Some upheld, recommendations

Summary

C complained to the council about various aspects of Social Work Services (SWS) involvement with their children. C complained that SWS failed to invite C to a 72-hour Looked After Child (a looked after child is a child under the care of the council) review. C further complained that at the review, SWS had not given appropriate consideration to the children's care planning, and had failed to correctly follow the Section 25 Children (Scotland) Act 1995 in placing their children with a family member.

We took independent advice from a social work adviser. We found that SWS had made reasonable attempts to contact C to advise them of the review meeting. Therefore, we did not uphold this aspect of the complaint. We found that information presented at the meeting was lacking in respect of the children's own views, and SWS had failed to fully document their discussions with one of C's children. However, we considered that appropriate consideration had been given to care planning for the children. Therefore on balance, we did not uphold this aspect of the complaint but provided feedback to the council about the importance of ensuring accurate recording of social work activities, including seeking views, to inform care planning.

We also found that although C was in disagreement with the placement, and the views of the children themselves had been lacking, C's estranged partner had authority under section 25 of the Children (Scotland) Act 1995 to agree to the voluntary arrangement. We found SWS had followed best practice in ensuring C's estranged partner was appropriately supported in their decision-making regarding the children's care planning, and although there had been a delay in signing the section 25 paperwork, the placement had been valid. Therefore on balance, we did not uphold this aspect of the complaint.

C further complained that SWS had unreasonably presented at their home during COVID-19 restrictions. We found that SWS had failed to follow their own COVID-19 guidance relating to home visits by not exploring the option of a remote meeting with C. We also found SWS had not provided C with a copy of the relevant guidance; had not made enquiries as to the status of C's health; and had not confirmed what PPE would be required to support the visit in advance. We upheld this aspect of C's complaint to the extent that SWS had failed to follow its own guidance, but not to the extent there had been a breach of public health guidance for which this office has no jurisdiction.

C also disagreed with the council's responses to their complaints and the manner in which these had been handled. We did not find any concerns with the manner in which the council had handled C's complaints, all of which were responded to in line with the Model Complaint Handling Procedure and good complaint handling principles.

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/information-leaflets.

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

• Feedback the findings of this investigation to relevant staff for reflection and learning, and to inform future practice.

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 and B complained about the board's handling of reports of alleged elder abuse in relation to a family member (A). They also complained that the board had failed to handle appropriately a referral made to the District Care Panel (DCP) for residential care for A, and had failed to give sufficient consideration to A's circumstances and that they were at risk of harm when rejecting the request. They also complained that following concerns for A's welfare, A had been removed from their place of residence, but the board had failed to properly assess A's care needs or to provide A with a reasonable level of support. In pursuing these matters, C and B said that the board's communication with them had fallen below a reasonable standard.

We took independent advice from a social worker. We found that although the Adult Support and Protection (ASP) investigation was procedurally sound, it had been lacking in quality. The board's analysis of A's circumstances and the Personal Outcome Plans were lacking, and were not persuasive in assessing a care need. As such, we found that the board had failed to safeguard A. We upheld this aspect of the complaint.

We also found that although the DCP handled A's referral for residential care appropriately, the information provided to the DCP was lacking in terms of the quality of the ASP investigation and the robustness of the case presented regarding A's situation. As such there was a failure by the board to prioritise securing urgent short-term accommodation that took account of A's circumstances. We upheld this aspect of the complaint.

We found that following A's removal from their place of residency, the board had followed up with A reasonably. We did not identify any further shortcomings in the board's assessments of A's care or living needs. We did not uphold this aspect of the complaint.

Finally, we found that the board had, at times, failed to respond to C and B's questions and requests for information regarding their concerns about A. We also found that there had been occasions where the board's correspondence with C and B had been unreasonably slow. We therefore upheld this aspect of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C and B for the poor handling of their correspondence. 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, B and A for the issues identified. 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:

• The board should (i) share this decision notice with the staff involved in A's case with a view to reflecting on how the ASP investigation could have better identified the nature and extent of their situation and pushed for an outcome that would have better protected A; and (ii) use this case as a reflective exercise to consider the effect of undue pressure and trauma on decision-making in ASP cases.
• The board should review how they track and respond to general correspondence to ensure all points are responded to fully and within a reasonable timescale.

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 MSP, complained on behalf of their constituent (A). A had suffered severe pain in the years following a porcine mesh implant (a surgical device, consisting of mesh made of animal tissue, such as intestine or skin, that has been processed and disinfected to be suitable for use implanted into a patient to strengthen a surgical repair) to rebuild their abdominal wall. For a number of years, a pursued treatment for the pain with the board and the possibility of the removal of the porcine mesh. The board's gynaecology department (specialists in the female reproductive system) ultimately advised that they were unaware of any relationship between porcine mesh implants and chronic pain. A was referred to plastic surgery but this was declined on the basis that the plastic surgery department had no additional treatments to offer A.

C asked the board for an independent review of A's case and an assessment for surgery to remove the porcine mesh. The board told C that the gynaecology and plastic surgery departments would review A's case in collaboration. A was ultimately only offered an appointment with gynaecology. Following further consideration, but without a joint appointment for A with the two departments, the board concluded that A was being offered appropriate treatment options and that removal of the porcine mesh would not relieve A's pain. The board advised A to seek a joint gynaecology and plastic surgery referral via their GP.

We took independent advice from a consultant plastic surgeon. While we found that the assessment of A's pain by the board had been reasonable, we concluded that this had not been reasonably explained to A in a single, clear and comprehensive communication that addressed all of the concerns and queries A raised regarding the nature of the mesh used, why this was distinct from the mesh referred to in media reports, why this was unlikely to be contributing significantly to A's pain and why there was no surgical procedure available to remove it. We concluded that it was unreasonable to have promised a joint consultation between gynaecology and plastic surgery and then not carry this out, despite acknowledging that A sought this and having several opportunities to arrange the joint consultation. Given this, we upheld C's complaint that the board had not reasonably assessed or explained the source of A's pain.

However, we concluded that the board's treatment plan for A's pain was reasonable. While the board's decisions on treatment and reasons for these were not well communicated to A, the board reasonably investigated A's condition and reached a reasonable position regarding treatment. Given this, we did not uphold this aspect of C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to A that they unreasonably failed to arrange a joint appointment with the plastic surgery and gynaecology departments, and to explain their conclusions regarding A's pain in a reasonable way. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.
• Arrange and undertake a joint appointment for A with the plastic surgery and gynaecology departments.

In relation to complaints handling, we recommended:

• Staff should handle complaints in line with the Model Complaints Handling Procedure, which includes addressing all the areas the board are responsible for and explaining the reasons for their decisions.

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 that they received from Tayside NHS Board following treatment in the A&E of Ninewells Hospital. C attended the A&E after sustaining an injury to the little finger of their right hand caused by a serrated knife. They were diagnosed and treated for mallet finger (a deformity of the finger when the tendon that straightens the finger is damaged at the fingertip), of which treatment involved the application of a splint to the injured finger.

C complained to the board that their injury had failed to heal correctly. C complained that they were not given an x-ray, that the splint was too big and that they were given insufficient information to allow them to care for their injury. C also complained that they had not been provided with a face-to-face physiotherapy appointment timeously.

We took independent advice from an emergency medicine adviser. We found that C's injury was wrongly diagnosed and that, consequently, the application of a splint in C's case was not the appropriate treatment. We found that the A&E should have referred C to a hand surgeon. We upheld this aspect of C's complaint.

We found that it was the responsibility of C's GP practice to arrange a timeous referral to physiotherapy. We, therefore, did not uphold this aspect 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/information-leaflets.

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

• Patients attending the A&E with this type of injury should receive appropriate diagnosis and treatment.
• The board have said that they will ensure C's feedback was used within the A&E to ensure that any ill-fit of splints is explained fully in future as part of the aftercare advice.

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, who suffered with hip problems, was diagnosed with a labrum tear (a condition which occurs due to damage of the soft cartilage that rims the socket portion of the hip joint) and underwent surgery.

C's symptoms failed to resolve following surgery and they were informed during a follow-up consultation that a metal artefact was visible on x-rays of their hip. C complained to the board about the advice to proceed with surgery and the treatment that they received.

C also complained about their concerns regarding their assessment and suitability for surgery to address their symptoms, and that the surgery had been carried out unreasonably.

We took independent advice from an orthopaedic (conditions involving the musculoskeletal system) adviser. With respect to C's complaint about diagnosis and treatment which resulted in the hip surgery being undertaken, we found that C underwent appropriate assessment. We found that the surgery, including relevant complications, was discussed and C had consented to the procedure. On this basis we did not uphold this aspect of the complaint.

With respect to the complaint that the board failed to provide appropriate care and treatment during, and following, the hip surgery, we found that whilst the surgery was performed to a reasonable standard, and subsequent problems investigated reasonably by clinicians, the board failed to comply with the duty of candour when they failed to inform C after the operation about the failure of a metal anchor used in the hip repair. We also identified that the board, in their complaints investigation and response to C, failed to adequately address the issue of the metal artefact in their hip following the operation. We therefore upheld this aspect of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to meet its duty of candour. 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:

• Discussion by the Orthopaedic Department Clinical Governance meeting of the requirements around Duty of Candour, including reflection on C's case.

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 that they received from Greater Glasgow and Clyde NHS Board. C was referred to the Early Pregnancy Unit (EPAS) by a private clinic on two occasions. C complained that EPAS took too long to declare the pregnancy non-continuing, that C was required to attend an unnecessary number of scans and that their care was not escalated to a doctor. C also complained that the advice and care that they received by phone, and the fact that they were contacted and invited to a reassurance scan, was unreasonable. C further complained that EPAS asked them for distressing information rather than gathering this from the private clinic and that EPAS did not gather consent from C for surgical management as they ought to have done. C also complained that the care and treatment that they received as an inpatient was unreasonable.

The board noted that they apologised for the delay in the time C waited to be seen, that during their admission C fainted and was lowered to the floor by a nurse who then called a doctor, that all options were not discussed and that on reflection there was a missed opportunity to obtain a second opinion. The board also noted, however, that this would not have changed C's management plan.

We took independent advice from a consultant obstetrician (the medical specialism for pregnancy, child birth etc) and gynaecologist (medicine of the female genital tract and its disorders). We found that a second opinion should have been sought, which may have allowed miscarriage to be diagnosed earlier. We also found that C should not have had to relay findings or be subjected to repeated examination when diagnosis had already been made by the private clinic and that the necessary documentation ought to have been obtained from the private clinic. We further found that during C's fainting episode, appropriate observations and actions were taken and the faint was well managed.

In light of the above, we found that whilst it was reasonable for EPAS to repeat some scans, a second opinion was not sought when it should have been. If this happened, C's miscarriage could have been diagnosed earlier, and therefore, the care and treatment provided to C was unreasonable. Additionally, the actions of EPAS asking C to relay findings and requiring C to undergo a further scan was unreasonable. We found that C's faint was well managed and the care and treatment provided to C during this time was reasonable.

We also considered the way in which the board handled C's complaint. We found that it does not appear that the board's complaint investigation took account of the clinical notes made by the doctor to ensure a full and accurate response was provided.

We partially upheld C's complaint and made recommendations to the board as a result.

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/informationleaflets.

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

• Patients attending EPAS should not be required to undergo unnecessary scans.

In relation to complaints handling, we recommended:

• When carrying out an investigation, consideration should be given to ensuring the response takes into account any relevant clinical notes so that the complainant receives a full and accurate response.

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 parent (A) by Dr Gray's Hospital. C complained that A's colorectal symptoms and weight loss were not properly investigated and that a planned scope investigation wasn't arranged on an urgent basis. C also complained that a head injury A sustained in a fall was not properly investigated and that A was inappropriately discharged when they were unfit to return into C's care. A was re-admitted the following day and died in hospital around two and a half weeks later. C complained about the standard of medical treatment provided during this admission. Furthermore, C complained about the nursing care provided during A's final admission. They complained that visits did not take place in an appropriate location to ensure A's comfort and privacy, and in particular that A was not transferred to a side room in light of their condition. C also considered that A was denied adequate nutrition and hydration. Finally, C complained of difficulties obtaining information from the ward and more generally about communication with the family and the lack of visiting opportunities that they were afforded.

We took independent advice from a consultant geriatrician (a doctor specialising in medical care for the elderly). We found that there was no evidence to indicate the need for urgent investigation. We did not uphold this aspect of the complaint.

We found that A's care surrounding the head injury was reasonable and that they did not meet the criteria for a head scan. However, we noted that there was a lack of care and attention to A's confusion and falls risk and that they should have been kept in hospital. On balance, we upheld this aspect of the complaint.

We noted that A received an appropriate medical review and treatment, apart from a delay in initially being reviewed by a consultant and a lack of attention to A's deterioration prior to their death. We also noted a failure to communicate the DNACPR process to C, but noted that the board had acknowledged this and outlined appropriate steps to address it. Taking communication and the lack of consultation together, in careful and close balance, we upheld these aspects of complaint.

In relation to C's complaint about the nursing care provided during A's final admission, we took independent advise from a nursing adviser. Other than an identified omission where nursing staff failed to sign for prescribed dietary supplements, which the board acknowledged, we found that A received a reasonable standard of nursing care. Therefore, on balance, we did not uphold this aspect of the complaint.

In relation to communication, the board acknowledged that the family weren't afforded the opportunities that they should have been following a change in guidance. We asked the board to provide evidence of the steps that they were taking to ensure staff are kept updated on changes to visiting guidance. We upheld this aspect of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the lack of care and attention to A's level of confusion and the unreasonable decision to discharge them, for the lack of consultant review after A's later admission, for the failure to communicate the DNACPR process to C and for the lack of recognition of A's deterioration and failure to inform C of this. 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:

• The findings of this investigation should be fed back to relevant staff for reflection and learning including, staff reflection on the decision making surrounding A's discharge, the level of consultant input in the days following their readmission and the care and attention given to A's deterioration and lack of communication with C. The consultants concerned should include the findings of this investigation as part of their annual appraisal process.

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 spouse (A) when they became unwell with severe lower abdominal pain and vomiting. A was visited and examined by an out-of-hours (OOH) GP, who administered an injection for vomiting and left some medication for A. A's condition worsened and a different OOH GP attended the same evening. A was taken to hospital by ambulance and was found to have a perforated bowel (hole in the large intestine) and kidney failure. Medical intervention was not considered appropriate and A's care was redirected to palliative care. A died in hospital two days later.

C complained that the first OOH GP missed important aspects of A's condition during their home visit. C further complained that when A was admitted to hospital, A was left in pain and discomfort for many hours and it was only when C raised concerns that A was given stronger pain relief.

We took independent advice from a GP adviser, as well as a registered nurse and a general physician in acute medicine.

We found that overall, the assessment and examination carried out by the first OOH GP was reasonable and appropriate. It was determined that there was nothing suggestive of an acute abdomen (sudden, severe abdominal pain) which would have necessitated admission to hospital. We did not uphold this aspect of C's complaint.

C also complained that A was given unreasonable care and treatment in the hospital, in relation to managing A's pain. We considered that overall, the approach to A's pain management by nursing staff was reasonable. Nursing staff identified A's level of pain from first admission and throughout and took appropriate action to try and address this.

However, we found that given the very high doses of morphine administered, medical staff should have checked the medication prescribed to see if it was working, and review or prescribe something else. Furthermore, given that the medical team would have been aware that A was on the ward round for comfort care, a palliative care referral could have been made earlier. We considered that an earlier referral may have supported better comfort care for A in the final stages of life. As such, we upheld this aspect 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/information-leaflets.

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

• Pain medication prescribed for patients should be appropriately checked by medical staff to see if it is adequately working. Referrals to palliative care should be made in a timely way without delay.

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 elderly parent (A) during their admission to St Andrew’s Community Hospital for post-surgery rehabilitation. C complained about several aspects of A's care during their admission including in relation to their eating and drinking, management of their medicines, the discharge arrangements, and the general care provided to them as a person living with dementia.

We took independent advice from a senior nurse. We found that aspects of A's care in relation to their eating and drinking had been reasonable. However, the board had failed to undertake regular weight checks or re-assess A's risk of developing malnutrition. As such, we upheld this aspect of C's complaint and made recommendations for learning.

In relation to the management of A's medicines, their discharge planning, and the care provided to them as a person living with dementia, we found the care provided by the board to A to be reasonable. Therefore, we did not uphold these aspects of C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failure to accurately assess or review A's MUST score or record their fluid output. 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:

• Assessments should be accurate and updated in keeping with care planning or when a change in the patient’s condition prompts a further review.
• Where poor food and fluid intake has been identified, there should be documentation of the necessary observations to enable full assessment and management of this (MUST scores, oral intake such as on a food record chart and urinary volumes measured and recorded on fluid balance charts).

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 to the board about an incident during which they were restrained by staff to receive emergency treatment when they experienced a life-threatening complication of their health condition.

At the time, C was being detained under a Compulsory Treatment Order by the board when the complication arose necessitating their transfer to the acute hospital site for further treatment.

C complained about several aspects of this episode including the conduct of the staff when restraining them, the failure by the board to contact or seek appropriate consent for the treatment from their court appointed welfare guardians, failure to maintain their privacy and dignity, and failure to tend to their comfort or basic hygiene needs. C also complained about the board’s suggestion that a pattern was emerging of them making unfounded complaints due to them previously complaining about a separate episode of care.

We sought independent advice from a senior mental health nurse on the care and treatment provided by the board to C. We found that C's treatment was of a reasonable standard. We noted that the emergency nature of C's condition allowed treatment without their guardians’ consent, and the steps taken to ensure their privacy, dignity and comfort had been reasonable in the circumstances. On considering the conduct of staff during the episode of care, the likelihood of having to restrain C for treatment had been anticipated in advance and plans were made to do so in line with board-approved techniques. We did not uphold this aspect of C's complaint.

In respect of the board suggesting that there was a pattern emerging of C making unfounded complaints, we referred to the rights of patients outlined within The Patient Rights (Scotland) Act 2011 and the Charter of Patient Rights and Responsibilities. As this legislation ensures the rights of patients to complain or give feedback about their healthcare encounters, we considered the board's response to C to be unreasonable and we upheld this part of C’s complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for this failing 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/information-leaflets.

In relation to complaints handling, we recommended:

• The board should have policies and procedures in place to support the management of problem complainant behaviour.
• Where problem behaviour is suspected or identified, this should be handled in line with the NHS Model Complaints Handling Procedures and in reference to other associated policies and procedures.

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.