Not upheld, recommendations

Summary

Mrs C complained about the support provided to her following the birth of her daughter at the Victoria Hospital. She raised concerns about both her hospital care and her care in the community following her discharge. In particular, she complained about a lack of breastfeeding support, which she considered contributed to her subsequent development of postnatal depression.

We took independent advice from a midwifery adviser, who reviewed the records and concluded that appropriate support was provided to Mrs C by both the hospital and community midwives, and by the breastfeeding support worker who visited her the day after discharge. It was noted that an apparent breakdown in communication within the breastfeeding support team meant that they did not follow up with Mrs C as planned. The board had already acknowledged this oversight and undertook to discuss how they can better document requests for follow-up. The adviser also observed that the community midwives documented Mrs C's tearfulness and low mood but that they did not pass this information on to the health visiting team, as they should have. It was noted that the board had asked the community midwives to carry out a piece of work in relation to women's emotional states. On balance, we did not uphold the complaint but we made some recommendations.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C for the breastfeeding support team's failure to contact her to arrange a follow-up appointment; and for the community midwives' failure to pass on details of her low mood to the health visitor. 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:

• The breastfeeding support team should review their follow-up referral process and implement measures to ensure follow-up appointments are not missed in future.

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

Summary

Mr C made a complaint to Business Stream that he was unreasonably invoiced for backdated water charges for the commercial premises he rents.

Business Stream responded to Mr C by advising that they had been billing Mr C's landlord for the period in question as they believed there to be a shared meter and therefore considered that it was a private matter between Mr C and his landlord to share costs through this period. Scottish Water had then made them aware that the pipework had been amended and that the two separate premises within the building should have been billed separately. Business Stream refunded Mr C's landlord and billed Mr C for backdated charges, beginning from the date they became aware that he had moved into the premises. Business Stream noted that, in the circumstances, The Prescriptions and Limitations (Scotland) Act 1973 allowed them to apply backdated charges for services which they had provided and Mr C had used. They also confirmed that the charges were based on the rateable value of the property which Mr C was using and the size of the meter serving the property. Following Mr C's complaint, Business Stream removed all recovery charges from his account and made credit payments as goodwill gestures. Mr C remained unhappy about the backdated charges and brought his complaint to us. He complained that Business Stream had unreasonably billed him for the water charges.

We obtained all of the information relating to the complaint from Business Stream. We noted that they were correct to calculate charges based on the rateable value of the property. The decision to backdate the charges was also reasonable and Business Stream provided evidence of the steps taken to minimise the charge to Mr C where possible. They also correctly cited legislation which allowed them to do this. We, therefore, did not uphold Mr C's complaint.

However, we noted that it took Business Stream almost 12 months to respond to Mr C's complaint. We therefore made a recommendation that they apologise for this.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for the unreasonable 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.

Summary

Ms and Mr C complained that the council failed to take reasonable action in response to reports of bullying of their children at school by another child. In particular, Ms and Mr C were concerned that a restorative conversation was not facilitated by the school between their children and the other child.

We did not uphold Ms C and Mr C's concerns about the actions taken concerning the bullying because we found that the actions taken by the school were inline with the steps set out in the council's policy. The school explained that they would normally take a restorative approach to bullying, but they explained why they did not consider the conditions were in place to do so. We felt the council's policy should reflect this so we made a recommendation in light of our findings.

Recommendations

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

• The council's anti-bullying policy and guidelines should address their practice in relation to restorative conversations.

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 to us about the care and treatment her former partner (Mr A) had received at the Queen Elizabeth University Hospital and the Beatson West of Scotland Cancer Centre after he was diagnosed with cancer. Mr A had died within three months of being diagnosed. We took independent advice from a consultant clinical oncologist. We found that there were no failings in the diagnosis or management of Mr A's cancer and that the treatment provided to him was reasonable and appropriate. We did not uphold this aspect of Ms C's complaint.

Ms C also complained that the board had unreasonably failed to retain Mr A's personal possessions for collection by his next of kin after his death. We took independent nursing advice. We found that the actions of the board in relation to this matter had been reasonable and did not uphold this aspect of the complaint.

Ms C also raised concerns that the board had failed to assist her with investigating a link between Mr A's cancer and their son's health. Based on the evidence available, we considered that the board had reasonably tried to assist Ms C with this matter. We did not uphold this aspect of her complaint. However, we found that the board had not handled Ms C's complaint regarding this appropriately and we made a recommendation in relation to this.

Ms C also complained about the board's handling of her request for Mr A's medical records. She complained that the board had not given her the imaging and scans they held for Mr A. The board had told Ms C that they would not release some of the records because Mr A had told a consultant that he did not want them to be disclosed. We found that the consultant should have made a note of Mr A's request in his records. However, we did not identify any other failings and, on balance, we did not uphold this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms C for not handling her complaint appropriately. 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.

Summary

Mrs C complained about the care and treatment of her late mother (Mrs A). Mrs A became unwell and was seen initially by an out-of-hours doctor, who diagnosed infection and prescribed antibiotics. Mrs C called the practice and spoke to a GP the following day as Mrs A was still unwell, and a home visit was arranged for the following day. When a GP reviewed Mrs A at home the next day, arrangements were made to admit her to the GP unit in a local care home. From there, she was transferred to hospital in the early hours of the following morning, where she deteriorated and died five days later.

Mrs C complained that, when she called the practice, they did not arrange for Mrs A to be reviewed that day. We took independent advice from a GP adviser, who considered that the GP carried out an appropriate assessment and, based on the information gathered, took steps to arrange for Mrs A to be reviewed within a reasonable timescale. We accepted the advice and did not uphold the complaint.

Mrs C also complained that the GP who reviewed Mrs A at home should have arranged to admit her directly to hospital. She also raised concerns that the GP retrospectively altered Mrs A's recorded oxygen saturation level. The practice indicated that this was to rectify a typing error. We were advised that the originally recorded level should have led to a direct hospital admission, whereas the amended level was in keeping with the actions taken. We were unable to establish the true picture and, therefore, could not conclude that there was an unreasonable failure to admit Mrs A to hospital. As such, we did not uphold the complaint however we made a recommendation in relation to record-keeping.

Recommendations

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

• The practice should take steps to clarify whether the entry in the clinical records accurately reflects the date that it was retrospectively amended. If it does not this should be rectified to ensure complete clarity.

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 safety of his son (child A), at his former school. Child A has complex support needs, and Mr C complained that the council had failed to investigate an incident involving his son leaving the school grounds unaccompanied. Mr C also complained that the council had failed to carry out a risk assessment of security at the school and had failed to appropriately follow child A's management plan in relation to his needs. In addition, Mr C raised concerns about a lack of communication and the way the council handled a placement request for his son.

We found that the council had carried out a reasonable investigation of the incident involving child A leaving the school grounds unaccompanied, and had taken action to try to prevent a similar situation arsing in the future. As such, we did not uphold the complaint.

We were also satisfied that risk assessments had been carried out and so we did not uphold the complaint that the council had failed to carry out a risk assessment of security at the school. However, we were concerned that there was no documentary evidence of the rationale used by the council in reaching decisions arising from the risk assessment, particularly relating to supervision arrangements. We were also concerned that the roles and duties of non-teaching staff in relation to the supervision of pupils was not documented. We made recommendations in relation to these concerns.

We were provided with a copy of the relevant management plan detailing child A's needs and we found no evidence that this was not being followed. As such, we did not uphold the complaint relating to the management plan. We were also provided with evidence which demonstrated there had been extensive communication with Mr C and we did not uphold the complaint about a lack of communication.

Finally, we found no evidence that the placement request had not been handled in line with the Education, Additional Support for Learning (Scotland) Act 2004 and did not uphold this aspect of Mr C's complaint.

Recommendations

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

• There should be a written document or protocol setting out the roles and duties for non-teaching staff in relation to supervision arrangements.
• The rationale for decisions arising from a risk assessment should be documented.

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 a number of consultations, for different medical complaints, that she had at her GP practice. Ms C also complained that she had been unreasonably removed from the practice list, and she complained about how the practice had responded to her complaint.

We took independent advice from a GP adviser. We found that Ms C had received a reasonable standard of care and treatment, and so we did not uphold this aspect of the complaint. However, we did find a consultation which had happened had not been noted in the clinical records. We made a recommendation to address this.

We found that the practice had followed the correct procedure when removing Ms C from their patient list and that they had responded thoroughly to her complaint. We did not uphold these complaints.

Recommendations

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

• All interactions with patients should be documented, adhering to the standard of record-keeping set out in the General Medical Council's Good Medical Practice 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.

Summary

Miss C was told by dental staff that she would require dental braces. She was subsequently told by orthodontic staff that she would not be provided with braces and she was discharged from the service. Miss C complained that the board failed to provide her with appropriate dental care.

We took independent advice from an orthodontics adviser who explained that the assessment criteria to consider whether a patient qualifies for orthodontic treatment funded through the NHS is covered by the Index of Orthodontic Treatment Need (IOTN). It would be expected that an orthodontics practitioner would provide a grade of IOTN which would substantiate their decision as to whether or not the criteria had been satisfied. We found that in Miss C's case the orthodontic staff had assessed her on a number of occasions as having a low IOTN, which was a reasonable judgement for them to make and had indicated that they had considered the IOTN criteria. As such, Miss C would not have qualified for orthodontic treatment and so we considered that the dental care provided had been appropriate. We did not uphold the complaint.

However, we did note that there was a failure by orthodontic staff to record the actual IOTN grade in the dental records, and so we made a recommendation in relation to this.

Recommendations

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

• The staff should be aware of the requirement to record the IOTN category in order to substantiate whether the criteria for providing orthodontic treatment has been met.

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 was admitted to Raigmore Hospital as she had a two day history of stomach pain and vomiting. She was found to have a small bowel obstruction for which she needed major surgery. The operation was carried out the next day and Mrs C was given an epidural (anaesthetic by spinal injection) and a general anaesthetic.

After the operation, Mrs C noted reduced mobility in her legs and a scan was carried out, but this showed no abnormality. Mrs C's mobility did not improve and she was seen by a neurologist and a repeat scan was performed but, again, was normal. It was explained to Mrs C that the likely cause of her lack of nerve sensation was a spinal stroke (where there is an interruption in blood flow to the spinal cord). Later, Mrs C complained to the board because she believed that she should not have been given an epidural and a general anaesthetic together because she had a history of heart problems. The board confirmed that she had had a spinal stroke, but said that the reason for it was unclear. Mrs C remained unhappy and brought her complaint to us.

We took independent advice from a consultant anaesthetist and a stroke specialist. We found that it was common practice for an epidural to be used in conjunction with a general anaesthetic for post-operative pain relief after major abdominal surgery like that given to Mrs C. We found that there was nothing in her medical history that would have discouraged clinicians from doing this and that the practice was in accordance with Royal College of Anaesthetists' advice. For this reason, we did not uphold the complaint. However, we also found that prior to the operation the full risks of an epidural, including the risk of nerve damage, were not discussed with Mrs C as we would have expected. We found that the consent checklist that was used did not have a box for relating to the risk of nerve damage. We made recommendations to address this failing.

Recommendations

What we asked the organisation to do in this case:

• Apologise for failing to fully discuss the risks of an epidural with Mrs C.

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

• The consultants involved in this case should use it as part of their reflective discussion in their annual appraisal.
• The consent checklist should include nerve damage as a risk to be discussed.

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 on behalf of his wife (Mrs A). Mrs A had undergone a colonoscopy (a procedure to examine the inner lining of the large intestine) at University Hospital Crosshouse and, during the procedure, a complication had occurred which caused a perforated bowel. As a result of the perforated bowel, Mrs A had to undergo emergency surgery and she spent time in an intensive care unit. Mrs A required a temporary colostomy (a surgical procedure where an opening is formed in the abdomen). Mr C complained that the colonoscopy was not carried out to a reasonable standard.

We took independent advice from a consultant general and colorectal surgeon. We found that a colonoscopy was the appropriate and recommended procedure in Mrs A's case, taking into account her existing medical conditions. We also found that the doctors involved in the colonoscopy had the relevant experience and were suitably qualified to carry it out. The board said that the perforated bowel was a recognised complication and risk of the colonoscopy. They also said that when the perforation occurred it was quickly recognised and prompt and appropriate action was taken. The board had apologised for the complication that had occurred, and had set out the action they had taken to improve clinical safety.

Taking account of the evidence and the independent advice we received, we did not uphold Mr C's complaint. However, we did ask the board to provide us with evidence of the action they said they had taken, and we made a recommendation to the board with a view to encouraging learning from this complaint.

Recommendations

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

• Where serious incidents occur in colonoscopy procedures, they should be reviewed at least quarterly.

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.