Some upheld, recommendations

Summary

C adopted a young child (A), however, the placement ended when C relinquished care via Section 25 of the Children (Scotland) Act 1995 due to irreconcilable behavioural difficulties and a breakdown in the relationship. A was placed in the care of the council.

C complained that the council unreasonably failed to produce balanced and accurate assessments in relation to child protection concerns and the breakdown of the adoption, and did not reasonably amend these reports when these matters were raised. C also complained that the council unreasonably failed to involve C in ongoing care planning considerations regarding A. Lastly, C complained that the council unreasonably failed to facilitate and enable contact between C and A following the invocation of the section 25 agreement.

We took independent advice from a social worker adviser. We found that while it is an essential requirement that any reports be balanced and accurate, the council had failed to give a complete picture of the history of A’s early life, to reflect the positive aspects of C’s parenting, and to reflect the views of other agencies who had provided support to the family. Overall, the reports were of mixed quality and contained inaccuracies. We upheld this aspect of the complaint.

We also found that there had been failings in information sharing and case transfer between the council and C’s previous local authority. We also found a lack of formalised adoption support. Significantly, a referral had not been made to the Scottish Children’s Reporter Administration following the adoption breakdown, and there were failings to involve C in ongoing care planning. We upheld this aspect of the complaint.

Lastly, we found that while continued attempts had been made to encourage contact, at the time of writing A, who had advocacy support, did not want to engage with C. The actions of the council were reasonable in this regard and we did not uphold this aspect of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failings identified in this decision. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/meaningful-apologies.

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

• When making decisions regarding the care and welfare of children, the council should ensure that reports are balanced, accurate, include all relevant information and reflect the evidence and discussions that have taken place. Clear reasoning should be recorded for any decisions made. When writing reports that may allow for cutting and pasting as the information is the same, they should always be checked to ensure that all aspects are up to date and accurate.

In relation to complaints handling, we recommended:

• There should always be a case transfer meeting when a case involving the adoption of a child moves from one local authority to another and a formalised system of transfer should be in place. Where there is disagreement on the care plan, a referral to the Reporter allows for this to be considered by a neutral authority and should be appropriately considered. If a parent has specifically requested this, it is their right to have that followed through and they should be advised that they can do this directly. An Unplanned Ending meeting should follow the terms of the Adoption and Children (Scotland) Act 2007 so it is clear what an adoptive parent should expect in the adoption process and what is the role of the relevant local authority. Where there has been disruption, an Unplanned Ending meeting should look at the whether the matching process was adequate and identify areas to learn from.

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 provided by the board to their late parent (A). Additionally, C complained about the nursing care that A received and the boards handling of C's complaint.

We took independent advice from a consultant geriatrician and a senior nurse.

We found the care and treatment of A to be reasonable. We did not uphold the complaint. In relation to nursing care and treatment, we found unreasonable care in a number of areas including but not limited to, failures in wound care, a delay in administering pain relief, shortcomings in the documentation of cannulation attempts, inaccuracies in key nursing documentation, errors in medication administration and inaccuracies in fluid balance.

While communication with C was compassionate and the timeframes were reasonable, the board’s investigation did not fully identify or address several significant failings in A’s care, resulting in an incomplete and unreasonable response to C’s complaint. We upheld this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failings we identified in nursing care and complaint handling. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/meaningful-apologies.

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

• The board should complete a Datix incident report (if not already completed) and identify appropriate learning action.

In relation to complaints handling, we recommended:

• Complaint investigations should be managed in accordance with the Model Complaints Handling Procedure. The complaint investigation should fully identify and address failings relevant to the 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 complained on behalf of their child (A) who was a patient of the practice. A's care was disrupted by COVID-19 and they were not seen by the practice for four years. C complained that the practice unreasonably charged them for white fillings after there was a delay in A being seen for routine check ups and the care could have been provided at a time when it would have been free of charge. C also complained that the practice failed to reasonably respond to C's complaint.

We took independent advice from dental adviser. We found that the decision to charge for the care and treatment provided was reasonable. It was not possible to evidence whether appointments had been sought prior to their appointment, and the decision to charge for the treatment provided was reasonable. Therefore the complaint was not upheld.

We found that while the content of the practice's complaint response was reasonable, there were significant delays in the practice providing a response and there were a number of times when C requested to escalate their complaint and this was not actioned, which we found unreasonable. Therefore, we upheld this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the delay in responding to the complaint. The apology should meet the standards set out in the SPSO guidelines on apology available HYPERLINK "http://www.spso.org.uk/meaningful-apologies" http://www.spso.org.uk/meaningful-apologies .

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 of their adult child (A) following A’s admission to hospital. A had a long standing, complex medical history including two kidney transplants and kidney cancer, and A died during their admission. In particular, C complained about A being prescribed Dapsone for a skin infection without discussion with A’s Renal Consultant and also that the Respiratory Team did not review A in the days prior to A’s death. C also complained that the board had failed to communicate in a reasonable way, in that critical information relating to A’s care had not been passed on between clinical teams or shared with the family.

The board said that A’s renal disease did not contraindicate Dapsone which was frequently used following renal transplantation. The progressive respiratory reaction which A suffered would be a very rare side effect. The board said that Dapsone was appropriately discussed with A and prescribed, with no known lung or kidney-related risks in standard guidance. The Renal Consultant was informed and raised no concerns. The board acknowledged that the communication between clinical teams as documented in the medical records was open to interpretation and that this aspect of the complaint could have been better addressed in the formal complaint response.

We took independent advice from a Renal Consultant and a Respiratory Consultant. We found that the clinical care and treatment was reasonable, and in keeping with normal practice. There was no requirement to seek advice from A’s Renal Consultant about the prescription, but they were aware of it and had no concerns. The side effect that A experienced is extremely rare such that the effect and outcome could not have been foreseen. We found that the Respiratory Team were appropriately involved where required and that the care provided was reasonable. We did not uphold this complaint.

However, we found that the board had failed to communicate in a reasonable way and that communication fell short of a reasonable standard in relation to the involvement of the Respiratory Team. We also found that there were complaint handling failings. We upheld this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to A’s family for the failings in communication. The apology should meet the standards set out in the SPSO guidelines on apology available at HYPERLINK "http://www.spso.org.uk/meaningful-apologies" www.spso.org.uk/meaningful-apologies .

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

• Clinicians should clearly and consistently communicate to patients and their families, as appropriate, the roles of different teams and relevant clinicians involved. If staff agree to arrange review from another team this should be followed up to ensure it happens, or an explanation given as to why this is not necessary.
• Where an adverse drug reaction causes or contributes to a death, this should be reported to COPFS in line with their guidance.
• Serious adverse medicine reactions should be reported in line with the Yellow Card Scheme guidance.

In relation to complaints handling, we recommended:

• Where failings are clear from the evidence available, organisations should openly acknowledge and apologise for these. The board should ensure that complaint responses are accurate and based on the available evidence and relevant guidance. We offer SPSO accredited Complaints Handling training. Details and registration forms for our online self-guided Good Complaints Handling course (Stage 1) and our online trainer-led Complaints Investigation Skills course (Stage 2) are available at https://www.spso.org.uk/training-courses.

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 provided to their parent (A). A had dementia and had suffered several falls. C complained that the board failed to reasonably investigate A’s fall and that they failed to reasonably consider carrying out a Significant Adverse Event Review (SAER).

We took independent advice from a consultant geriatrician (a doctor specialising in medical care for the elderly) and a registered nurse. We found that the board should have identified ambiguous and confusing language was used to describe A’s fall in its investigation. It should also have established that the fall was unwitnessed. We upheld this complaint.

In relation to a SAER, the board were able to demonstrate that they had followed the guidelines in place at the time for determining if an SAER was required. In the period following the incident, local guidelines governing the holding of an SAER were superseded by national ones. We did not uphold this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C and their family for failing to provide a clear explanation about A’s fall at the time, or in the subsequent complaint investigation. The apology should meet the standards set out in the SPSO guidelines on apology available at HYPERLINK "http://www.spso.org.uk/meaningful-apologies" www.spso.org.uk/meaningful-apologies .

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, an independent advocate, complained on behalf of B, about the standard of medical and nursing care provided to B’s late spouse (A) by the board following a liver cancer diagnosis.

B complained about A’s diagnosis, noting that A was initially seen to have one lesion and to be suitable for a liver transplant, however, three months later multiple lesions were found and A was no longer seen as a viable candidate. B also complained of subsequent delays in cancer treatment and that the nursing care provided to A was below a reasonable standard, including failures to prevent an unwitnessed fall.

B said that communication from clinicians regarding A’s diagnosis, prognosis and treatment was lacking detail and infrequent, and that the board’s stage two complaints response was inaccurate.

We took independent advice from a consultant hepatologist (specialist in diseases of theliver, gall bladder, bile ducts and pancreas) and a registered nurse adviser. We found that A’s diagnosis and treatment were reasonable and did not consider that multiple lesions had been unreasonably missed initially. We did not uphold this aspect of the complaint.

However, we found that there had been failings with respect to communication, particularly when A’s care was transferred to a specialist transplant unit outwith the board. We also found that the nursing care provided was unreasonable, including failings to record comfort, pain, and personal care, and in relation to delirium, falls prevention and risk assessments. Lastly, we noted inaccuracies in the complaints responses provided to B. As such, we upheld these aspects of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to B for the failings identified. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/meaningful-apologies.

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

• Patients (and where appropriate their family / carers) should be kept fully informed in a timely manner about their diagnosis, prognosis, and treatment.
• Patients who are admitted to hospital should have appropriate risk assessments carried out.

In relation to complaints handling, we recommended:

• Complaints should be investigated and responded to in accordance with the board’s complaint handling procedure and the NHS Model Complaints Handling Procedure. Complaint responses should be accurate, clear, and supported by the relevant evidence. We offer SPSO accredited Complaints Handling training. Details and registration forms for our online self-guided Good Complaints Handling course (Stage 1) and our online trainer-led Complaints Investigation Skills course (Stage 2) are available at HYPERLINK "https://www.spso.org.uk/training-courses" https://www.spso.org.uk/training-courses .

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 provided by the board during a planned caesarean section. C said that complications occurred during the procedure which could have been avoided based on information available from antenatal scans. C also complained about the timing of the procedure, record keeping, delays in arranging a debrief meeting, postnatal care for high blood pressure and infection, and the board’s handling of the complaint.

We took independent advice from a midwifery adviser. We found that the care C received during the caesarean section was of a reasonable standard. It was reasonable to schedule C last on the theatre list due to an active COVID-19 infection, and there were no clinical indicators requiring enhanced planning. While complications occurred, we found that these were reasonably managed. We found that offering C the option of vaginal birth reflected good practice. We did not uphold this complaint.

In relation to C’s post-natal care, we found that the monitoring and management of blood pressure, infection treatment, and follow-up care were appropriate and in line with clinical guidance, and the medical records were accurate. We did not uphold this complaint.

We considered C’s complaint about the board’s handling of their complaint. We found that the board acted unreasonably by refusing to investigate on the grounds of time limits, despite the delay being due to a postponed debrief meeting and reassurances given that a complaint could still be made. The board did not provide a clear explanation for refusing to extend the timescale, contrary to complaint handling guidance. We upheld this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failings identified in this report. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/meaningful-apologies.

In relation to complaints handling, we recommended:

• Complaint investigations should be managed inaccordance with the Model Complaint Handling Procedure. The board should ensure that their complaints handling complies with the SPSO Statement of Complaints Handling Principles| SPSO. We offer SPSO accreditedComplaints Handling training. Details and registration forms for our onlineself-guided Good Complaints Handling course (Stage 1) and our onlinetrainer-led Complaints Investigation Skills course (Stage 2) are available athttps://www.spso.org.uk/training-courses.

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 provided to their late spouse (A) during their admission to hospital. A was admitted with symptoms suggestive of a stroke and significantly elevated blood pressure. Initial CT imaging and angiography (a type of x-ray used to check blood vessels) were inconclusive, and possible diagnoses included stroke, hypertensive encephalopathy (brain dysfunction caused by severely elevated blood pressure), or a post-ictal state (following a seizure). An MRI scan was planned but aborted for safety reasons. A’s condition later deteriorated, and a repeat CT scan showed stroke in the back of the brain. A died a day after admission.

We took independent advice from a consultant stroke physician. We found that there were aspects of A’s care which were reasonable, including prompt assessment, appropriate imaging, decisions made regarding treatment of blood clots, and MRI scanning and safety. We found that it was also reasonable to consider and treat hypertensive encephalopathy. However, we found that record-keeping fell below the expected standard. In particular, there was a failure to keep contemporaneous records on the day that A was admitted as there was no repeat National Institutes of Health Stroke Scale score noted after the initial CT scan. There was also inconsistent recording of staff grades, which reduced clarity regarding levels of clinical oversight. This added to uncertainty about the diagnosis, but it did not affect A’s outcome. We upheld this part of C's complaint.

C complained about the board's communication with A and their family during the admission. We found that that the board reasonably explained the working diagnosis, management plan and diagnostic uncertainty. Where miscommunication occurred, the board acknowledged this and apologised. Overall, we found that communication was reasonable and did not uphold this part of C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failings identified in this report. 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:

• Medical records should be comprehensive and completed in line with professional standards.

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 on behalf of their partner (A) about the care and treatment that A received from the board during their two admissions to hospital for suspected pulmonary embolus (when a blood clot blocks a blood vessel in the lungs). A had a stroke during their second admission.

We took independent advice from a consultant in general medicine. For A’s first admission, we found that the triage nurse who took A’s bloods, clearly documented that a D-Dimer (a test to detect blood clots) had been done and the results were available on the board’s system before A was discharged but it was not noted or considered. We found that A’s D-Dimer result should have been considered and doing so could have led to an earlier diagnosis of A’s pulmonary embolus. We found this aspect of A’s care unreasonable and we upheld this aspect of the complaint.

For A’s second admission, we found that the treatment of A’s blood clots with medication appeared to be in accordance with relevant guidance which was reasonable. We did not uphold this aspect of the complaint.

We noted that the board advised C in their complaint response that they would take A’s case forward to their adverse events review group for further consideration and that 16 months later, there had been no indication that a significant adverse events review had taken place, which appeared unreasonable. In addition, we found that in their complaint response, the board should have provided C with an explanation of what happened when A was readmitted to hospital, and the nature of A’s stroke, as well as more detailed description of when the adverse events review group’s decision would be made and if this would be communicated to C.

Recommendations

What we asked the organisation to do in this case:

• For the board’s staff in the CAU to read notes made by triage staff when patients are passed on to them.
• The board should carry out SAERs in a timely manner.

In relation to complaints handling, we recommended:

• For the board to provide C with a written explanation of what happened when A was readmitted and the nature of A’s stroke. For staff to address all aspects of a complaint in the complaint response. For the board to obtain statements from key staff during their investigations. We offer SPSO accredited Complaints Handling training. Details and registration forms for our online self-guided Good Complaints Handling course (Stage 1) and our online trainer-led Complaints Investigation Skills course (Stage 2) are available at https://www.spso.org.uk/training-courses

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 on behalf of their spouse (A). The first of C’s complaints was that the board had failed to reasonably and accurately record and report an alleged incident between A and a member of staff. They also complained about the board’s investigation, and future references in records to the incident. We identified a number of failings including that the incident referred to was not reliably recorded on the board’s incident reporting system, that the board did not properly investigate C’s concerns, and that medical record correction notices issued were inaccurate and inconsistent. We upheld the complaint.

C also complained about the care and treatment that A had received. We took independent advice from a psychiatrist. We found that the care and treatment was of a reasonable standard. We did not uphold this aspect of C’s complaint.

Finally, C complained about the board’s handling of their complaints. While acknowledging that the complaints were numerous and complicated, we were of the view that the board could have taken action at an earlier point to define the complaints. They also could have investigated to a higher standard and responded more promptly. We therefore upheld this aspect of C’s complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C and A for their failings in relation to recording and reporting of, future references to, and investigation into, the alleged incident; and for failings in relation to complaint handling. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/meaningful-apologies.
• Place a new medical record correction notice in A’s records that accurately identifies the incorrect entries and corrects these.

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

• Where a patient raises concerns about accuracy of medical records, this should be properly investigated and responded to.

In relation to complaints handling, we recommended:

• Complaints should be responded to timeously and investigations should accurately identity failings.

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.