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  • Report no:
    201806286
  • Date:
    August 2020
  • Body:
    Greater Glasgow and Clyde NHS Board - Acute Services Division
  • Sector:
    Health

Mr C complained about the care and treatment that he received from Greater Glasgow & Clyde NHS - Acute Services Division (the Board) after he sustained a navicular fracture to his left foot (a fracture of the navicular bone on the top of the midfoot). Mr C also complained that the Board failed to respond reasonably to his complaint.

In March 2017, Mr C attended the Emergency Department (ED) of the Queen Elizabeth University Hospital, Glasgow (the Hospital). Mr C was assessed by a junior doctor and found to have pain on touching some of the bones in his foot. An xray was ordered, which the junior doctor interpreted as showing an un-displaced fracture (a fracture where the bone fragments do not separate) of one of the metatarsal bones (the 'forefoot' bones linking the toes to the middle part of the foot). Mr C was given a walking boot, advice and discharged. Two days later, the x-ray was reported by a radiologist as showing no acute joint or bony injury.

At the start of May 2017, Mr C attended again at the ED following a referral from the GP out-of-hours service as his foot was swollen and he was still in pain. Further xrays were taken. Mr C was reviewed by the on call orthopaedic doctor. The doctor's diagnosis was that there was possibly a hairline fracture (a very fine fracture) of the fourth metatarsal. Mr C said he was advised nothing further could be done and was sent home. The following day, Mr C attended the orthopaedic out-patients department at the Hospital following a call asking him to attend. He was advised by an orthopaedic doctor that the third and fourth metatarsal were broken, in addition, the navicular bone was broken in three parts with a 5mm gap.

Subsequently, Mr C underwent surgery to address the fracture. However, he continued to experience problems with his foot. Mr C had a major limb amputation of the lower part of his left leg in October 2019.

We took independent advice from a consultant in emergency medicine, a consultant orthopaedic surgeon and a consultant radiologist.

We found that it was not unreasonable that the ED junior doctor did not identify Mr C's fracture in March 2017 as it was uncommon to see a patient present at the ED with a navicular fracture and a junior doctor will rarely see a patient present with this type of fracture and often not at all. In addition, the fracture was subtle on the x-ray. On account of this, the junior doctor who saw Mr C made an understandable, reasonable, mistake in not diagnosing that he had sustained a navicular fracture.

Notwithstanding this, Mr C's fracture should have been identified in the radiology report of the x-ray taken in March 2017 and although the fracture of the navicular on the x-ray was subtle; it was unreasonable that the radiologist did not report this fracture.

Mr C was diabetic. We found that the clinical history supplied on the request for the radiograph did not include this information. While we did not consider the failure to identify and include this information in Mr C's clinical history amounted to an unreasonable standard of treatment, had the information about Mr C's diabetes been supplied it may have further alerted the reporting radiologist to the possibility of a stress fracture.

We found that when Mr C re-attended the Hospital in May 2017 after being referred by the out-of-hours service, a further opportunity to identify the navicular fracture was missed.

In conclusion, we found that overall the Board failed to provide Mr C with a reasonable standard of care and treatment and that it was likely that the failure to identify Mr C's fracture in March 2017 had a detrimental impact on his outcome. In light of the failings identified, we upheld this aspect of Mr C's complaint. 

Finally, we found that the Board failed to handle Mr C's complaint reasonably and upheld this aspect of his complaint.

 

Redress and Recommendations

The Ombudsman's recommendations are set out below:

What we are asking the Board to do for Mr C:

Complaint number

What we found

What the organisation should do

What we need to see
(a) and (b)

The Board failed to provide Mr C with a reasonable standard of care and treatment

The Board's own complaint investigation did not identify or address the failings in Mr C's medical care

 

Apologise to Mr C for the failings in care and treatment identified in the report.

The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets

 

 

A copy or record of the apology.

By: 19 September 2020

We are asking the Board to improve the way they do things:

Complaint number

What we found

What should change

What we need to see
(a)

The Board unreasonably failed to identify Mr C's navicular fracture

 

 

X-rays of patients attending hospital with a possible fracture should be appropriately reported.

Patients re-attending should have their presenting symptoms fully assessed and investigated

 

 

 

Evidence that the case has been discussed at a radiology Learning from Discrepancies meeting.

Evidence that the Board have reflected on the failings identified in Mr C's case and given consideration to any required changes to processes and guidance.

Evidence that these findings have been fed back to the relevant staff and managers in a supportive manner that encourages learning, including reference to what that learning is (e.g. a record of a meeting with staff; or feedback given at one-to-one sessions).

By: 19 November 2020

We are asking the Board to improve their complaints handling:

Complaint number

What we found

Outcome needed

What we need to see
(b)

The Board's own complaint investigation did not identify or address the failings in Mr C's medical care

 

 

The Board'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.

 

 

 

 

Evidence that the Board have reviewed why its own investigation into this complaint did not identify or acknowledge the failings highlighted here, what learning they identified, and what action has been taken as a result.

My findings have been shared with relevant staff in a supportive way for reflection and learning.

By: 19 November 2020

 

 

 

Feedback

Points to note 
  • While it was not unreasonable that the junior doctor did not identify the navicular fracture when Mr C first attended the ED in March 2017, the Board may wish to consider raising awareness of a navicular fracture with junior doctors joining the ED on placement.
  • When a patient attends with a fracture at the ED, the Board may wish to give consideration to recording past clinical history as this can provide a potential alert for subsequent care and treatment.
  • Adviser 2 commented that the subsequent management of Mr C's case by the Board's consultant orthopaedic surgeon after the navicular fracture had been identified should be commended.

Related reading

  • Report no:
    201707281
  • Date:
    August 2020
  • Body:
    The Moray Council
  • Sector:
    Local Government

Summary

Ms C complained on behalf of Mrs A, about Moray Council (the Council) Children and Families social work department. Mrs A's two children, Child Y and Child Z, were removed from Mrs A's care in September 2016 as a result of a Child Protection Order (an emergency legal order granted by a Sheriff which allows the local authority to remove a child from their parent's care). Ms C complained that the Council unreasonably failed to gather and take into account relevant information when making decisions regarding the children's care and education, both before and after the children were removed from Mrs A's care and placed into accommodation.

During our investigation, we took independent advice from a social worker (the Adviser). We identified the following failings: 

  • Prior to the children being accommodated:
    • little or no evidence of exploring parenting style, family or other supports; or questioning and challenging what was observed;
    • little or no evidence of clear assessments of risk and need;
    • little evidence of the Getting It Right For Every Child practice model (GIRFEC; the Scottish Government's approach to supporting children and young people) being utilised, including a robust, multi-agency assessment; and
    • failure to make attempts to engage the family in supporting the prevention of a breakdown in the family or to provide kinship care as a means of preventing statutory care.
  • Following the children being accommodated:
    • failure to consider and arrange independent advocacy for the children in a timely manner; 
    • in the absence of independent advocacy, failure to explore ways of communicating with the children to elicit their views and feelings;
    • failure to include the views and feelings of the children in many reports;
    • failure to facilitate Child Y attending their hearings when Child Y voiced their wish to attend;
    • when Child Y changed their story about allegations made, it appeared that the allegations were given less weight and there was not enough understanding of the way in which children and young people may retract their stories. Rehabilitation with the children's father (Mr A) went ahead without this being resolved or there being more clarity on the risks and safeguards in place;
    • failure to reasonably consider and assess potential kinship placements and follow national guidance and legislation in relation to kinship care assessments;
    • failure to communicate in a reasonable and timely way with extended family in relation to kinship care;
    • no evidence that Child Z's views were obtained in relation to moving school; or that Child Z or the new school were prepared for the transition;
    • failure to promote or encourage extended family relationships;
    • failure to inform Mr & Mrs A of Child Z's admission to hospital shortly after they were accommodated; and
    • failure to complete a number of Looked After Child forms which should have been completed at the point of the children being accommodated, in a timely manner.

Given these numerous and significant failings, we upheld the complaint and made a number of recommendations to address these failings.

Ms C also complained that the Council failed to handle complaints raised by herself and Mrs A in a reasonable and timely manner. We acknowledged that the complaint was complex, involved correspondence from a number of different people, some of which had overlapping issues, and that there were concurrent information requests. The Council had taken some action to address their complaint handling failings. However, we considered that it remained that much of the handling of Ms C and Mrs A's complaints was unreasonable and we did not consider the action previously taken by the Council to address all of the complaint handling failings. We therefore upheld this aspect of Ms C's complaint.

 

Redress and Recommendations

The Ombudsman's recommendations are set out below:

What we are asking the Council to do for Ms C and Mrs A:

Rec. number

What we found

What the organisation should do

What we need to see
1.

Under complaint (a) we found that the Council unreasonably failed to gather and take into account relevant information when making decisions regarding the children's care and education. (The individual failings are listed below.)

Under complaint (b) we found that the Council failed to deal with complaints raised by Mrs A and Ms C in a reasonable and timeous manner

Apologise to Mrs A, Child Y and Child Z for the failure to reasonably gather and take into account relevant information when making decisions regarding the children's care and education.

Apologise to Mrs A and Ms C for the failure to reasonably and timeously respond to their complaints.

The apologies should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/informationleaflets

Copy or record of the apologies.

By: 16 September 2020

We are asking the Council to improve the way they do things:

Rec. number

What we found

Outcome needed

What we need to see
2.

Under complaint (a) we found that there was no clear use of the Getting It Right For Every Child practice model being applied (including appropriate multi-agency and risk assessments) when recording the concerns highlighted in the months prior to the children's admission to care; which would have assisted practitioners to identify the cumulative concerns and collated information from other agencies

 

The Council's child protection function should be delivered within the context of supporting families and meeting children's needs through the Getting It Right For Every Child practice model as stated in the National Guidance for Child Protection In Scotland and the Children and Young People (Scotland) Act 2014

 

 

Evidence that the findings of this investigation have been fed back to relevant staff in a supportive manner that encourages learning.

Evidence that the Council have considered any training needs for social work staff in relation to the Getting It Right For Every Child practice model and child protection. The Council may wish to consider using this case as a training tool.

Evidence that the Council have reviewed their Child Protection guidance to ensure it takes into account the Getting It Right For Every Child practice model and the relevant legislation in relation to supporting families and meeting children's needs.

By: 9 December 2020
3. Under complaint (a) we found that there was a failure to engage the extended family in supporting the prevention of a breakdown in the family or to provide kinship care as a means of preventing statutory care In line with the Children (Scotland) Act 1995, the Council should promote the upbringing of children by their families and the possibility of kinship care placements should be considered at the earliest opportunity and if this is not possible, the reasons should be recorded

Evidence that the findings of this investigation have been fed back to relevant staff in a supportive manner that encourages learning.

Evidence that there is appropriate policy and guidance in place to ensure that the possibility of kinship care placements are considered at the earliest opportunity.

By: 9 December 2020
4. Under complaint (a) we found that there was both an absence and delay in properly seeking the views of the children, including by use of independent advocacy, and including these views in the relevant plans and paperwork The views of children should be sought in line with the Getting It Right For Every Child Framework and as laid down in the Children (Scotland) Act 1995 and the Children and Young People (Scotland) Act 2014. The views of children should be listened to, considered and recorded; and independent advocacy should be considered for children in a timely manner

Evidence that social workers have been reminded of the importance of recording children's views appropriately and considering the use of independent advocacy.

Evidence that the Council have considered any training needs for social work staff in relation to seeking and including children's views.

Evidence of an audit being carried out of Looked After Child and Child Protection paperwork, and Child's Plans, to ensure that children's views are being sought and included appropriately.

By: 9 December 2020
5. Under complaint (a) we found that there was a failure to facilitate Child Y attending their hearings when Child Y voiced their wish to attend If a child expresses a wish to attend their Children's Hearing, they should be facilitated to attend, regardless of whether they have previously been excused; in line with national guidance

Evidence that social workers have been reminded of a child's absolute right to attend their hearings; and of their responsibility to facilitate this if a child has expressed a wish to attend.

Evidence that the Council have considered any training needs for staff in relation to their responsibilities to facilitate children to attend their hearings.

By: 9 December 2020
6. Under complaint (a) we found that the timescales to complete the kinship care assessments were considerably outwith the recommended timescales laid down by the statutory guidance Timescales for kinship care assessments should be in line with the Looked After Children (Scotland) Regulations 2009 and the Adoption (Scotland) Act 2007 - Part 9 Kinship Care unless the reasons as to why this is not possible are specifically recorded

Evidence that the Council's policy and procedures on kinship care assessments are in line with the timescales in statutory guidance.

Evidence that social work staff at the Council have been reminded of the guidance in relation to kinship care assessments.

Evidence that there is a system in place to monitor timescales for kinship care assessment and management action taken to address when timescales are not being adhered to.

By: 9 December 2020
7. Under complaint (a) we found that communication with the extended family regarding consideration and assessment of kinship care placements was delayed, unclear, and not proactive Communication with extended family in relation to potential kinship care placements should be proactive, clear, and timely

Evidence that the findings of this investigation in relation to communication with extended family members have been fed back to relevant staff in a supportive manner that encourages learning.

By: 9 December 2020
8. Under complaint (a) we found that Child Z moved school without any proper sharing of information and preparation and the decision was made outwith a Looked After Child review and prior to a Children's Hearing, without reasonable evidence that this was warranted Prior to any decision that brings about a change to the child's plan, or before a decision to seek a Children's Hearing for a child whose supervision order they think should be varied or terminated, a Looked After Child review should be held

Evidence that social workers have been reminded that significant decisions concerning a child should not be made outwith a formal review.

Evidence of an audit to ensure Looked After Child reviews are being held appropriately.

By: 9 December 2020
9. Under complaint (a) we found that when Child Z moved school, the new school were not notified of the background and did not learn of the involvement of other agencies until they received the child's educational file some time later When a child who has social work involvement moves school, the new school should be informed of this in a timely manner in line with the Getting It Right For Every Child national framework principles of working collaboratively with the child at the centre

Evidence that the findings of this investigation in relation to the Getting It Right For Every Child national framework principles of working collaboratively with the child at the centre have been fed back to the relevant staff in a supportive manner which encourages learning.

By: 9 December 2020
10. Under complaint (a) we found that the records evidence that the attitude of social work was at times judgemental and based on pejorative personal opinions Social workers should avoid making statements based on assumptions and pejorative personal opinion

Evidence that the findings of this investigation in relation to record-keeping and attitude towards families have been fed back to relevant staff in a supportive manner that encourages learning.

By: 9 December 2020
11. Under complaint (a) we found that the parents were not notified that their child was admitted to hospital despite still having parental responsibilities and rights Parents with parental rights and responsibilities should, as far as possible, be consulted prior to medical treatment or in cases of an emergency admission be notified as soon as possible, in line with the Children (Scotland) Act 1995

Evidence that social workers have been reminded of and understand their legal obligations in respect of children and parents.

By: 9 December 2020
12. Under complaint (a) we found that although Child Z moved to a new local authority area, a letter to the authority informing them that Child Z was living there and requesting a transfer Child Protection Case Conference was not sent until three weeks after they moved. This was outwith guidance and also caused the receiving local authority to be outwith the timeframe for holding the Child Protection Case Conference The Council should adhere to the National Guidance for Child Protection in Scotland in relation to notifying the receiving local authority immediately when children and/or their family move

Evidence that social workers have been reminded of their obligations under the National Guidance for Child Protection in Scotland.

Evidence that the Council's procedures and guidelines meet the National Guidance for Child Protection in Scotland standards.

By: 9 December 2020
13. Under complaint (a) we found that Looked After Child forms, including a general medical consent form, were not completed at the point of admission to care and there was a delay of almost four weeks following accommodation The relevant Looked After Child forms, including general medical consent, should be completed at the point of a child being admitted to the care of the local authority, or in cases of emergency, as soon as is practicably possible after the child is placed; in line with The Looked After Children (Scotland) Regulations 2009

Evidence of an audit to ensure that Looked After Child forms are completed prior to or at the point of a child being accommodated.

By: 9 December 2020
14. Under complaint (a) we found that there were numerous and significant failings in relation to gathering and taking into account relevant information when making decisions regarding the children's care and education When making decisions regarding the care and education of children, the Council should appropriately gather and take into account relevant information

Evidence that the findings of this investigation have been reviewed in full by a senior member of staff at the Council and that they are satisfied that all failings have been addressed by the recommendations above or actions already taken by the Council. If they are not, an action plan should be devised to ensure that all issues are addressed appropriately and fully.

By: 9 December 2020

We are asking the Council to improve their complaints handling:

Rec. number

What we found

Outcome needed

What we need to see
15.

Under complaint (b) we found that there were serious and significant failures in relation to complaints handling

 

Complaints should be handled in line with the relevant complaint handling procedure

 

 

Evidence that the Council have carried out a review into the handling of this complaint, identified where improvement action (such as training) is required, and developed an action plan to improve complaint handling.

By: 9 December 2020

 

Feedback

Points to note

The Adviser noted that there was a regular programme of supervised contact with both parents, but commented that, in their view, the timetable of contact placed a heavy burden on the children as on occasion they were having two contact visits a day, one with each parent and some that included extended family. The Adviser acknowledged that it is always a difficult balance to ensure there is sufficient contact but also that it is relaxed and comfortable to promote a good experience and build relationships. However, they considered the contact plan, while demonstrating a regular arrangement, was a demanding one for everyone, not least the children. The Council may wish to reflect on this matter.

Related reading

  • Report no:
    201811019
  • Date:
    April 2020
  • Body:
    The Moray Council
  • Sector:
    Local Government

Summary

Ms C complained to my office on behalf of her son, Mr A, about the care and support provided to Mr A by the Council. Mr A was a Looked After Child under Section 25 of the Children (Scotland) Act 1995 (a child who is looked after by the local authority as part of a voluntary arrangement). In September 2015, Mr A moved to a residential school placement outwith the Moray area. In June 2019, the Education component of Mr A’s placement ended following his eighteenth birthday. The Council then transitioned Mr A from Children’s to Adult Social Work Services. Adult Services agreed to financially support Mr A to remain in the residential placement for one year until June 2020 or until an appropriate resource was found in the Moray area.

Ms C is concerned that the Council have not fulfilled their responsibility to provide her son’s residential placement under Continuing Care (the local authority’s duty to provide the same accommodation and other assistance as was being provided by the local authority, immediately before the young person ceased to be looked after).

We took independent advice from a social work adviser. We found that:

  • the Council failed to begin transition planning for Mr A at least 3 years before he was due to leave school;
  • the Council failed to carry out a pathway assessment prior to making the decision that Continuing Care was not available to Mr A and prior to transitioning Mr A to Adult services; the Council did not take reasonable steps to ensure that Mr A could make informed choices. In particular:
    • there is no evidence in the records that Mr A was given concrete examples of the type of care he might be offered or that he was taken to see possible care settings;
    • a recommendation made at a Looked After Child Review in January 2018 to offer Mr A independent advocacy was not actioned until over a year later.

In view of these failings, we upheld Ms C’s complaint that the Council failed to act reasonably regarding Mr A’s care and support.

Ms C also complained about the Council’s communication with her about her son’s care and support. Following advice from a social work adviser, we found that:

  • the Council largely engaged with Ms C via email rather than holding meetings outwith the formal Looked After Child Review process;
  • an invite to a Looked After Child Review was sent three days before the Review was due to take place;
  • there was a delay in the Looked After Child Review minutes being available and there was a delay in these being sent to Ms C;
  • Ms C was not provided with information on how to make a Continuing Care request when she requested this.

In light of these findings, we upheld Ms C’s complaint that the Council failed to communicate reasonably with her.

Lastly, Ms C complained about how the Council handled her complaint. We found that there was an unreasonable delay in Ms C receiving a response to her complaint and the Council’s complaint response had been copied directly from an email that had been sent to Ms C before she submitted her complaint.  There was no evidence that the Council had investigated Ms C’s complaints, and the Council’s complaint response did not address all the complaints that Ms C made to the Council or indicate whether her complaints were upheld or not upheld. In view of these significant failings, we upheld Ms C’s complaint that the Council had failed to handle her complaint reasonably.

 

Redress and Recommendations

The Ombudsman's recommendations are set out below:

What we are asking the Council to do for Ms C and Mr A:

Rec. number

What we found

What the organisation should do

What we need to see
1.

Under complaint (a) we found that:

  • the Council failed to begin transition planning for Mr A at least three years before he was due to leave school.
  • the Council failed to carry out a pathway assessment prior to making the decision that Continuing Care was not available to Mr A and prior to transitioning Mr A to Adult Services.
  • the Council did not take reasonable steps to ensure that Mr A could make informed choices. In particular:
    • there is no evidence in the records that Mr A was given concrete examples of the type of care he might be offered or that he was taken to see possible care settings.
    • a recommendation made at a Looked After Child Review in January 2018 to offer Mr A independent advocacy was not actioned until over a year later.

Under complaint (b) we found that the communication with Ms C was unreasonable. In particular:

  • the Council largely engaged with Ms C via email rather than holding meetings outwith the formal Looked After Child Review process.
  • an invite to a Looked After Child Review was sent three days before the Review was due to take place.
  • there was a delay in the Looked After Child Review minutes being available and there was a delay in these being sent to Ms C.
  • Ms C was not provided with information on how to make a Continuing Care request when she requested this.

Under complaint (c) we found that:

  • there was an unreasonable delay in Ms C receiving a complaint response.
  • the Council’s complaint response was copied directly from an email that had been sent to Ms C before she submitted her complaint.
  • there was no evidence that the Council had investigated Ms C’s complaints.
  • the Council’s complaint response did not address all the complaints that Ms C made to the Council or indicate whether her complaints were upheld or not upheld.

Apologise to Ms C and Mr A for:

  • failing to begin transition planning for Mr A at least three years before he was due to leave school.
  • failing to carry out a pathway assessment prior to making the decision that Continuing Care was not available to Mr A and prior to transitioning Mr A to Adult Services.
  • failing to communicate reasonably with Ms C about her son’s care and support.
  • failing to handle her complaint reasonably.

The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/informationleaflets

A copy or record of the apology.

By: 20 May 2020
2. Under complaint (a) we found that the Council failed to act in line with their ordinary residence policy when they indicated that all out of area children have to move back to the Moray area as the basis for only providing funding for Mr A to remain in the residential placement for one year. Consider whether it would be appropriate to fund Mr A to remain in the residential placement until he is 21 years of age or whether this could be achieved through Self-Directed Support.

Evidence that the Council have considered funding Mr A’s residential placement until he is 21 years of age or whether this could be achieved through Self-Directed Support, taking into account the findings of this investigation, discussing the matter with Ms C and providing Ms C with full reasons for any decisions reached.

By: 20 May 2020

We are asking the Council to improve the way they do things:

Rec. number

What we found

Outcome needed

What we need to see
3.

Under complaint (a) we found that the Council failed to begin transition planning for Mr A at least three years before he was due to leave school.

Where a young person has significant additional support needs, transition planning should begin at least three years before a young person is due to leave school.

 

 

Evidence that the findings on these complaints have been fed back to relevant staff in a supportive way (e.g. a record of a meeting with staff; or feedback given at one-to-one sessions).

Evidence that the Council have considered any training needs for social work staff in relation to transition planning.

By: 22 October 2020
4. Under complaint (a) we found that the Council failed to carry out a pathway assessment in line with their Transition to Adult Services Policy prior to making the decision that Continuing Care was not available to Mr A. Where a young person is approaching adulthood, a pathways assessment should also be carried out to assess throughcare and aftercare options (including an assessment of whether it is in the young person’s best interests to remain in their current placement under Continuing Care rather than transitioning to Adult Services) with the input of the young person, their parents/guardians, Adult Services and any other interested agencies.

Evidence that the findings on these complaints have been fed back to relevant staff in a supportive way (e.g. a record of a meeting with staff; or feedback given at one-to-one sessions).

Evidence that the Council have considered any training needs for social work staff in relation to pathways assessments, Continuing Care and Ordinary Residence.

Evidence that the Council have reviewed their Continuing Care Procedure taking into account Mr A’s case and the legislative framework.

By: 22 October 2020
5.

Under complaint (a) we found that the Council did not take reasonable steps to ensure that Mr A could make informed choices. In particular:

  • there is no evidence in the records that Mr A was given concrete examples of the type of care he might be offered or that he was taken to see possible care settings.
  • a recommendation made at a Looked After Child Review in January 2018 to offer Mr A independent advocacy was not actioned until over a year later.

Looked After Children with complex needs should be given examples of the type of care they might be offered and be taken to see possible care settings.

Where a recommendation has been made to offer a Looked After Child independent advocacy, this should be acted on timeously.

Evidence that the findings on these complaints have been fed back to relevant staff in a supportive way (e.g. a record of a meeting with staff; or feedback given at one-to-one sessions).

Evidence that the Council have considered any training needs for social work staff in relation to making sure that Looked After Children with complex needs can make informed choices.

By: 22 October 2020
6. Under complaint (b) we found that the Council largely engaged with Ms C via email rather than holding meetings outwith the formal Looked After Child Review process. The Council should engage in a meaningful way, including holding meetings with parents/guardians, outwith the formal Looked After Child Review process, when planning the future care for Looked After Children with complex needs.

Evidence that the findings on these complaints have been fed back to relevant staff in a supportive way (e.g. a record of a meeting with staff; or feedback given at one-to-one sessions).

By: 22 October 2020
7. Under complaint (b) we found that Ms C was not provided with information on how to make a Continuing Care request when she requested this. Information on how to make a Continuing Care request should be provided to individuals when they request it.

Evidence that the findings on these complaints have been fed back to relevant staff in a supportive way (e.g. a record of a meeting with staff; or feedback given at one-to-one sessions).

By: 22 October 2020
8.

Under complaint (b) we found that:

  • an invite to a Looked After Child Review was sent three days before the Review was due to take place.
  • there was a delay in the Looked After Child Review minutes being available and there was a delay in these being sent to Ms C.

Invites to Looked After Child Reviews should be distributed in a timely way.

Minutes of Looked After Child Review should be typed up and distributed in a timely way.

Evidence that the Council have a system in place to timeously:

  • distribute invites to Looked After Child Reviews.
  • type up and distribute minutes of Looked After Child Reviews.

By: 22 October 2020

We are asking the Council to improve their complaints handling:

Rec. number

What we found

Outcome needed

What we need to see
9

Under complaint (c) we found that:

  • there was an unreasonable delay in Ms C receiving a complaint response.
  • the Council’s complaint response was copied directly from an email that had been sent to Ms C before she submitted her complaint.
  • there was no evidence that the Council had investigated Ms C’s complaints.
  • the Council’s complaint response did not address all the complaints that Ms C made to the Council or indicate whether her complaints were upheld or not upheld.

The necessary systems should be in place to ensure that complaints are handled in line with the Moray Council’s complaint handling procedure and the Model Complaints Handling Procedure and that all staff responsible for dealing with complaints should be aware of their responsibilities in this respect.

Evidence that the findings on these complaints have been fed back to relevant staff in a supportive way (e.g. a record of a meeting with staff; or feedback given at one-to-one sessions).

Evidence that the Council’s systems demonstrate senior level/governance responsibility for complaint handling.

By: 22 October 2020

Feedback

Points to note:

I note that the Ordinary Residence Policy and Procedure on the Council’s website appears to be out of date. The SPSO appear to have been provided with the most up to date copy of this policy and procedure. The Council may wish to consider updating this on their website.

Related reading

Strategic Plan 2020-2024 published

Today Rosemary Agnew, Scottish Public Services Ombudsman, laid her Strategic Plan for 2020-2024 before the Scottish Parliament, as required by section 17A of the Scottish Public Services Ombudsman Act 2002.

In it the Ombudsman sets out her vision for the delivery of the SPSO’s functions under the strategic themes of accessibility, access to justice, capacity and standards.

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