Some upheld, no recommendations

Summary

C complained about the board’s decision not to provide thyroid chondroplasty (a surgery to reduce the size of the Adam’s apple) as part of their gender affirming treatment. The board explained that though they used to have surgeons who could carry out this surgery, they no longer do. They said that the Scottish Government does not fund thyroid chondroplasty and therefore they cannot recruit surgeons for the purpose of performing the surgery and are prevented from using public finances to fund it.

We found that there is no obligation for the board to provide thyroid chondroplasty on the basis of Scottish Government protocols. However, protocols state that health boards should ensure they have clear documentation on what is available to their patients and have local policies in place regarding access to them. We gave feedback to the board on this point, but ultimately did not uphold C’s complaint.

C also complained that when they were in the process of having hair removal prior to gender reassignment surgery, the board stopped providing this service. Because hair removal at the site of surgery is a requirement, C had to pay for the hair removal to be completed privately.

During the course of our investigation, the board accepted that they had not been clear to them at the point of C’s complaint that it is the responsibility of the health board where the patient lives to arrange hair removal prior to gender reassignment surgery. The board apologised for the failure and financial inconvenience caused and offered to reimburse C for the laser hair removal. We upheld the complaint and made no further recommendations.

Summary

C complained about their experience of labour and post-birth care. C felt that they had been left too long without assessment and without medical review. C also complained about the actions of a specific doctor, who attempted manual removal of their placenta post birth. C said that this had been painful and that their birth plan had not been followed, making the experience distressing and difficult for C and their partner.

The board had already acknowledged failings in C’s care and the investigation assessed whether the actions set out were reasonable and proportionate means of addressing these. We took independent advice from an obstetrics adviser. We found that the board had acted to address the identified failings. Although C’s experience was distressing, there was no evidence that their baby was put at risk at any point. We upheld some of C’s complaints, but made no further recommendations due to the appropriate actions already taken by the board.

Summary

C complained that the council had failed to keep their child (A) safe whilst in the council’s care and that A had been inappropriately placed in secure accommodation. A had been in care in a number of different settings, including secure units. Some were run by third party care providers or the NHS. It was accepted by the council that A had been able to harm themselves whilst in care and that A had been placed in secure accommodation when the council was not legally entitled to do so. The council said that some incidents had occurred despite the best efforts of staff to keep A safe.

We took independent advice from a registered social worker. We found that the council had taken reasonable steps to try and ensure A’s safety, and had worked with third parties to ensure incidents were fully reviewed. They had also taken reasonable steps to prevent a reoccurrence of the error that led to A being accommodated. We did not find communication with C had been unreasonable given C’s restrictions on the kind of communication that they would accept from the council. We did not uphold these aspects of the complaint.

Summary

C complained about the actions of the board when carrying out a post-mortem examination of their adult child (A). C said that the board had failed to secure A’s admission blood samples, resulting in them being lost. C also believed that the board had failed to carry out the post-mortem properly, as no further blood samples had been taken.

We found that A’s admission blood samples had been collected by Police Scotland and taken to another board for tests. There was no audit trail of paperwork other than the police statement of their actions. Once Police Scotland had collected the samples they ceased to be the responsibility of the board. While the board are not responsible for the misplacement of A’s admission blood samples, they should have ensured the samples were signed for and copies of the paperwork retained. Therefore, we upheld this part of C's complaint. The board had already apologised for this failing and taken appropriate action so we did not make any further recommendations

In relation to the post-mortem, we found that the pathologist had followed the appropriate guidance. This recognised that admission samples were always preferable to post-mortem samples and at the time the post-mortem was carried out, there was no reason to suppose the admission samples were lost. Therefore, we did not uphold this part of C's complaint.

C also complained about the board's communication. We found that the board's communication with C was reasonable. Therefore, we did not uphold this part of C's complaint.

Summary

C’s child (A), was a pupil at a school in the council’s area. C said that A experienced bullying and a sexual assault by another pupil at the school, resulting in changes to A’s behaviour, anxiety and distress to the extent that A could no longer attend. Following discussions with the council, it was agreed that C could apply for A to attend a new school, outside of their local area.

C complained about school 1’s handling of A’s support needs and their response to A’s disclosure about the alleged sexual assault and events stemming from this. C also complained about the council’s failure to arrange transport for A to the new school, which C said had been discussed as part of the decision to apply for a place there.

C raised a number of complaints with the council regarding their concerns, including that the council had unreasonably contacted Police Scotland regarding the actions of C’s partner (B). C did not consider that the council responded reasonably to the points that they raised.

We accepted the council’s position that MAAP (Multi-agency assurance panel) meetings would not have been required over the relevant period. We also found that there was clear evidence of the school assessing A’s needs and putting in place reasonable measures to support them. We did not uphold this aspect of C’s complaint.

Overall, we found that the school appropriately recorded A’s disclosure of sexual assault, instigated the involvement of relevant third parties to ensure that the matter was investigated properly, communicated and collaborated well with A and their family to arrange support for A and to explain why there were limitations to the action that they were able to take. Given the circumstances the school had to work with, we are satisfied that they proposed a range of supports that gave A options for safe places to go should they feel threatened. Whilst we acknowledge C’s view that these arrangements did not eliminate the risk to A, overall, we found that the school’s support plans were reasonable and appropriate. We did not uphold this aspect of C’s complaint.

We found that the available evidence supported the council’s account of events related to the contacting of Police Scotland in connection with B’s actions and that the school’s actions on the day reflected the situation as it unfolded in a number of physical locations and involving different staff members being approached by different individuals with information. We did not uphold C’s complaint in this respect.

Whilst we have no cause to doubt C’s recollection of events, we found that there was no evidence to support C’s recollection that the council had agreed that door-to-door transport for A to the new school was required or would be provided. We are satisfied that the council considered A’s specific circumstances in reaching their decision on the request for transportation. We did not uphold this aspect of C’s complaint.

Overall, we found that the council took C’s complaints seriously, conducted reasonable investigations, responded fully to the points C raised and that these responses were supported by the council’s policies and the contemporaneous records that they held. However, there was a clear and unreasonable delay to the council’s handling of one of C’s complaints, as the council had accepted and apologised for. Given the length of this delay, on balance, we upheld C’s complaint about the council’s complaints handling.

Summary

C complained about the care and treatment that their relative (A) received from the board. A had a history of dementia and was admitted to hospital. C complained that during A's admission the family were given inaccurate information about COVID-19 visiting restrictions, and about the care and treatment that A was receiving. A had also fallen whilst in hospital and C questioned how this could have happened.

We took independent advice from a nursing adviser. We found that there had been failings in A's care, and in the communication with C and the family. A should have received enhanced monitoring prior to the fall, although it was not possible to determine how the fall had taken place.

We considered that the board had accepted this and provided evidence of the actions that they were taking to improve care for patients and communication with families. We found that these actions were a reasonable and proportionate response and the board had provided evidence that they were implementing the changes required. C's complaints were upheld, as there were acknowledged failings in A's care, however, no further recommendations were made.

Summary

C complained about the handing of their Internal Case Management (ICM) case conference. C was unhappy that the Scottish Prison Service (SPS) refused to postpone this meeting in light of ongoing appeals/complaints and COVID-19 restrictions, and also that the SPS subsequently failed to review and amend the minutes.

The SPS confirmed that they acted in line with the relevant guidelines in terms of the timescale for holding the case conference. However, they reflected that it may have been prudent to postpone to a later date given the complexities surrounding it. Notwithstanding this, we concluded that the SPS acted reasonably, in what were unprecedented circumstances. We did not uphold this aspect of C's complaint.

Summary

C complained about the care and treatment provided to their late parent (A) when they were admitted to hospital for investigations of lung cancer. A had an out-patient appointment for a CT scan, however, the day before this appointment, A was admitted to hospital due to increased haemoptysis (coughing up of blood). There was a delay in performing the CT scan due to miscommunication between the clinical team and radiology, which the board have acknowledged. When A was taken for the scan, they suffered a massive haemoptysis and a subsequent cardiac arrest and died.

C complained about the communication failures which led to a delay in arranging the CT scan and that insufficient efforts were made to resuscitate A. To investigate C's complaint, we reviewed the clinical records and sought independent advice from a consultant radiologist (a specialist in the analysis of images of the body).

Our investigation found that while there were communication failures in arranging A's CT scan on an in-patient basis, we did not consider the delay caused to be unreasonable as A's condition was stable and there were no further episodes of haemoptysis. We did however, uphold the complaint on the basis that there were communication failings. We made no recommendations due to action already taken by the board.

Our investigation also found that reasonable attempts were made at resuscitation when A suffered the cardiac arrest. We did not uphold this aspect of the complaint.

Summary

C and B complained about the care and treatment that their adult child (A) received from the practice. A had sought advice and treatment for a lack of energy, loss of libido and difficulty gaining weight. They were referred to the metabolic unit in hospital and, subsequently, to an adult eating disorders service. A had been diagnosed with a hormonal deficiency and a number of potential causes for their symptoms were considered. However, A and their family were concerned about the practice's clinical management of A's condition and the lack of a clear diagnosis or effective treatment plan.

A subsequently completed suicide. Following a meeting and written correspondence with the practice, C and B remained dissatisfied with a number of aspects of the treatment A received.

We took independent advice from a GP. A's case was complex and whilst with hindsight it was clear that A had an underlying mental health condition, a physical cause for their symptoms could not be ruled out. We were satisfied that the practice arranged numerous tests and investigations to explore a physical cause of A's symptoms. Additional tests were carried out by third parties and we found that the practice appropriately reviewed these and communicated clearly with A as to the results, their significance and the next steps in terms of finding a clear diagnosis.

We found that the practice considered at an early stage that there may have been a mental health element to A's condition. However, A was not keen to pursue this. We were satisfied that it would have been inappropriate in the circumstances for the practice to push further investigations into A's mental health. We were also satisfied that the practice communicated well with secondary care specialists and managed A's overall diagnostic pathway reasonably. Therefore, we did not uphold these aspects of C and B's complaint.

However, we were critical of the practice's communication with C and B. It was A's clear intention that they be included in conversations regarding their health. Although the practice were not able to communicate via C and B's preferred medium, they did not take reasonable steps to ensure clear communication between all parties and the communication broke down as a result. We also found that the practice failed to instigate an internal review following A's death and, having completed a review following C and B's complaint, they failed to provide them with a copy of their findings. Therefore, we upheld these aspects of C and B's complaint. We did not make any recommendations due to the appropriate action already taken by the practice.

Summary

C complained that the practice had failed to provide the correct prescription for their child (A). A had been diagnosed with type 1 diabetes and had been self-administering their medication with no issue. C said that this had changed and A found injections very painful. This had caused both A and the family significant distress. C said that the practice had prescribed the wrong type of needle and that this was not the type of needle specified by the hospital.

We took independent medical advice. We found that the practice had reasonably relied on their prescribing software. This was in line with both hospital and pharmacy requirements. The software had substituted a different product, and it was reasonable for this to have been prescribed. Additionally, the practice had responded timeously to C when they reported the problems A was having. Therefore, we did not uphold this aspect of C's complaint.

C also complained that the practice had failed to provide an adequate supply of needles.

The practice had accepted that A was not provided with the correct number of needles. They did not accept that they had not responded to C's requests for assistance timeously. We found that it was clear that C had not been prescribed the correct amount of needles and that it would be appropriate for the practice to reflect on this error, to improve future practice. Therefore, we upheld this aspect of C's complaint.

We noted that the practice had already committed to reviewing A and C's case through a Significant Event Analysis (SEA) and we asked them to provide us with a copy of their findings, as well as feeding them back to the board. We did not make any further recommendations.