Not upheld, recommendations

Summary

C complained that the board failed to reasonably assess their mental health condition. C had been receiving treatment for a number of years in England, before returning to Scotland. C said that the board’s assessment questioned C’s existing diagnosis and sought to remove this. C asked for a second opinion and a different consultant reviewed their notes. C felt that they should have been seen face-to-face and complained that the board failed to offer an independent second opinion.

We took independent advice from a consultant psychiatrist. We initially upheld the complaint. However, in response to our provisional decision, the board provided evidence showing that they had not sought to remove C’s diagnosis. We found that if C’s existing diagnosis was not being removed, then there was no need for a second opinion. Rather the board should offer C an opportunity to work with a different clinician to repair the therapeutic relationship. As C’s diagnosis was not being removed, the basis for C’s complaints no longer applied. Therefore, we did not uphold C’s complaints. However, we recommended that the board apologise to C given the extent of the misunderstanding, which was not clarified early enough by the board.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the misunderstanding arising from the assessment of their condition. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

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

Summary

C complained about the care and treatment that their adult grandchild (A) received from the board.

A received regular anti-psychotic medication from the board's mental health service. Separately, A suffered from episodes of paralysis, for which they attended A&E on numerous occasions. A died suddenly at home.

C complained that the board failed to recognise A was seriously unwell, with their episodes of paralysis wrongly being attributed to their mental health condition. On the day of A's death, A had fainted at the health centre after receiving their injection. C said that A attended A&E for assessment but was discharged without treatment.

The board’s response to C’s complaint advised that A had been fully assessed during each of their A&E attendances, with appropriate referral being made to neurology (specialists in the diagnosis and treatment of disorders of the nervous system) and advice sought from the mental health service. The board said that there was no evidence of A attending A&E on the day of their death so were unable to account for the hospital ID band that they had been wearing at the time. The board completed a Significant Adverse Event Review (SAER) in response to C's complaint.

We took independent advice from an A&E consultant and a consultant psychiatrist. We found that A received reasonable care from the board during their A&E attendances and confirmed that there was no record of A having attended A&E on the day of their death. We found that the management and review of A’s mental health was both reasonable and appropriate. Therefore, we did not uphold C's complaint.

We found that the board's complaint response was delayed following the conclusion of the SAER. Therefore, we made a recommendation on complaint handling in keeping with our powers to monitor and promote best practice.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to respond timeously to their complaint following completion of the SAER. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.
• In relation to complaints handling, we recommended
• Complaint responses should be issued in keeping with the timeframe given by the complaints handling procedure. Where a delay is necessary such as to allow completion of other review processes, the final complaint response should be issued as soon as it is practicably possible on conclusion of the other review process.

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

Summary

C attended the A&E department at the Royal Infirmary of Edinburgh having suffered a fall and was diagnosed with muscular pain. They re-attended four months later, when a diagnosis of fractured vertebrae was made. C complained to the board that there were failures to fully investigate their symptoms and arrange appropriate x-ray imaging at the initial attendance.

When responding to the complaint, the board had initially concluded that a ‘red-flag’ symptom had been missed which should have prompted imaging. They upheld C’s complaint, apologised and outlined the steps that they would take to learn from this. They subsequently reviewed their position with neurosurgery colleagues and decided that C had been managed appropriately.

We took advice independent advice from an emergency medicine consultant. We found that C was appropriately assessed and did not meet the criteria in the relevant guidelines for their injury to have been considered high-risk and requiring imaging. We did not uphold the complaint. We found that we weren’t critical of the board for reviewing and revising their decision. However, we were critical that they had not communicated this to C and shared recommendations.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to inform them that they had changed their position, as outlined in their final complaint response. 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 board should follow-up on the findings of complaint investigations and ensure that any identified learning actions are taken forward. If the board decide against taking promised actions, and particularly if this is as a result of a change / retraction.

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 an incident in which their late parent (A) fell from their wheelchair prior to being assisted into bed by two home carers employed by the council. Following the fall, the carers assisted A from the floor and proceeded with the transfer into bed. However, A was later taken to hospital where it was discovered they had sustained a fractured femur as a result of the fall. C considered that the fall had been caused by the carers’ failure to check A was safely secured in the wheelchair by failing to ensure A’s lap belt was fastened, the footrests were in the correct position and a glide and lock sheet was in place. C also complained that the carers had failed to obtain medical assistance following the fall despite A being in pain.

The council’s position was that A had been safely secured in their wheelchair and the fall had occurred when the carers were preparing to move A with the use of a hoist, at which point it was discovered that a lock and glide sheet had not been inserted into A’s wheelchair. The council also stated that the carers had proceeded to move A into bed after checking whether A had suffered any injury and required medical assistance, which A had declined.

We took independent advice from an occupational therapy adviser. We found that it was not possible to say how A’s fall had occurred given the differing versions of events. We noted that, based on A’s risk assessments, A had not required the use of a lock and glide sheet and that the carers would not have been responsible for ensuring it had been placed into A’s wheelchair. In any case, this may not have prevented the fall from occurring. Additionally, we noted that lap belts were not considered a measure of restraint and it was normal practice for this to be removed by carers when attending to a service user, unless otherwise specified. We also considered that it had been appropriate for the carers to have moved A after the fall given the evidence suggested that they had checked whether any injury had been sustained and assistance was required.

Therefore, we did not uphold the complaint. However, we identified that the council had failed to adequately investigate the incident involving A and accordingly made recommendations under section 16G of the SPSO Act 2002, which requires the Ombudsman to monitor and promote best practice in relation to complaints handling.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failure to carry out a fact finding investigation in relation to the incident involving A despite advising this had been commissioned in the complaint response and the lack of certainty as to the correct date on which A had been admitted to hospital in the council’s complaint response. The apology should meet the standards set out in the SPSO guidelines on apology available at https://www.spso.org.uk/information-leaflets.

In relation to complaints handling, we recommended:

• Incidents like this should be reviewed and/or overseen by senior management to identify the root causes of the incident and whether any learning can be taken forward.
• The council should ensure that information provided in response to complaints is factually accurate.

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

Summary

C complained about the care and treatment that they received after they underwent a minor surgical procedure as a day patient at Forth Valley Royal Hospital. C said that after the procedure they did not recover well from the anaesthetic (drugs administered to cause numbness of pain) and experienced severe chest pain. Despite this, they said that staff had tried to discharge them before they had properly recovered from the anaesthetic and that staff had ignored the symptoms they were experiencing. C said that they had experienced a heart attack and were later admitted to the Intensive Care Unit (ICU). They complained about the conduct of staff while they were there and that they acted inappropriately.

We took independent advice from a consultant anaesthetist (a medical specialist who administers anaesthetics) and a nursing adviser. We found that, while there was a lack of detail in the clinical records, the evidence available demonstrated that the anaesthetic for the procedure had been given in accordance with good practice and guidelines and doses of drugs were appropriate. In particular, there was no evidence of over dosage of general anaesthetic drugs. We noted that there may have been some delay in recognising that the chest pain C was experiencing was not resolving, however, this had no effect on the outcome and when investigations showed that some heart muscle damage had occurred, appropriate treatment was started. We also found that the nursing care given to C had been reasonable and that the nursing notes were completed to a good standard. We noted that the board had apologised that C felt that a member of staff's attitude had been dismissive and also for the behaviour of staff in ICU.

We considered that the care and treatment given to C was reasonable and did not uphold the complaint. However, having reviewed the handling of the complaint, we concluded that the board failed to appropriately investigate and respond to C's complaint. In particular, that there had been a failure to obtain a formal report from the anaesthetist in response to C's original complaint. Therefore, we made a recommendation under section 16G of the SPSO Act 2002, which requires the Ombudsman to monitor and promote best practice in relation to complaints handling.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to fully investigate and respond to their complaint. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

In relation to complaints handling, we recommended:

• Relevant staff should be aware of the requirements of the complaints handling procedures, particularly regarding collating and assessing relevant evidence in determining a complaint.

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

Summary

C, a prisoner, complained about the decision by the prison health care team to discontinue their prescribed pain medication. The decision to discontinue the medication was made after C failed a medication spot check. It was recorded that C did not cooperate and C was deemed to have failed the spot check.

We took independent medical advice from a GP. We were unable to reconcile the conflicting accounts provided by C and the board regarding what happened during the spot check. We were unable to conclude that the spot check was not conducted appropriately. In the context of a failed spot check, we concluded that it was reasonable that C’s medication was discontinued. We did not uphold C’s complaint; however, we made a recommendation after we identified an issue with the board’s complaint handling.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C that the frontline complaint response contained an inaccuracy about what they reportedly said during the spot check. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

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

Summary

C complained about the way the council handled their request for their child (A) to attend a specific secondary school. C considered that their request should have received priority over others as A had a sibling in the school. In order to determine catchment places for the school, the council conducted a ballot. A was not allocated a place during the ballot and was unable to attend the school. C remained dissatisfied with the council's handling of their complaint and brought the complaint to us.

We found that the council had followed their policy to allocate catchment places. We were satisfied that, throughout the process, the council kept C appropriately informed about what was happening. At the end of the process, the council also informed C of their right to make a placing request. We did not find that the council had treated C and A less favourably than other families in the same position. We did not uphold C's complaint.

During our consideration of complaint handling, we found that the council initially failed to correctly log C's correspondence as a complaint and handle it in line with their procedure. This resulted in the complaints process becoming unnecessarily prolonged by over two months. Therefore we made a recommendation under section 16G of the SPSO Act 2002, which requires the Ombudsman to monitor and promote best practice in relation to complaints handling.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to handle their complaint appropriately. 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

Mrs C complained about the care and treatment provided to her child (Child A). Mrs C felt that Child A was denied access to NHS doctors with experience in paediatric autoimmune neuropsychiatric disorder associated with streptococcus (PANDAS - a neurological and psychiatric condition in which symptoms are brought on or worsened by infection). She also felt that the board had unreasonably refused to treat Child A with antibiotics and had instead suggested mental health treatment as an alternative. Mrs C had requested that Child A be referred to specialist clinicians in England and felt that the board had unreasonably denied this request.

We took independent advice from a paediatrician. We found that there was evidence that the board were engaged with the medical literature on PANDAS and used this to inform their decision not to offer antibiotic treatment. We considered this to be a reasonable position and concluded that the board provided appropriate care and treatment in this respect. We also considered that the board's approach to obtaining second opinions and referring Child A to alternative clinicians was reasonable. We did not uphold this aspect of Mrs C's complaint.

Mrs C also complained about the board's communication with her. We found that there was evidence in the records of timely and appropriate communication, and there was no evidence of unfair treatment. We did not uphold this aspect of Mrs C's complaint. However, we did identify that there were issues with the board's handling of Mrs C's complaint, as there was a delay in issuing a response and the response did not address all the issues Mrs C had raised. Therefore we made a recommendation under section 16G of the SPSO Act 2002, which requires the Ombudsman to monitor and promote best practice in relation to complaints handling.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C for the delay in issuing the formal response to her complaint, and for the failure to address the issues she had raised in the formal response to her complaint. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

In relation to complaints handling, we recommended:

• Complaint responses should be full and timely.

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

Summary

C complained that the council had failed to reasonably administer their council tax account. They complained that the council had failed to keep accurate records of payments made to them. The council appointed sheriff officers to recover council tax debt. C complained that the council's failure to keep accurate records had resulted in sheriff officers trying to recover more debt than was due.

We found that the council had kept accurate records and had taken enforcement action appropriately when C failed to keep up with regular payments of a satisfactory amount. We did not uphold the complaint.

However, during our investigation we identified that the council did not make it clear to C at which stage of the complaints process they were considering C's complaint. We therefore made a recommendation under section 16G of the SPSO Act 2002, which requires the Ombudsman to monitor and promote best practice in relation to complaints handling.

Recommendations

In relation to complaints handling, we recommended:

• Council staff should be familiar with the Model Complaints Handling Procedure and ensure complainants are made aware of which stage their complaints are at.

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

Summary

C's sibling (A) is a permanent resident of a care home. A was admitted to the Queen Elizabeth University Hospital with a bowel obstruction. A was initially admitted to the acute receiving unit, then transferred to a ward, before being discharged two evenings later. C had concerns about the care and treatment A received, the way the board sought information about A and their decision to discharge A. The board upheld some parts of C's complaint, provided apologies and undertook some process changes to address these matters. However, the board concluded that their actions overall had been reasonable. C was unhappy with the board's response and brought their complaint to us.

We found that the board provided reasonable care and treatment to A, that the prescription and administration of laxatives was reasonable in the circumstances, that the board's seeking of information about A was reasonable and that the decision to discharge A was reasonable. Therefore, we did not uphold C's complaints. However, we were concerned about the board's failure to respond to matters that had been complained about and where their initial failure to respond had been highlighted to them. We made a recommendation to the board in light of this under section 16G of the SPSO Act 2002, which requires the Ombudsman to monitor and promote best practice in relation to complaints handling.

Recommendations

In relation to complaints handling, we recommended:

• In line with their Model Complaints Handling Procedure, the board should be clear from the start of the investigation stage exactly what they are investigating.

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.