Some upheld, no recommendations

Summary

Mr C, a patient advocate, complained on behalf of his client (Mrs B) about Western Isles Hospital. Mrs B was unhappy with the care provided to her mother (Mrs A) who was admitted to the hospital and received treatment for sepsis (a blood infection). Mrs A's condition significantly deteriorated in the weeks following admission. She was then transferred to a hospital in Glasgow, where she died from her illness.

In response to the complaint, the board identified learning and improvement in relation to communication and nursing monitoring records.

Mr C complained about the care and treatment provided to Mrs A during the admission and that there was a delay in transferring her when her condition deteriorated.

We took independent advice from a consultant orthopaedic surgeon (specialist in the treatment ofdiseases and injuries of the musculoskeletal system) and from a registered nurse. We found that medical staff managed Mrs A's condition in a reasonable manner. In particular, there were regular reviews, reasonable investigations were arranged and treatment was responsive to her condition. We did not identify any delay in the board transferring Mrs A when her condition deteriorated. We also found that the nursing care provided was reasonable. We noted that there was evidence of appropriate care planning, monitoring and interventions. We did not uphold these aspects of the complaint.

Finally, Mr C complained that the board did not communicate reasonably with Mrs B about Mrs A's care. The board upheld this complaint and outlined improvement work. We were satisfied that the board had taken appropriate action. We upheld this complaint but made no recommendations.

Summary

Mr and Mrs C complained about the care and treatment their children (Child A and Child B) received at Royal Alexandra Hospital following their birth. They also complained about the level of communication with them about Child A and Child B's care and treatment.

We took independent advice from a paediatrician. We found that, overall, the care and treatment Child A and Child B received had been reasonable and we did not uphold these aspect's of Mr and Mrs C's complaint.

However, the board accepted that there had been failings in communication regarding some of the problems Child A and Child B had faced following their birth. We also found that there was a lack of documentation about the communication with Mr and Mrs C about Child A and Child B's care and we raised this with the board. We upheld these aspects of Mr and Mrs C's complaint but noted that the board had already apologised for these failings so made no further recommendations.

Summary

Mr C complained to the council after they restricted his access to council properties following allegations of aggressive behaviour towards staff. He considered these accusations were unreasonable, and that the decision to ban him from properties was disproportionate. Mr C also complained about a delay in the council's response to his request to appeal the decision.

We found that the council had sufficient evidence that staff had felt intimidated by Mr C's behaviour to enact restrictions to his contact. We also found that they had reasonably put in place a point of contact through which Mr C could arrange access to facilities by prior appointment. We considered that the council had acted reasonably and within their discretion in making these decisions. Therefore, we did not uphold these aspects of Mr C's complaint.

In response to Mr C's complaint to them, the council had accepted that the delay he had experienced was unreasonable, provided an explanation for the causes of this, committed to ensuring this did not happen in future and apologised. Given this, we upheld Mr C's complaint about delays, but did not consider any recommendations were required.

Summary

Mr C, an advocate, complained on behalf of his client (Mrs B) about the care and treatment provided to Mrs B's daughter (Ms A) by the partnership. Ms A was referred to the partnership after she was considered to have experienced an episode of psychosis (a mental health problem that causes people to perceive or interpret things differently from those around them).

Mr C complained that the mental health team had failed to provide Ms A with reasonable care and treatment in response to physical symptoms she was experiencing. He complained that there was a failure to communicate appropriately with Ms A's GP and with her parents. Mr C also complained that the mental health team inappropriately had meetings with Ms A in public settings.

We took independent advice from a consultant psychiatrist and from a mental health nurse. We found that Ms A's care and treatment was reasonable in relation to her physical symptoms and we did not uphold this aspect of the complaint.

We found that there was an unreasonable gap in updating Ms A's GP, which the partnership had already acknowledged and apologised for. We upheld this aspect of the complaint and we asked for evidence of the actions carried out by the partnership in response to this.

We found that the communication with Ms A's parents was reasonable. We found that there were occasions where meetings were offered to Ms A's parents, which were not arranged. However, we did not find evidence that this affected Ms A's care and treatment so we did not uphold this aspect of the complaint.

We found that it was reasonable that the mental health team had meetings with Ms A in public settings as this was at her request and consideration was given to maintaining her confidentiality. We did not uphold this aspect of the complaint.

Summary

Ms C complained about the care and treatment her late mother (Ms A) had received at Glasgow Royal Infirmary. Ms A had been admitted to the hospital after taking a mixed overdose, including opiate-based painkilling medication. She was given naloxone (a drug that can reverse the effects of opioids). On the following morning, Ms A had a respiratory arrest and was transferred to the high-dependency unit, where her naloxone was increased. She was reviewed by the liaison psychiatry department several days later and was discharged home.

We took independent advice from a consultant psychiatrist. We found that, although the hospital had delayed in issuing the final discharge letter, the care and treatment provided to Ms A had been reasonable. We did not uphold this aspect of the complaint.

Ms C also complained that the board's communication with her family had been unreasonable. We found that there was a lack of consistency in Ms A's records in relation to communication with her family. It was not recorded who was present, who had a discussion with the family or what was discussed. We found that this was unreasonable and we upheld this complaint.

Ms C further complained that the board had provided inaccurate information to her about their review of Ms A's treatment. We did not consider that the response from the board to Ms C had been inaccurate or that that it misinformed her. We did not uphold this aspect of the complaint.

Finally, Ms C complained that the board's response to her complaint had been unreasonable. After the board had issued their initial response to Ms C's complaint, an MSP wrote to them again on behalf of Ms C. In response to this, the board agreed that a further review by a clinician in a separate part of the board would be carried out. However, they delayed in informing Ms C of this and in then carrying out the further review. In view of this, we also upheld this aspect of Ms C's complaint.

The board said they had taken action to address these failings, so we asked for evidence of this, but made no further recommendations.

Summary

Ms C attended Perth Royal Infirmary where she was treated for a suspected stroke. Her condition improved but she was found to have sustained brain damage, leaving her with ongoing communication difficulties. Ms C complained that her symptoms were misread, and that she was misdiagnosed and mistreated for a stroke. She considered that the treatment (thrombolysis injection to dissolve a suspected clot) contributed to her brain injury and resulting speech difficulties.

We took independent advice from a consultant geriatrician (a specialist in medicine of the elderly). We considered that Ms C's symptoms, together with CT scan findings, supported the diagnosis of a stroke. We found that the treatment given was appropriate to the findings, and did not cause any direct side effects. Therefore, we did not uphold this aspect of Ms C's complaint.

Ms C also complained about a delay in responding to her complaint, and errors and inconsistencies in the response. The board had acknowledged that the response was delayed and apologised to Ms C. They told us that they had reminded staff of the need to ensure complainants are provided with updates if deadlines are not going to be met. We recognised the complexity of the complaint contributed to the delay and, on balance, considered that the response was reasonable and proportionate. However, we did not consider that the board fully explained the reasons for the delay to Ms C and found that they did not agree a revised target timescale as they are required to do. For this reason, we upheld this aspect of Ms C's complaint but made no further recommendations.

Summary

Mrs C complained that the council had failed to provide accurate information for couples seeking to adopt and that they unreasonably prevented her from progressing her adoption application. Mrs C said that she had not been clearly informed that her weight would be an issue, or how much weight she needed to lose in order to progress. Mrs C also felt that the process was unfair as it relied on Body Mass Index (a measure for estimating human body fat) which she felt was not an accurate measure of her health.

We found that the council had provided appropriate information to Mrs C in relation to weight and adoption. We also found that the council had appropriately followed medical advice and had not unreasonably prevented Mrs C from progressing her adoption assessment. Therefore, we did not uphold these aspects of Mrs C's complaint.

In relation to complaint handling, we found that the council had not handled Mrs C's complaint reasonably. Therefore, we upheld this aspect of Mrs C's complaint. We noted that the council had recognised and apologised for this failing and we made no further recommendations.

Summary

Mrs C complained to the partnership about decisions made by her father's power of attorney (POA, a legal document appointing someone to act or make decisions for another person). Mrs C said that the partnership should have reconsidered the appropriateness of the POA given the nature of the concerns raised. Mrs C also complained about the partnership's investigation of her concerns about an advocacy worker and how they handled her complaint.

We took independent advice from a social worker. We found that an authority would only be required to take action against a POA if they believe the adult was at risk. We received sufficient evidence to demonstrate the partnership considered the concerns raised and we considered that the partnership's decision to take no further action was reasonable. We also found that the partnership's investigation of the complaint about the advocacy worker was thoroughly investigated. We did not uphold these aspects of Mrs C's complaint.

In relation to the handling of Mrs C's complaint, we noted that the partnership acknowledged that they did not respond to Mrs C's complaints within the required timescale and apologised for this. Therefore, we upheld this aspect of Mrs C's complaint but made no further recommendations.

Summary

Mr C complained about the support provided to him by the partnership following his release on licence from prison. Mr C also complained about the content of a report that the partnership submitted to the Parole Board recommending his recall to prison.

We took independent advice from a social worker. We did not find evidence that the partnership's decision-making or the support provided to Mr C was unreasonable. We did not uphold these aspects of Mr C's complaint.

Mr C also complained about the way that the partnership handled his complaints. We found that the partnership did not provide a response to two of Mr C's complaints, specifically that no response was provided to an email about Mr C's complaint and that the partnership did not keep Mr C updated about the reason for the delay in responding to his complaints or provide a revised timescale for when he could expect to receive a response. We upheld this aspect of Mr C's complaint.

Recommendations

What we asked the organisation to do in this case:

Apologise to Mr C for failing to respond to an email about his complaint and for failing to keep him updated about the reason for the delay in responding to his complaints and provide revised timescales for completion. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/leaflets-and-guidance.

In relation to complaints handling, we recommended:

Emails from complainants should be responded to appropriately. Where an extension to complaint response timescales is necessary, this should be agreed with the complainant and they should be provided with a new timescale for when they can expect a response. This is in accordance with the Social Work Model Complaints Handling Procedure.

Summary

Miss C complained on behalf of her brother (Mr A) about the care and treatment he received while he was a day patient at a psychiatric hospital. Miss C complained that the hospital wrongly decided to not detain Mr A under the Mental Health (Care and Treatment) Act (Scotland) 2003 (MHA) and that they failed to appropriately supervise him. Miss C also complained that the board unreasonably delayed in responding to her complaint.

As part of their investigation of Miss C's complaint, the board carried out a Significant Adverse Event Review (SAER). The SAER concluded that Mr A did not meet the legal criteria for detention under the MHA as he was capable of making decisions, he consented to treatment, and they were satisfied that Mr A was under the usual levels of supervision. The board acknowledged there was a delay in completing the SAER and subsequently in providing the final response to the complaint. Miss C was unhappy with this response and brought her complaint to us.

We took independent psychiatric advice. We found that it was appropriate that Mr A was not detained under the MHA as he did not meet the legal criteria. We also found that appropriate assessments were carried out on Mr A's mental health and that he received an appropriate level of supervision. We did not uphold this aspect of Miss C's complaint.

In relation to complaint handling, we concluded that the board unreasonably delayed in responding to Miss C's complaint due to the delay in completing the SAER. Therefore we upheld this aspect of Miss C's complaint. The board have acknowledged this failing and have taken action to address this.