknowledged a number of issues relating to communication with the family and a failure to involve them in care planning. We found that there was an overall failure to involve family members as partners in the care process. We, therefore, upheld all aspects of C’s complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C and B for the identified shortcomings in the crisis assessment, and failures to involve and communicate with them regarding 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:

• Approaches to risk assessment should be systematic and evidence-based, and clinical judgements effectively reasoned in clinical records.
• Families’ views should be respected and they should be involved as partners in the care process as far as confidentiality imperatives allow. Working with families should be central to recovery-focussed mental health care, and should be governed by agreed guidelines/standards for practice and regular monitoring.
• Risk management should explore all available options for keeping people safe within the context of placing the minimal necessary restrictions upon their freedoms. In the interests of transparency, clinical records should demonstrate the options considered for keeping people safe and why chosen courses of action were preferred over other available alternatives.
• There should be more robust approaches to risk assessment, record-keeping and family participation. Families' views should be respected, and they should be involved as partners in the care process as far as confidentiality imperatives allow.
• To be effective in preventing recurrences of serious incidents, investigations should be carried out with due thoroughness to get to the root causes underlying tragic events. SAER processes should be robust and allow critical information to be gathered from all stakeholders.
• Systems and processes for monitoring the effectiveness of record-keeping should be robust, and clinical record-keeping practice should form part of each practitioner's clinical supervision activity.

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.

When this report was first published on 21 December 2022, it referred to A as the 'child' of C.  This was in reference to their familial relationship however the summary was amended to read 'adult child' on 22 December 2022 for clarification.  We apologise for any confusion caused.

Summary

C complained about the board's handling of their grandparent's (A) consent for a surgical procedure. A had vascular dementia (a common form of dementia, caused by problems in the supply of blood to the brain) and was resident in a care home. A had Adults With Incapacity (AWI) status and their child had Power of Attorney (PoA) for their welfare and financial needs. A was admitted to hospital due to abnormal liver function tests. It was subsequently decided that they should undergo an invasive procedure.

C complained to the board that A’s consultant obtained their consent for the invasive procedure without any contact being made with A’s next of kin or listed PoA. In response to C’s complaint, the board said that the relevant consultant considered that A had the capacity to make this decision. The board reiterated that the presence of a PoA does not mean that an individual is unable to make their own decisions. They said that it was the consultant's clinical professional opinion at that time that A had the capacity to consent to the invasive procedure as they were aware of being previously offered the procedure and said that they wanted something done.

We took independent advice from a mental health nurse adviser. We found that there was sufficient information available in the clinical records to highlight A’s potential capacity issues and it was unreasonable that this was not properly considered. We found that A’s consent for the procedure was not properly obtained. In light of this, we upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C and their family for not obtaining consent properly and deficiencies in the documentation surrounding the assessment of A's capacity, PoA arrangements and consent process. 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 board take steps to ensure full compliance with the requirement to assess and review patients’ capacity where necessary.
• That the board take steps to ensure that staff fully complete the MDT assessment documentation to ensure full information relating to capacity and welfare arrangements is recorded and available.

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 operates a restaurant who contracted with Clear Business Water (CBW) for their water supply. C complained that prices charged by CBW increased which was in contrast to what had been agreed. C also complained that CBW unreasonably charged a termination fee when they changed supplier for a better deal.

CBW said that they agreed a contract with C for the supply for a fixed term of 3 years at a discounted rate. They told C that the price being charged increased because of a number of factors but that the discount applied to the account always remained the same. As C left CBW for another supplier, CBW were satisfied that a termination fee was correctly applied in line with the terms and conditions of the contract. C was dissatisfied with the response and brought their complaint to our office.

We reviewed the relevant call recording together with supporting materials CBW said were issued to C following the call. We also considered CBW’s own processes and procedures with respect to the handling of such calls. We found that the communications with C were unreasonable as it was clear during the call that there was a barrier to C and the CBW adviser’s ability to understand each other. The information provided to C after the call did not provide confirmation of certain key aspects of the contract, nor was there confirmation that prices may be subject to variation. Therefore, we upheld the complaint that CBW failed to communicate with C in a reasonable manner. We also found failings with respect to CBW’s handling of C’s complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for not communicating in a clear manner and failing to appreciate there was the potential for misunderstanding during the call. The apology should also acknowledge that the complaints investigation should have identified issues with respect to the quality of communication with C. 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:

• Clear failings should be identified by complaints investigations, with appropriate actions being taken to remedy these.
• Relevant managers and advisers should have a clear understanding on the difference between ‘price’ and ‘discounts’ and the importance of clear communication in this regard. Staff should receive appropriate training on communication with customers and be provided with supporting materials, including call scripts, which provide sufficient clarity and guidance during a call.
• Relevant staff should have an awareness of potential barriers to communication and be able to identify what these are and how these may be addressed and overcome.

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 runs a small business and was unhappy with the way Business Stream managed their account. In particular, C was unhappy with what they believe were unreasonable changes to their contract and changes to the amount they were expected to pay for water.

We found multiple failings by Business Stream in their dealings with C; including not taking reasonable steps to address the issue of the removal of the water meter for C’s premises, having no evidence that C agreed to a change of contract or agreeing to online billing only. In relation to moving C to unmetered charging, Business Stream have acknowledged that their failures led to an unacceptable delay and offered the maximum allowable payment and credit available under their Redress and Compensation Policy. However, there is no evidence that the causes of the failings have been investigated or identified. We considered that this was essential given the impact on small businesses of large and unexpected bills, particularly in the aftermath of the COVID-19 pandemic. We upheld C’s complaint.

Recommendations

What we asked the organisation to do in this case:

• Contact C to provide a clear explanation of their options for paying for water usage moving forward, including a site visit with C present to discuss water meter installation if requested.

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

• A review of C’s case identifying where Business Stream’s procedures failed to work appropriately and assessing whether changes are required to prevent a recurrence.
• A review of the process for agreeing ‘signatureless’ contracts to ensure that the customer’s agreement is obtained and formally recorded in a retrievable format.
• All staff involved in moving customers onto new contracts to be reminded that it is essential evidence is retained showing the customer’s agreement.

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 clients about a decision made by the Scottish Environmental Protection Agency (SEPA) not to renew a ‘Paragraph 19 Exemption’ (the exemption) for a land re-engineering project. Normally, waste management requires a licence, however an exemption can be applied which allows for the use of waste for the construction, maintenance or improvements of a building, road, railway, airport, dock or other transport facility; recreational facilities; drainage; or certain engineering works. C’s clients had been granted an exemption for four consecutive years but their fifth renewal application was declined by SEPA.

We confirmed that we would not be considering the professional judgement of SEPA, but could look at whether they provided a reasonable explanation for their decision not to renew the exemption.

We noted that the original reason SEPA gave for refusing the application was that the proposed infill of the upcoming phase was of a depth exceeding the dimension of the final cross sections shown on the plans. Additionally, SEPA said that when their officers inspected the site, they observed that waste had been deposited onto waterlogged land. This is not permitted under the terms of an exempt activity.

In the correspondence with C that followed, we found that SEPA gave a number of differing reasons for their decision not to renew the exemption. When C advised SEPA they had referred to the wrong plans in reaching their decision, rather than provide an explanation or apology, SEPA gave a different reason for declining the renewal application. We found that SEPA did not adequately address a number of matters raised by C in relation to their decision. As such, we upheld this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to provide a reasonable explanation for the decision not to renew C’s clients’ Paragraph 19 Exemption. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.
• Consider what we have said in our decision and assess whether it is appropriate to reassess the Paragraph 19 Exemption on the basis of our findings. If SEPA do not consider that reassessment is warranted, or if they reassess and decline the application, they should write out to the applicant providing clear and justifiable reasons for their decision.

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

• Appropriate and clear reasons should be provided for decisions in relation to waste management exemptions.

In relation to complaints handling, we recommended:

• Complaints should be accurately identified as such and dealt with through the correct 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 the Crown Office and Procurator Fiscal Service (COPFS), regarding interactions they had before, during and after a homicide prosecution following the death of their adult child (A). C did not consider that COPFS had adopted a reasonable approach to victim support in their case. They expressed a number of concerns about the support that they had initially been provided. They told us that this led them to request no further contact with the officer initially allocated to provide support, but when they changed their mind and asked for contact to resume, COPFS had refused to allocate another officer to support their family. They also raised concerns about COPFS communication with them and their family, both in terms of the tone, and failures to respond to specific points raised by them. In addition, they told us they did not consider COPFS had reasonably handled their resulting complaints about these matters.

On investigation, we found that COPFS had failed to provide C and their family with appropriate support in a number of ways. We found that COPFS had internally recorded a number of concerns about C’s attitude and behaviour, suggesting that they were acting in a way that was difficult or unreasonable, without recording what behaviours they considered were unreasonable or why, or raising these concerns with C to allow them the opportunity to amend any behaviours COPFS considered unreasonable. This was despite the difficult circumstances C’s family were facing, and nothing within the records evidenced that COPFS had considered the additional pressures facing C and their family.

We considered that COPFS had effectively refused to provide normal victim support to C and their family, by failing to honour clear requests by C for support to resume. We also found that COPFS had failed to follow their normal protocols when the case had been handed over from the Police, which negatively impacted C’s family’s experience of that process. Overall, we considered that COPFS had failed to meet the standards they had committed to provide in the Victim’s Code for Scotland by failing to treat C’s family with sensitivity and tailor their approach to support based on C and their family’s needs.

Regarding C’s communication concerns, we found a number of examples of unreasonable failures in communication. We found that there were a number of delays and/or failures to respond to contacts from C. We also found that a number of COPFS communications failed to treat C with appropriate sensitivity, including failures to offer appropriate condolences to C’s family on their loss. We also found a number of entries in COPFS internal records which used a concerning tone when referring to C. We did not consider that this could be said to meet the standards that COPFS committed to providing to victim’s families under the Victim’s Code.

Regarding C’s complaints handling failures, we found that COPFS had failed to respond appropriately to all of C’s complaints. A number of their responses failed to respond to specific points C had raised or failed to respond in sufficient detail.

Given all of these points, we upheld all of C’s complaints.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C and their family for failing to provide them with appropriate support, failing to communicate with them reasonably, and failing to handle their subsequent complaints 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:

• All of COPFS interactions with victims and their families should meet the standards of the Victims’ Code. Communication should be sensitive and tailored to victims’ individual needs. Records made about individuals should also be sensitive and appropriate in tone.
• The Managing Family Liaison Protocol should be followed whenever making initial contact with a victim or their family.
• When concerns are held about someone’s behaviour, COPFS should make a clear record of the reasons for this and follow their Unacceptable Actions Policy if they wish to take action to address those concerns.

In relation to complaints handling, we recommended:

• COPFS should fully investigate all complaints and provide detailed explanations of their findings. Where failings are evident, these should be highlighted and appropriate steps taken to avoid similar mistakes in future.

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 their parent (A) received from the partnership. A was referred to the partnership’s Rapid Early Assessment Care Team (REACT) for Hospital at Home care due to shortness of breath upon exertion. A’s condition did not improve with treatment and they subsequently developed sepsis (a life-threatening reaction to an infection) and died. C considered that A should have been admitted to hospital for treatment, rather than being expected to continue with oral antibiotics which were making no improvements to their condition.

We took independent advice from a consultant geriatrician (a specialist in medicine of the elderly). We found that the initial care provided by the REACT team was of a reasonable standard. However, we could not find clear evidence to support the decision to continue antibiotic treatment, which did not appear to be improving A’s condition, without trying other options. We were critical of the decision to discharge A from the Hospital at Home service without a full medical review and treatment of their ongoing treatable symptoms. It was not clear whether these failings contributed to the deterioration in A’s condition, but we found that clearer decision making and closer attention to A’s treatable symptoms may have provided their family with some reassurance as to the standard of care they were receiving. Taking all of this into account, we upheld this part of C’s complaint.

C also complained about the communication between the REACT team and A’s GP practice. We did not consider there to be a systemic issue. However, as accepted by the partnership, there had been a clear delay in issuing the discharge letter after A’s discharge from the Hospital at Home service. We found that if A had lived, there could have been significant implications for their ongoing care due to the request for monitoring and bloods not reaching the GP within the requested timescale. With this delay in mind, we upheld this part of C’s complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C and their family for the failings 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:

• Ensure that the partnership raise this case for discussion at a mortality and morbidity meeting (or other such team forum) with a view to discussing: the delay in communicating with A’s GP, the lack of medical input before their discharge, and the lack of evidence for continuing the same antibiotic for so long.
• (It is noted from the partnership’s comments on our provisional decision that this case was discussed at a mortality and morbidity meeting last year, but the partnership have agreed to discuss the case with the team again in view of our findings).

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 their partner (B) complained about the actions of the partnership’s social work department. B’s sibling (A) had been removed from their parents’ care. B and C wished to be considered as carers for A, and also requested contact with A. However, they did not have contact with A for several months. C complained that the partnership failed to take appropriate action to facilitate and support contact between A and B during this period. Following contact being initiated, kinship care assessments were carried out and A was placed to reside with B and C.

We took independent social work advice. We noted the partnership’s explanation regarding the challenges contact with B potentially posed and the need for A to settle into their placement with foster carers. However, we found that it would have been reasonable to support some contact between A and B during this period. We found that the partnership had not provided a reasonable explanation as to why contact did not take place. We also noted that contact should not have been contingent solely on B’s capacity to provide kinship care of A, and we found it unreasonable that contact was only pursued when it was required to progress the kinship assessment. Therefore, we upheld C’s complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to B for the failure to facilitate and support contact between B 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:

• Contact between care-experienced children and their siblings should be promoted where possible, even if this is not straightforward. If there are concerns about potential emotional distress, there should be a focus on how to help children manage this rather than seeking to avoid the contact in the first place.

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.