Some upheld, recommendations

Summary

C complained that the partnership failed to handle their application for their child (A)'s placement at a residential facility reasonably. A has a genetic condition, mental health issues and significant learning disabilities. A had identified a residential placement for individuals with their condition. C applied for a place supported by A’s social worker and medical professionals. The decision on the placement was taken by the Strategic Resource Allocation Group (SCRAG). The SCRAG met to discuss and declined the placement on the basis that A could explore support closer to home, in keeping with the national ‘Coming Home’ agenda.

C believed that there had been a second SCRAG meeting that also rejected the application but that no minute was available for it. C said that the SCRAG had not given due consideration to the medical and other supporting evidence.

We took independent advice from a social worker. We found that the SCRAG had followed procedure and considered all the evidence submitted. The Ombudsman does not act as an appeal body for SCRAG decisions and so our investigation looked at whether procedures had been properly followed. We noted that the second meeting was not a SCRAG meeting but a meeting in response to the placement decision, which had asked social workers to explore support options for A further.

We found that the SCRAG was conducted in line with its terms of reference and the decision was one it was entitled to make. Therefore, we did not uphold this part of C's complaint. However, it should have been made clearer to the family what the SCRAG process involved and that the decision from the first meeting was final.

C also complained that the partnership failed to follow the Child Friendly Complaints Process reasonably. We found that A was capable of understanding and being involved in the complaint process. The partnership failed to comply with its legal duty to involve A in the complaints process and give them the opportunity to express their views. The partnership did not seek A’s informed consent for the complaint to proceed or establish what was in A’s best interests. We upheld this part of C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to A for failing to engage with them about the complaint or obtain their consent to take the complaint forward. 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 Child Friendly Complaints Handling Process must be considered as part of the parternship’s investigation into complaints. All organisations under our jurisdiction have a legal duty to comply with this in all cases, and our Child Friendly Complaints Handling Process Guidance, which provides additional practical tools for meeting the Principles.

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, a council tenant, complained that the council had failed to replace their kitchen, which was outdated and in a state of disrepair, and their windows, which were aluminium framed, did not have working vents, and as such were promoting the growth of mould. C gave up the tenancy due to concerns about the condition of the property, the potential health impact, and their frustrations with the delays. C complained that the council remedied both longstanding issues very shortly after, to allow the property to be re-let. C also complained that the council’s complaints response was inaccurate.

The council had stated that C’s kitchen was due to be replaced, however, that there had been a backlog due in part to the pause in all but essential works during the pandemic. They said that when C moved out the kitchen was replaced by a team whose role was to prepare tenancies to be re-let, who had a different caseload and worked to different timescales. The council stated that C’s windows had been replaced as part of a broader programme of window and door replacements. They said that this had been communicated to C earlier in the year, and that the work had not been brought forward because the tenancy had been vacated.

We found that a referral had been made for a new kitchen to be installed approximately a year prior to C moving out. It was also evident that the council had engaged with C regarding the condition of the windows, and that they had instructed a contractor to survey the windows and to make minor repairs. It was communicated to C on a number of occasions that the windows were due to be replaced and a survey had been carried out in preparation. It was also apparent that C’s property had been prioritised as part of the scheme. As the council had taken steps to investigate these issues and make the necessary referrals and preparations, acknowledging the impact of COVID-19 and the council’s discretion with respect to planning large scale works, overall, we did not consider there to be evidence of maladministration or service failure and C’s complaint was not upheld.

However, we did find evidence of a number of inaccuracies in the council’s complaints responses to C and therefore did not consider the council’s complaints handling to have been in line with the Model Complaints Handling Procedure. As such we upheld this part of C’s complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C 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.

In relation to complaints handling, we recommended:

• Complaints responses should be accurate, objective and proportionate, in line with the Model Complaints Handling Procedure.

Summary

C complained to the council about a number of aspects of the council’s handling of a planning application for development on a site opposite C’s home, including that the Report of Handling was not reasonable as it did not reference any assessment of how waste would be managed and stored on the site. The council told C that the specific materials that they had mentioned, manure and old bedding, their storage and management, had not been addressed in the Report as they were not part of the application.

We took independent advice from a planning adviser. We found that the contents of the planning application meant that the council were entitled to take the view that their policy on waste management requirements for new development were not determinative in this instance and that not explicitly mentioning this in the Report did not make it unreasonable. We did not uphold the complaint.

C also complained about various aspects of the council’s response to their complaints. In some cases, we found that the council provided responses which were not reasonable,including responses that were not clear and did not include reasonable explanations, responses that raised uncertainty about planning matters, a response that had been incorrect, not responding to clear concerns C had raised and not confirming whether they considered specific planning conditions had been met. We upheld the complaint that the council did not respond reasonably to C’s complaints.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C that they did not respond reasonably to C’s complaint. 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:

• The council respond reasonably to complaints.

Summary

C complained about the care and treatment that the board provided to their elderly parent (A). A was an active and independent adult who tripped in the community and was admitted to hospital. In hospital, A developed a grade 4 (most severe) sacral (lower back) pressure sore. The board treated A’s pressure sore using Negative Pressure Wound Therapy (NPWT). A deteriorated while in hospital and died approximately twenty weeks after they were admitted.

C raised concerns about the medical and nursing care that the board provided to A. In particular, C was concerned about how the board handled A’s deterioration in hospital, that there were missed opportunities to discharge A from hospital and A’s end of life care.

The board said that A’s mobility was limited due to pain after admission and that there were no missed opportunities to discharge A. The board apologised for delays in obtaining pressure-relieving equipment for A and that discussions with A regarding the commencement of NPWT were not fully recorded. The board shared an improvement plan regarding the care of pressure sores.

We took independent advice from a consultant geriatrician (medicine of the elderly) and a registered nurse. We found that the medical care provided to A was reasonable. We did not uphold this point of C’s complaint. We found that A’s pressure sore was avoidable. We also found that the board failed to provide reasonable nursing care and treatment to A, failed to reasonably assess and treat A’s wounds, failed to reasonably use NPWT in A’s case and failed to complete a significant adverse event review and follow duty of candour procedures in response to A’s avoidable pressure sore. Therefore, we upheld this point of C’s complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failures in nursing care identified in this investigation. 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:

• Negative Pressure Wound Therapy should only be applied where appropriate and in accordance with manufacturers guidance, board policy and Health Improvement Scotland Guidance.
• Where failings occur, they should be acknowledged and appropriate action should be taken in line with relevant legislation, policies and procedures (particularly duty of candour and adverse event policy).
• Nursing staff should make sure patient’s physical needs are assessed and responded to.
• Patients should receive appropriate and timely wound care in line with the patient’s presentation. In particular:
• Assessments should be completed holistically and on a timely basis, including any required referrals, and should appropriately document the progression/deterioration of a wound;
• Treatment of the would should be appropriate using the correct products for the type of wound; and
• Patients should receive appropriate treatment for pressure damage in line with relevant guidance.

In relation to complaints handling, we recommended:

• Cases involving a death, the circumstances of which are the subject of concern to, or complaint by, the nearest relatives of the deceased about the medical treatment given to the deceased with a suggestion that the medical treatment may have contributed to the death of the patient should be referred to the Procurator Fiscal, in accordance with relevant guidance.

Summary

C complained on behalf of their client (B) about the care provided to B's late parent (A) during their admissions to hospital. A was admitted and discharged from the hospital. A was readmitted a few days later following a fall at their home. A suffered significant injury including spinal and sacral fractures. A remained in hospital for treatment but died a few weeks later. C's concerns related to the clinical and nursing care provided to A during their admissions, particularly in relation to the assessment of A’s cognitive function and capacity, their falls risk, and overall assessments carried out with respect to their condition and deterioration.

In response to the complaint, the board acknowledged that protocols on completion of falls and bed rail risk assessments were not followed and that in the day prior to A’s death, guidance on the timeliness and extent of observations which should have been carried out were not followed, and that the care fell below the expected standard. The board confirmed that appropriate documentation with respect to the assessment of A’s capacity was completed during their admission. C was dissatisfied with the board’s response.

We took independent advice from a consultant geriatrician and a registered nurse. With respect to A’s clinical care, we found that documentation used to assess A’s capacity was not completed to a reasonable standard and we upheld this complaint. We found that the clinical treatment of A during the two days immediately prior to their death was reasonable and we did not uphold this aspect of the complaint.

We considered the nursing care provided to A during the two admissions. We found that the care regarding falls management was unreasonable as appropriate documentation and assessments were not completed correctly or in a timely manner. We also found that there was a lack of evidence of the monitoring of A’s condition which would have made clinical assessment of A’s condition and deterioration more difficult. We found that the level of care and record keeping was unreasonable and upheld the complaint for each admission.

Recommendations

What we asked the organisation to do in this case:

• Apologise to B for the failures identified the decision. 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:

• Relevant staff are aware of National Standards with respect to falls prevention; the requirements to complete and update Falls Risks Assessments and that these are carried out accurately and in a timely manner. Assessments, evaluations, and intervention should be completed in line with guidance.
• Relevant staff are familiar with the adult with incapacity process and the importance of delirium screening tools with patients where delirium is observed and evident.

Summary

C had concerns about the care and treatment that their late parent (A) received from the practice. At the time the care and treatment took place, the practice was being managed as a GP partnership arrangement. By the time C had submitted their complaint to the practice, the previous partnership arrangement had ended and a medical group took over the running of the practice. The named GP Partner who C had raised concerns about had also left the practice. C was concerned that the practice, under its new management, refused to respond to their complaint and did not follow the complaint handling procedure.

GPs are independent contractors who deliver general medical services to patients on behalf of the health board. If a complaint is received about care given by a practice and the practice still has an active contract, then the practice will deal with the complaint accordingly. However, if the complaint relates to a closed practice or a partnership arrangement that no longer exists, as is the case here, this means that the contract with the health board would no longer be active. The practice’s position is that they had no involvement in the care and treatment provided to A because this took place under the dissolved partnership arrangement.

We found that the practice should have advised C to contact the NHS board at the earliest opportunity, in line with the complaints handling procedure.

The board could have facilitated, where possible, communications between the former partner(s) and C. If the former partners were not able to provide a response, the Primary Care Service department within the board could then have considered either providing a response, or commissioning an external review and/or signposting to another appropriate body if applicable. We upheld this aspect of C’s complaint.

Additionally, C considered whether the practice should have carried out a Significant Event Analysis (SEA) or similar review in line with the Healthcare Improvement Scotland national framework. Given the particular circumstances, we found that it was reasonable that the practice, under its new management, did not carry out a SEA when the complaint was brought to their attention. As such, I do not uphold this aspect to the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for not advising them to contact the NHS Board about their complaint at the earliest opportunity given that it related to the care and treatment provided under a dissolved partnership arrangement. 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:

• If someone complains about the service of another Primary Care service provider, and the practice has no involvement in the issue, the person should be advised to contact the relevant board or service provider directly.

Summary

C complained that they had received substandard care across a series of surgeries to their nose. They said that the board inaccurately stated that C was suffering from a recognised complication and that the board failed to provide C with sufficient information about the possible complications of surgery. The surgery had left C with a deformed nose, significant impairment to their breathing, constant pain and affected their ability to work. C was seen for a second opinion by another Health Board in Scotland and had received surgery in England from a surgeon with expertise in this area. C believed that their medical records had been deliberately falsified or altered to conceal mistakes in their care.

The board had responded to a series of complaints from C, but their position was that C was suffering from recognised complications, which treatment had been unable to resolve. They did not accept C had been misled about their treatment, or that C’s records had been altered or falsified.

We took advice from a consultant surgeon, with expertise in the type of surgery C underwent. We found that C's complications were ones associated with the type of surgery that they had undergone. Therefore,we did not uphold this aspect of the complaint. Parts of C's records were not well maintained, although there was no evidence of falsification or alteration. Consequently, it could not be demonstrated that C had given informed consent to some of the procedures, and board staff failed to have full and frank discussions with C about their surgeries and the condition of their nose. We upheld this aspect of the complaint around providing sufficient information on the complications of surgery.

We found that C was suffering from a recognised complication of surgery, but that the consent process had fallen below a reasonable standard. There were errors in C's medical records, particularly around the first surgery C underwent, but overall, we found that C's care and treatment was reasonably documented. Therefore, we did not uphold this aspect of C's complaint.

There was not, however a clear enough treatment plan for C, and some aspects of the complications C was experiencing were not being addressed. We also found that the board's own complaint investigations should have identified the errors in C's records. Therefore, we upheld this aspect of the complaint around ongoing treatment plans.

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.
• The board should confirm that they have considered whether there are additional referrals required to manage the issues caused to C by their surgeries and that staff have reflected on whether these should have been made earlier as part of C’s treatment plan.

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

• Patients should be given complete and accurate information during the consent process for surgery to enable them to make informed decisions about the planned procedure. Discussions with patients should be fully documented in the medical record and include key areas of discussion in relation to the pros/cons of the procedure, the risks associated with the procedure generally, and with reference to any specific risks for the individual patient.

In relation to complaints handling, we recommended:

• The board's complaint handling monitoring, and governance system should ensure that concerns raised are appropriately investigated, failings, and good practice, are identified and that learning from complaints is used to drive service development and improvement. There should be a review of complaints by senior staff during the board’s investigative process.

Summary

C complained about the treatment provided to their late parent (A) when they attended hospital with shortness of breath and abdominal distension (swelling). Following assessment, A was prescribed a blood-thinning medication and was discharged with a plan to return for a scan within 48 hours to look for blood clots in the lungs. A deteriorated within hours of returning home. They were taken to hospital by ambulance and admitted for treatment. Their condition deteriorated significantly. Investigations revealed worsening heart failure and they died within a few days. The board initially considered sepsis to be A's cause of death but a post mortem later established this as congestive heart failure.

We took independent advice from a consultant cardiologist (specialists in diseases and abnormalities of the heart). We found that it was reasonable for A to have been prescribed blood thinners and referred for a CT scan when they first attended hospital. However, on the basis that A’s clinical observations were abnormal, in particular their blood gas results, we found that A should have been admitted as they required oxygen. Therefore, we upheld this part of C's complaint.

C complained that the board failed to provide appropriate care and treatment in response to A's deterioration. We were critical of the board for gaps in A’s records, meaning we were unable to establish what nursing checks were carried out on the day A deteriorated. However, we found that medical staff acted appropriately in response to A’s deterioration. A’s deterioration was a result of heart failure, leading to multi-organ failure. A’s family felt that there was a lack of clarity regarding A’s condition and what they were being treated for. The board recognised that there had been communication failings, apologised and confirmed that learning had taken place. We found that the plans for investigation and treatment were appropriate. It was reasonable for clinicians to suspect sepsis when A’s condition deteriorated, and to commence treatment with broad spectrum antibiotics. There was no evidence that the outcome in this case could have been avoided. We did not uphold this part of C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C and C’s family for not admitting A when they attended hospital. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.
• Apologise to C and C’s family for the poor complaints handling in this case. 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:

• Clinical staff are confident about when to admit patients with respiratory failure who do not have a specific diagnosis.

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 the board provided to their late spouse (A). A had a history of heart failure and severe left ventricular systolic dysfunction (LVSD, a severely weakened function in heart pumping) as well as other chronic health conditions.

C complained about the cardiac (heart) care and treatment that A received prior to their death from cardiac failure.

We took independent advice from a consultant cardiologist. We found that clinical aspects of A’s care were reasonable; however, the board’s communication was unreasonable in relation to a prescription for A’s heart medication, an echocardiogram (an image of the heart) and a possible referral to a specialist heart failure service. We upheld this part of C’s complaint on the basis of unreasonable communication.

C also complained about how the board handled their complaint.We found that the board’s handling of the complaint was reasonable. We 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 by this investigation. 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:

• Discussions and outcomes from multi-disciplinary team meetings should be clearly documented in medical records and patient notes.

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 care and treatment provided to them by the board in relation to diagnosis and treatment of prostate cancer. C had concerns about medical treatment both prior to and after surgery, and about nursing care when they were in hospital following surgery.

We took independent advice from a urologist and a nurse. We found that overall, medical care and treatment had been reasonable and did not uphold these aspects of C’s complaint. However, in relation to nursing care, we found that C’s needs and risks were not properly assessed, resulting in a lack of person-centred care planning and implementation. We upheld the complaint about nursing care.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failings in nursing care. 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 admitted to hospital should receive appropriate nursing care including complete assessments and development of person-centred care plans. These should be updated to reflect the patient’s presenting condition.

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.