Upheld, recommendations

Summary

C complained about various aspects of the care and treatment their spouse (A) received from the partnership.

A was an in-patient at a community hospital. Over the course of a few days, A was repeatedly admitted to a larger, specialist hospital for treatment before being transferred back to the community hospital.

C complained to the partnership about the care and treatment A received in both hospitals. The partnership apologised for any distress caused to A or C but did not identify any failings in A’s care. C remained unhappy and brought their complaint to us. C complained that there had been a failure to adequately monitor, manage, and treat A in both hospitals, which had led to a serious deterioration in their condition.

We took independent advice from a consultant in care of the elderly and general medicine. We found that there had been a failure to medically review A. We also found that there had been a failure to obtain a urine sample during A’s first admission to the specialist hospital and that this had resulted in a failure to detect a serious infection. Therefore, we upheld C’s complaint.

We also found that the partnership’s response to the complaint failed to fully reflect the information they obtained during the investigation and failed to adequately detail the learning taken from A’s experience.

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:

• When there is an acute deterioration in the condition of a patient at the community hospital, a prompt medical review of the patient should be carried out. Nursing staff at the hospital should be appropriately trained to ensure they are empowered to request a prompt medical review of a patient from the out-of-hours teams when there is no medical cover on site. At the second hospital, appropriate systems should be in place to ensure that when a urine sample is requested, it is actioned and the result fed back to the appropriate clinical 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 about the care and treatment provided to their parent (A) by the board. A was admitted to the hospital due to a catheter blockage. On examination, it was determined that A required specialist treatment and an ambulance transfer to another hospital within the board was arranged. It took approximately six hours for the ambulance to arrive by which time A was showing signs of sepsis (a life-threatening reaction to an infection).

Antibiotics treatment was initiated on A’s arrival and they had regular washouts of their catheter and continuous irrigation due to blockages and bleeding. A had ongoing uro-sepsis and required blood transfusions. A suffered a heart attack during their admission and blood-thinning medication was prescribed. However, this made the bleeding at the catheter site increase. A died in hospital several days later.

C complained to the board about A’s care and treatment but the board did not identify any failings. The board did identify and apologise for failure in communication with C. C remained unhappy and asked us to investigate. C complained that the staff in the first hospital had unreasonably delayed in treating A with antibiotics. C complained that staff in the second hospital subjected A to unnecessary pain while irrigating their catheter. C also complained that staff failed to identify that A’s catheter had been incorrectly placed. C complained about a decision to prescribe A with the anti-coagulant. C also complained about the palliative care given to A.

We took independent advice from a consultant in emergency medicine and a consultant urological surgeon (specialist in the male and female urinary tract, and the male reproductive organs). We found that staff in the first hospital had unreasonably delayed in treating A with antibiotics and we upheld this aspect of C’s complaint. We found that the care and treatment given to A in the second hospital was reasonable. However, we considered that staff had failed to recognise that A’s catheter was in the incorrect position within a reasonable timescale and therefore upheld this aspect of C’s complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the delay in treating A with antibiotics until they had been transferred to the specialist; and in recognising that A’s catheter was in the incorrect position. 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 diagnosed with sepsis should have antibiotics administered promptly and without delay.
• Patients undergoing catheter insertion should be closely monitored so that any complications such as incorrect placement are recognised and treated without delay.

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 medical practice failed to provide reasonable care and treatment to their spouse (A) after they presented with a lump in their right breast.

We took independent advice from a GP. We found that the time taken to refer A to hospital when they first consulted the medical practice with the lump in their right breast was unreasonable. It was also unreasonable that the referral was not marked as urgent.

The medical practice had carried out a detailed review of A’s care and had accepted that there was a complete systems failure in the care and treatment provided to A. They had made a number of changes which we welcomed and considered were appropriate. Nevertheless, we found that they had not fully acknowledged their specific role and responsibility in relation to the failings which had occurred given their responsibilities for the supervision, training and actions of their employed staff.

We also identified additional issues not addressed by the medical practice in their consideration and response to the complaint. In particular, that the medical practice should have a system in place to ensure any outstanding referrals were identified when a colleague is unexpectedly absent due to sickness or ill-health and that it was unreasonable that A was not contacted by the medical practice after the cancer diagnosis given the significance of the diagnosis and their delay in sending the referral and marking it as urgent. We also found that the medical practice did not appear to have considered their duty of candour responsibilities in this case. Therefore, we upheld C’s 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:

• Patients should receive appropriate assessment and referral in line with relevant guidelines. Patient referrals should be reviewed and actioned when the responsible member of staff is absent unexpectedly. Where appropriate, patients should be contacted after receiving a significant diagnosis. This should include when the practice become aware that harm has occurred as a result of an unintended incident in healthcare to take into account duty of candour responsibilities, individual roles and their role responsibilities in making sure this happens.

In relation to complaints handling, we recommended:

• The practice should ensure that, where failings have been identified during a complaint investigation, the investigation and response fully acknowledges and take responsibility for the failings and ensures there is appropriate learning across the practice.

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

Summary

C complained that the board took too long to offer them steroid/local anaesthetic injections for vulvodynia (chronic pain or discomfort in the vulva). C felt this was dismissive and unsatisfactory. The board said that C did not receive the treatment initially as it was not clinically appropriate at that time. They said in order for the treatment to be effective, there should be a locally tender area to inject which C did not have. The board added that it was important to note that the treatment is unlicensed and so is only to be considered for use when definitely clinically indicated.

We sought independent clinical advice from a consultant. We found that it is right for the board to have a cautious approach to the use of unlicensed treatment. We noted that the treatment C received for many years was reasonable. However, it was later indicated that C had developed a localised area of pain and it would have been reasonable to discuss the treatment with C at that point.

We considered that whilst the care and treatment provided to C was generally reasonable, the board should have discussed the treatment option of steroid/local anaesthetic injections earlier than they did. For this reason, on balance, we upheld C’s complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for not discussing the pros and cons of steroid/local anaesthetic injections as a treatment option or offering C the chance to decide whether or not they wanted to try this treatment. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

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

• Patients attending vulval pain clinics should be fully informed about their condition as well as the pros and cons of available treatments. Staff caring for patients attending vulval pain clinics should be aware of the full range of treatment options so that they are able to provide holistic care and advice to patients.

In relation to complaints handling, we recommended:

• Complaints should be responded to in line with the Model Complaints Handling Procedure (MCHP) and issued within the expected timescale of 20 working days. If the board are unable to meet the 20-working day deadline, updates and a new deadline should be issued to C in line with the MCHP.
• Letters of complaint received by the board should be logged and forwarded as appropriate to the complaints and feedback team.

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 adult child (A) received from the practice. A had undergone surgery to remove infected fluid on the right lung. Gabapentin (an anticonvulsant medication primarily used to treat partial seizures and neuropathic pain) was prescribed to manage nerve pain at the incision site. The practice later stopped prescribing gabapentin and A’s mental health deteriorated significantly.

C complained about the abrupt withdrawal of gabapentin. They highlighted that gabapentin had been prescribed to manage ongoing nerve pain following surgery and noted the risks of sudden withdrawal. The practice stated that prior to the discontinuation of gabapentin there had been an increase in early requests for renewal of medication, which caused concern. A had not attended appointments with the GP or with cardiology (specialists in diseases and abnormalities of the heart). The GP felt that they could not justify further prescription of controlled drugs without seeing the patient.

We took independent advice from a GP. We found that there was no record of any significant harm from gabapentin or evidence of overuse, or had there been any discussion around reducing or stopping gabapentin. We noted that gabapentin is known to cause problems during the withdrawal period and it should therefore be withdrawn slowly. We also found that no withdrawal support was given. In light of this, we considered that the practice had failed to appropriately manage A’s prescription for gabapentin and upheld C’s complaint.

We also found failings in the practice’s handling of C’s complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to A for abruptly stopping gabapentin. 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 for the complaint handling issues. 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 acknowledgements should include all the information required by the Model Complaints Handling Procedure. Points of complaint should be agreed with the complainant at the outset. Points of complaint should be addressed in the response. Care should be taken with the tone of the response.
• GPs should be familiar with the guidelines for withdrawal of medicines associated with dependence.
• The practice should have a policy around how they contact patients especially when their phones are unobtainable. Alternative modes of communication like home visit, letter or taking help from a household contact to confirm phone number could help clinicians provide safe care to patients.

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 client (A). Following an incident at A’s home, A agreed with the council's Child Protection Team that their two children should be placed in the care of a relative. This was a voluntary placement under the Children (Scotland) Act 1995. C emailed the council’s social work team to inform them that A would withdraw their consent to the placement if no progress was made in their case.

A attended their youngest child’s school and attempted to take custody of their child, but was prevented from doing so by social workers and the child left in the custody of relatives. Later that day, A attended their relatives’ house and A was prevented from taking custody of the child. Social workers were not present, but police attended and then refused to intervene after speaking to the social workers.

A then agreed to the voluntary placement again. C advised A that they should withdraw their youngest child from the placement and attend their school to collect them and C informed the social workers of this advice. In response, social workers obtained a Child Protection Order (CPO). C complained to the council that they had failed to respond to A’s wishes regarding the placement. The council did not identify any substantive failings.

C complained that the council’s response was inadequate and inaccurate and that the council had failed to obtain a CPO timeously. We took independent advice from a children's social work adviser. We found that A had tried to end the voluntary placement twice and that A had been prevented from exercising their parental rights. We found that the council had failed to obtain a CPO timeously and that they had failed to adequately investigate or respond to C’s complaint. We upheld C’s complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to A for their failure to take A’s parental rights into consideration and their failure to administer the placement of A’s children adequately. The apology should meet the standards set out in the SPSO guidelines on apology available at https://www.spso.org.uk/information-leaflets.
• Apologise to C for their failure to investigate and respond adequately to C’s complaint. The apology should meet the standards set out in the SPSO guidelines on apology available at https://www.spso.org.uk/information-leaflets.

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

• Council staff should be aware of and take into account relevant guidance and legislation in a situation like this including parental rights and carrying out timeous checks of voluntary placements of children under section 25 of the Act.
• Staff dealing with complaints should be familiar with the council’s Complaint Handling Procedure, understanding the importance of communication and the need to demonstrate thorough investigation of the points raised.

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 way in which the council discharged a planning condition. C told us that planning permission for a development of new properties located next to a busy road, included a condition which required the installation of a close boarded fence and/or earth bund at least 1.5 metres tall and enhanced glazing for rooms facing the busy road to mitigate noise. The developer was required to provide detailed plans in advance which would be subject to written approval. C also complained that the council failed to refer the issue to their Enforcement Team, which C believed to be contrary to the enforcement charter.

We took independent advice from a planning adviser. We found that the process to discharge a condition should be transparent, properly recorded, and easily accessible as part of the public record. There had been failings in the way in which the decision was reached as the council failed to keep adequate records. We concluded that whilst the council appear to have considered the location and height of the fence when discharging the condition, they do not appear to have considered the quality. When new information came to light (about the quality of the fence and questioning whether the height of the fence was adequate) the council should have reviewed the evidence and reconsidered the adequacy of the information that they used to discharge the condition.

In light of the evidence, we found that there was maladministration in the way in which the council made the decision to discharge the planning condition, which was unreasonable. We also found that the council unreasonably failed to investigate C’s concerns about the quality of the fencing. As such, we upheld C’s complaints.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the way in which the decision was made to discharge planning condition 9, and particularly that the decision was not transparent or easily accessible to the public. Apologise to C for failing to reasonably investigate their concerns about the quality of the fencing and apologise to C for failing to ensure the developer carried out the agreed remedial works. 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 of suspected planning breaches should be investigated in line with the planning enforcement charter and all new evidence should be given reasonable consideration. Enforcement action should be considered if and when appropriate.
• Decisions to discharge planning conditions should be transparent, properly recorded and easily accessible as part of the public record.
• Agreed actions should be monitored with sufficient follow-up to ensure compliance.

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 association did not respond reasonably to reports of anti-social behaviour.

We found that there was a lack of consistency in the way that C’s reports of anti-social behaviour were recorded and indications that some incorrect information had been recorded in relation to C’s reports. The association’s policy required them to categorise reports of anti-social behaviour but some of C’s reports were not categorised, other cases were categorised in a way that was inconsistent with other evidence available and there was no evidence of how the association had arrived at the categories they had selected in most cases. Concerns about actions taken as a result of reports of anti-social behaviour are difficult to resolve given the restricted amount of information that can be shared with a reporting party or complainant. Therefore, it is important that suitable records are kept to demonstrate, when necessary, that policies were applied consistently, decisions arrived at reasonably and appropriate action taken.

We also found that C had requested to meet association staff to discuss the anti-social behaviour but this request was not acknowledged or responded to. The actions taken by the association were not always consistent with their policy and were occasionally contradictory. In most cases, the association’s records did not reasonably record what factors were considered or taken into account when reaching decisions on action to take.

We considered that the association were not able to demonstrate that their policy was applied consistently and appropriately in the case of C’s reports, and what records there are relating to C’s reports are not uniform and do not reasonably explain inconsistencies in the action the association took. Therefore, we upheld C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failure to respond reasonably to reports of anti-social behaviour. 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 association should follow their anti-social behaviour procedures when handling all reports of anti-social behaviour, including the consistent categorisation of reported anti-social behaviour, meeting with reporters of anti-social behaviour, and the clear recording of decision-making in relation to reports of anti-social behaviour.

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

Summary

C complained about the care and treatment provided by the board to their child (A) during a consultation with an orthoptist (specialist in the diagnosis and treatment of eye movement disorders) and optometrist (healthcare professional who provides primary vision care) in relation to the management of A’s strabismus (a squint) and wide-angled esotropia (inward turning of the eye). C made several complaints, including the board's failure to assess the size of the squint, failure to adequately dilate A’s irides using cycloplegic drops (drugs used to paralyse muscles in the eye), issuing a prescription for glasses based on an inaccurate refraction test result, displaying poor clinical knowledge about A’s condition and poor record-keeping. C also complained about how their complaint had been handled by the board, particularly in relation to a meeting that had taken place to discuss the complaint.

In response, the board stated that, while A’s refraction test indicated a greater amount of myopia (short-sightedness) than previous tests, differences could occur for a variety of reasons, such as the amount of dilation of the irides. In patients with dark irides, such as A, dilation could be difficult but this had been recognised by the clinicians and drops to dilate were appropriately re-instilled, with the prescription issued in accordance with the test results. The board accepted, however, that there had been communication issues between the orthoptist and optometrist but measures had been put in place to improve this. The board also agreed to amend A’s notes to reflect more accurately what had been discussed at the consultation and arrange a further review of A much sooner than had been agreed.

We took independent advice from a consultant in paediatric ophthalmology. We found that A’s refraction test results were inaccurate and should have caused the optometrist to question whether A’s irides had been adequately dilated rather than issuing an incorrect prescription. We also found that the records showed that the drops instilled by the clinicians had been administered at inappropriate intervals, which had likely resulted in A’s irides being inadequately dilated. We were critical of the board’s handling of the complaint, particularly in relation to the board taking advice from an optometrist who had insufficient clinical experience of the issues under consideration. 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 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:

• Where the outcome of a refraction test indicates that a significant increase to a prescription is required, clinicians should (i) question whether the patient’s irides have been sufficiently dilated, particularly in patients with darkly pigmented irides; and (ii) consider whether it is necessary to repeat the refraction at a follow-up appointment rather than proceed to issue the increased prescription.
• Where different types of eye drops require to be administered in order to achieve dilation of irides before carrying out a refraction test, clinicians should administer each set of drops at intervals of at least five minutes.

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 pregnant partner (A) attended a local hospital as A was experiencing abdominal discomfort. A was examined and recommended to attend the main regional hospital, advising C to drive them there. The journey time was approximately 3 hours and on arrival A was examined and advised that labour may be starting. A was later told that labour was unlikely to be starting but remained in hospital overnight and discharged the following day.

The following week, A suffered vaginal leakage and attended the local hospital where they were examined by a clinician and advised that they suspected A’s waters had broken. A was advised to go to the main regional hospital and they were told that an ambulance was not needed. C therefore drove A to the main regional hospital.

An examination at the main regional hospital revealed that A’s waters had broken and in the early hours of the following day they went into labour. Later that afternoon clinicians gave A and C a number of options: continue with natural labour, attempt a process of augmentation (helping along a labour that's not progressing as it should), or an immediate caesarean delivery (an operation to deliver a baby that involves cutting the front of the abdomen and womb). A and C both agreed to a caesarean. The procedure was carried out and the baby (B) was delivered. However, clinicians had to resuscitate B.

A scan of B’s brain three days after birth revealed a likely injury which was later confirmed as periventricular leukomalacia (PVL, a softening of white brain tissue near the ventricles which often causes problems later with muscle control and thinking or learning problems). Following repeated scans over several weeks as the cysts continued to form, this was eventually categorised as grade three level of severity.

C raised concerns with the board regarding the care and treatment that A and B had received. C met various clinicians but remained dissatisfied. The board offered to have the events subjected to an external review but terms could not be agreed and the review was not carried out.

We took independent advice from a neonatal consultant. We found that, during both admissions, the board failed to provide reasonable care to A and their unborn child and that the board failed to fulfil their obligations under duty of candour. We upheld the complaints.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C and A for failing to provide optimal care, for failing to carry out adequate assessment, for failing to complete suitable documentation and for failing to make safe transport arrangements. 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 and A for failing to provide reasonable care by omitting to timeously administer prophylactic antibiotics to A on arrival at the regional hospital and apologise for the board failing to fulfil their duty of candour obligations when the antibiotic incident was identified. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.
• The board should offer C a final opportunity to address their outstanding questions in relation to the care of A and B in a format agreeable to both parties.

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

• Establish record keeping systems that prompt midwives to detail a full assessment and ensure there is cross checking with the consultant unit at the regional hospital.
• Establish a protocol for managing premature rupture of membranes in remote locations and commence treatment where appropriate, prior to transfer.
• Establish standard documentation and standard operating procedures for risk assessing pregnant women in remote locations, to determine the most appropriate mode of transfer to the obstetric units.

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.