Not upheld, recommendations

Summary

Miss C complained about the care and treatment provided to her child (Child A) by the board. Child A was born by caesarean section. When Child A was older, they experienced a seizure and a scan showed right-sided ventricular enlargement (when the muscle on the right side of the heart becomes thickened and enlarged) and associated white matter loss, indicating brain damage or brain injury.

Miss C had concerns about how the brain damage occurred, when it occurred, and the delay in identifying this. She said that her view was that the board had caused the brain injury when Child A was born. She also complained that Child A had not received a brain scan earlier despite developmental difficulties.

We took independent advice from a paediatrician (doctor dealing with the medical care of infants, children and young people). We found that there was no indication in the medical records of any events which were likely to have caused brain injury in Child A during birth or during the neonatal period. We also found that Child A's early developmental course did not suggest the need for a scan and there did not appear to have been any delay in diagnosing the brain injury. We did not uphold Miss C's complaint.

However, we noted during our investigation that there were failings in the board's handling of Miss C's complaint in relation to updating Miss C, not responding to her questions, failing to refer to SPSO, and failing to acknowledge correspondence in a timely manner. Therefore, 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:

• Complaints should be handled in line with Model Complaint Handling Procedures.

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 submitted a complaint on behalf of their child (A) about the treatment provided by the board in relation to A's eating disorder. C said that A had been diagnosed with Avoidant Restrictive Food Intake Disorder (ARFID), however, in subsequent contact this term was not used by board staff.

We took independent advice from a consultant psychiatrist who had experience working with people with eating disorders. We found that the board had provided reasonable treatment to A. It was recognised that A would benefit from intensive input and the board offered an individualised approach to treatment. The board set out a clear rationale for the proposed treatment that was appropriate for A's identified needs. While there was inconsistency in using the term ARFID to describe A's diagnosis this did not impact on the treatment offered to A. Therefore, we did not uphold C's complaint.

While we did not uphold this complaint, we have made recommendations to the board for failing to explain the varying use of ARFID in the complaint response. We have made these 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 failing to provide a reasonable explanation regarding the varying use of the term ARFID when responding to their complaint. The apology should meet thestandards set out in the SPSO guidelines on apology available atwww.spso.org.uk/information-leaflets.

In relation to complaints handling, we recommended:

• The board's complaints responses should provide reasonable explanations of the actions taken/terms used as necessary to respond to 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

Ms C complained about the care provided to her by the Scottish Ambulance Service (SAS) when she experienced an episode of cellulitis (a potentially serious skin infection). She said that SAS failed to identify that she was suffering from sepsis (a serious complication of infection) and take the appropriate action.

We took independent advice from an adviser who is experienced in pre-hospital, emergency and unscheduled care. We found that the care and treatment provided by SAS to Ms C was reasonable and in line with relevant guidance. We did not uphold Ms C's complaint.

However, during our investigation we identified that SAS had failed to respond to Ms C's complaint within the appropriate timescales and had not kept her updated on the delay. 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

What we asked the organisation to do in this case:

• Apologise to Ms C that her complaint was responded to outwith 20 working days and she was not provided with an explanation for the delay or a revised timetable for sending the response. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

In relation to complaints handling, we recommended:

• Complaints should be responded to within 20 working days, and if the investigation will take longer, SAS should discuss this with the complainant and agree revised time limits.

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

Mr C complained about the treatment his wife (Mrs A) received from the board for breast cancer. Mrs A attended University Hospital Crosshouse where she was diagnosed with breast cancer and underwent chemotherapy (a treatment where medicine is used to kill cancerous cells), surgery and radiotherapy (a treatment using high-energy radiation). Mrs A was later diagnosed with metastatic breast cancer (cancer that spreads to other parts of the body) and died. Mr C complained that Mrs A did not receive appropriate treatment, that an alternative surgery would have provided a better outcome and that the treatment provided was experimental.

We took independent advice from a consultant clinical oncologist (cancer specialist). We found that Mrs A's treatment by the board was reasonable and found no failings in the treatment offered. Therefore, we did not uphold Mr C's complaint.

However, during the consideration of the complaint we found there were factual errors in the board's complaint response. 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 Mr C for the errors identified in the complaint response. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/leaflets-and-guidance.

Summary

Ms C complained about the care and treatment provided to her late mother (Mrs  A) at Vale of Leven hospital. Mrs A had been admitted with a fractured hip after a fall and remained in hospital for four months before her death. Ms C complained about a number of medical issues, including the timing of the diagnosis of the hip fracture, hydration and nutrition, diagnosis of dementia and end of life care.

We took independent advice from a consultant physician. We found that whilst the documentation of the initial assessment of Mrs A should have been more detailed, her care and treatment was reasonable. We found that Mrs A's hydration and nutrition was managed appropriately and in line with national guidelines, that the diagnosis of dementia was appropriately handled and that her care was holistic and reasonable given her declining health. We did not uphold Ms C's complaint; however, we made a recommendation to the board regarding the documentation of the initial assessment.

Recommendations

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

• Patients with an unwitnessed fall should have a full neurological (nervous system) and musculoskeletal (muscles and bones) system examination documented on admission.

Summary

Mrs C complained about the standard of medical care and treatment provided to her late husband (Mr A) at Dumfries and Galloway Royal Infirmary. Mr A had a complex medical history and his condition deteriorated soon after admission. He was first transferred to the high dependency unit and then the intensive care unit. Mr A died a few weeks after he was admitted. Mrs C was concerned that medical staff failed to recognise the significance of his deterioration, diagnose him and refer him to the intensive care unit within a reasonable time. Mrs C was also concerned about treatment decisions and management, and lack of communication from medical staff.

We took independent advice from an adviser who specialises in general medicine. We were satisfied that the overall standard of medical care and treatment provided was reasonable and we did not uphold Mrs C's complaint. However, we found failures in communication and that Mr A and Mrs C were not kept updated about his condition as they should have been. We made recommendations to the board in light of these findings.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C for the shortcomings in communication. The apology should meet the standards set out in the SPSO guidelines on apology available at https://www.spso.org.uk/leaflets-and-guidance.

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

• Staff should ensure they keep patients and/or their families/carers regularly updated.

Summary

Mr C complained about the medical care and treatment his late mother (Mrs A) received at Hairmyres Hospital. In particular, Mr C complained that a biopsy was not carried out and that the board had failed to give Mrs A an appointment for a ring pessary (a device used to support the uterus, vagina, bladder or rectum) change.

We took independent advice from a consultant gynaecologist (a doctor who specialises in the female reproductive system). We found that there had been no indication to carry out a biopsy when Mrs A attended the hospital following a referral from her GP. Therefore, we did not uphold this aspect of Mr C's complaint.

In relation to Mr C's concern that Mrs A had not been given an appointment for a ring pessary change, we found that the board had initially advised Mr C that this was as a result of a system failure. However, they later clarified that this was not the case. We found that the failure to attend an appointment for a ring pessary change was not caused by a failing on the part of the board and we did not uphold this aspect of Mr C's complaint. However we were concerned that incorrect information had initially been given to Mr C about this matter and made a recommendation to the board.

Recommendations

In relation to complaints handling, we recommended:

• Complaint responses should be accurate and issues raised should be thoroughly investigated.

Summary

Mr C was referred by his GP to the board's spinal service at Gartnavel General Hospital for assessment. The referral was vetted on receipt and considered appropriate for a virtual appointment. The appointment took place nine months after the referral was received. Mr C's referral was not considered appropriate for the spinal service and he was referred to the board's back pain service for physiotherapy. Mr C complained that he was unreasonably referred back to the physiotherapy service.

We took independent medical advice from a consultant orthopaedic surgeon (a  surgeon who diagnoses and treats a wide range of conditions of the musculoskeletal system). We found that the response to Mr C's referral was reasonable as the back pain service was the appropriate service for Mr C to be redirected to. We did not uphold Mr C's complaint. However, we noted that there was a delay in recognising that the referral should have gone to the back pain service in the first instance. The board's vetting system did not highlight that Mr  C's referral was not appropriate for the spinal service and we made a recommendation to the board in light of this.

Recommendations

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

• Have systems in place to ensure that inappropriate referrals are identified promptly.

Summary

Mrs C complained about the care and treatment her late mother (Mrs A) received when she was a patient in the geriatric long stay facility at Mearnskirk House. Mrs A became unwell and was treated for a presumed urinary tract infection. Her condition deteriorated and she developed sepsis (blood infection) and jaundice (a condition with yellowing of the skin or whites of the eyes), and later died.

Mrs C suspected that Mrs A's urinary tract infection was from a liver source and raised concerns about the board's response to Mrs A's jaundice. However, the board considered that a urine source was more likely and that the treatment Mrs  A received had been reasonable.

We took independent advice from a consultant geriatrician (a doctor who specialises in medicine of the elderly). We found that the source of infection often remains uncertain in particular situations, and that treating the sepsis would be the correct priority. We considered that more vigorous medical investigations or interventions would have been disproportionate. We did not uphold Mrs C's complaint.

However, we noted that there was insufficient documentation to demonstrate adequate discussions with Mrs C regarding Mrs A's management plan, particularly surrounding the uncertainty of her recovery. We also highlighted that adequate internal communication was not demonstrated and that communication failings were contrary to Scottish Intercollegiate Guidelines Network (SIGN) guidelines on the care of deteriorating patients. We made recommendations relating to these observations.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C for the failure of clinical staff to communicate adequately, both with her and with each other. The apology should meet the standards set out in the SPSO guidelines on apology available at: https://www.spso.org.uk/leaflets-and-guidance.

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

• As per SIGN 139, patients identified as deteriorating with limited reversibility should have a written management plan which considers and includes discussion with the patient and family (which may include discussion of uncertain recovery and medical plan, preferred place of care and concerns or wishes); and standardised and agreed ceilings of care.
• As per SIGN 139, all communication about patients identified as deteriorating should be formalised and should include a structured handover process which includes all relevant clinical information.

Summary

Mr C complained that the council failed to reasonably uphold access rights to a field. Mr C was of the view that the landowner had unreasonably locked the gate without providing a stock gate or a stile. Mr C noted that the public had accessed the field for over 20 years. The council contacted the landowner, who confirmed that there was now livestock in the field and that the gate had to be locked to keep the animals in.

The council cited the Land Reform (Scotland) Act 2003 and the Scottish Outdoor Access Code as guiding parameters for their decision not to take enforcement action against the landowner for locking the gate. We found that the council had given due time and consideration to all of the issues brought before them, and had assessed a number of different sources of evidence. The council have stated that they expect the gate to be unlocked at times when no livestock are in the field. We confirmed that it is not for this office to give a definitive intepretation of the Land Reform (Scotland) Act 2003, or the Scottish Outdoor Access Code. We noted that the Land Reform (Scotland) Act 2003 sets out in section 28 that it is for a Sheriff to determine the existence and extent of access rights. We did not uphold Mr C's complaint.

While Mr C did not ask us to investigate how the council handled his complaint, during our investigation we observed that the complaints handling fell below the standard that we would expect. We have therefore made a recommendation that the council apologise to Mr C for this.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for the unacceptable delay in responding to his complaint. The apology should meet the standards set out in the SPSO guidelines on apology available at https://www.spso.org.uk/leaflets-and-guidance.

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