Some upheld, recommendations

Summary

C, an advocate, complained on behalf of their client (B). B's spouse (A) died of advanced lung cancer.

A started experiencing pain between their shoulder blades and was referred by their GP practice to University Hospital Hairmyres for a chest x-ray. A attended A&E at University Hospital Hairmyres on three different occasions and received further x-rays. A was admitted to University Hospital Wishaw and after undergoing further investigations, they were diagnosed with advanced lung cancer.

C complained about the clinical assessment of A's symptoms when they attended A&E. C complained that A had signed a Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) form during a hospital admission when they did not have capacity to understand it. B was unhappy that they had not been consulted about the DNACPR.

C also complained that communication about A's diagnosis was very poor. They complained that A was not informed that their cancer was life limiting or terminal. According to B, they were unaware of the prognosis or that A only had a short time to live.

We took independent advice from an emergency medicine adviser. We found that A's symptoms were appropriately assessed and treated during each of their attendances at A&E. We considered that A was appropriately referred for further investigation and we did not uphold this aspect of the complaint.

We also took advice from a consultant physician. In relation to communication regarding the DNACPR, we found that A's capacity was appropriately assessed and that their consent was reasonably obtained. We considered that there was no obligation for staff to discuss the DNACPR with A's family and we noted that A's admission was during the initial weeks of the COVID-19 outbreak when restrictions for visits were in place and hospitals were under considerable pressure. We did not uphold this aspect of the complaint.

We noted that there was a disparity between what clinicians thought that A's family understood regarding A's condition and what their understanding actually was, although it was not possible to say whether this was due to a communication failing on the clinicians' part or whether the family had failed to grasp what they were being told. We took into account that B said that they did not realise how ill A was until they found the DNACPR form on which it was noted that they were not expected to live more than 28 days. In recognition of the impact that this must have had on B and taking into account that A's family did not feel sufficiently informed about A's condition throughout their illness, on balance, we upheld the complaint that the board's communication regarding A's condition was unreasonable.

Recommendations

What we asked the organisation to do in this case:

• Apologise to B for the communication failings our investigation has 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:

• This case should form part of the annual appraisal for staff involved in communicating A's condition, with training undertaken where any gaps are identified.

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 was a grower of seed potatoes. They complained about the actions of the Scottish Agricultural Science Agency (SASA), a division of the Scottish Government. C complained that SASA failed to follow their own published procedures when handling the assessment and certification of C's seed potato crops.

C complained that SASA unreasonably delayed inspecting their crops by requiring payment for the inspections in advance, contrary to the normal procedure of paying after the inspection. C also complained that the initial crop inspection identified an unrealistically high level of plant virus. Whilst a check inspection found C's crops to be well within the tolerance levels for virus, C was advised that the crops would not be certified until further lab tests were carried out. C complained that they were subjected to unreasonable additional testing and that they were not treated the same as other farmers. C said that the testing process caused unnecessary delays to their crops being certified and listed on the Potato Register. As such, C was unable to market the seed potatoes for sale until the purchasing season had ended. C explained that, as a result of the issues they encountered, they lost sales worth hundreds of thousands of pounds.

We found that SASA required C to pay for the inspection in advance as their account was in arrears. We were satisfied that this was standard practice in the circumstances and, whilst there was a delay to the payment being confirmed by SASA, this did not have a significant impact on the time taken to arrange C's initial crop inspection.

We were satisfied that SASA were able to demonstrate that they took a reasoned approach to inspecting and testing C's crops that focussed on the health of the crops and their suitability for sale. We did not find any evidence to suggest that C was treated unfairly or that SASA instructed additional testing without giving proper consideration to all of the circumstances. We did not uphold these aspects of C's complaint. Whilst we were satisfied that SASA followed their normal procedures, we were critical of their failure to state these procedures clearly in the guidance they issue to farmers. We also found that they failed to explain their actions clearly to C, or to proactively guide them towards the appeals process.

We found that there was an unreasonable delay of three months between C's crops being certified and them being listed on the online Potato Register. We were critical of SASA's communication with C regarding the stratus of the crops during this period. Therefore, we upheld this aspect of C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the issues highlighted in this 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:

• SASA should review how they communicate their appeals procedure.
• SASA should review how they communicate their procedures for crops that fail their inspections or that are certified later in the season than normal.

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 to the council about their child's (A) move to a residential placement under a section 25 arrangement (Children (Scotland) Act 1995). They said that the placement had been highly inappropriate and had not met A's complex needs. C and B further complained that they had felt pressurised into agreeing to the move and had been given inaccurate information by social workers about the resource.

In response the council said that the placement had been made on an emergency basis and in good faith that it would meet A's needs. They disagreed that it had been highly inappropriate. Although at the time they had been unaware of the provider's personal search practices, they agreed as a result of the complaint to request this information from all residential providers moving forward.

We took independent advice from a social worker. We found that the council had taken reasonable steps to find the best possible resource to meet A's complex needs within the limited timeframe available. Although we agreed that the council should have been made aware of their provider's personal search practices, we concluded that the council had acted reasonably in terms of their communications with C and B regarding the suitability of the resource and the information given to them and found no evidence to support that C and B had been pressurised into agreeing to the move. As such, we did not uphold these aspects of the complaint.

C and B further complained that the council had failed to explain to them that it had been their intention to move A to secure accommodation and social workers had relied on inaccurate health reporting to inform this decision. C and B explained that they had been invited to a meeting with social workers but had been unaware it would be to discuss secure measures. As such, they had been denied the opportunity to have legal representation to challenge the council's decision and to prevent the move.

We were unable to reach a finding on what information had been given to C and B about the purpose of the meeting. While we acknowledged that having legal representation may have aided their understanding of the process, we found that this would not have had any bearing on the decision to move A to secure care. We concluded that the council had provided C and B with all the appropriate information leading to the decision, including the legal process and their rights of appeal. As such, we did not uphold this aspect of the complaint.

C and B further complained that the council had failed to respond appropriately to their concerns that A may be self-harming during their placement.

While we found that overall the incidences of A's self-harm had been taken seriously, one particular incident had not been considered as thoroughly as it should have been and there had been a failure to report A's injuries to C and B at the time. Therefore, on balance, we upheld this aspect of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C and B, and to A, for failing to give appropriate consideration to an incident where A had self-harmed. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.
• In situations where a young person is at risk of self-harm, there should be clarity in the council's contract with external care providers about the reporting of such incidents to the family/carers and to the council themselves.

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 sought advice from the council regarding development that they were planning at their home. C received a response, with input from the building standards service, that the council would not be asking for a building warrant in relation to the development.

A few years later the building standards service contacted C to advise that complaints about the use of their property had been received and the council considered a building warrant was required.

C felt that, before being given advice some years previously, they had communicated the information about the use of the development the council now advised were the reasons a building warrant was required. C complained to the council about this and the actions of the building standards service.

The council responded that the advice provided had been correct at the time of issue and based on the current regulations and guidance at that time. The council said that they considered the use of C's property had changed and, therefore, the basis upon which the advice had been given had also changed. C was unhappy with this response and brought their complaint to us.

We found that the passage of time meant that it was not possible to determine whether the advice received from the buildings standards service had been reasonable as it was not clear what information the service were in possession of. We did not uphold this aspect of C's complaint but provided feedback to the council to reduce the likelihood of any confusion over the response to requests for advice in future.

We found that the recent actions of the building standards department had been reasonable given the terms of relevant guidance and standards, and did not uphold this aspect of C's complaint.

We found that the council's response to C's complaint had inaccurately suggested that C had not made the council aware of the intention to invite the public into the proposed development. Therefore, we upheld this aspect of C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C that the response to C's complaint inaccurately suggested that C had not made the council aware of the intention to invite the public into the proposed development. 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's responses to complaints do not contain inaccurate suggestions.

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 Scottish Ambulance Service (SAS) after calling an ambulance for their spouse (A). The ambulance crew that initially attended C diagnosed that A's condition was not sufficiently serious to require hospital attendance and instead requested that a GP attend instead. C considered that this was unreasonable as, when the GP did later attend, they requested a further ambulance to take A to hospital. C was also concerned about the SAS' handling of their subsequent complaints.

We took independent advice from an emergency medicine clinician. We found that the original ambulance crew had carried out a detailed diagnostic investigation and reasonably concluded that requesting a doctor to attend the home was the best option. Therefore, we did not uphold C's complaints in that respect.

However, our investigation did raise concerns about the SAS' complaints handling. We found that there were unexplained inaccuracies in their response and also that they had failed to clarify the nature of C's complaints when this was not clear from the complaint correspondence, leading to a misunderstanding of the nature of the complaint. We upheld this aspect of C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to accurately respond to their complaints. 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:

• Where a complaint is not entirely clear, clarification should be sought from the complainant to ensure 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 that their parent (A) received from the board. Following surgery to remove bladder lesions, A experienced severe pain and urinary problems. It was established that they had a bladder perforation. C complained that, whilst A's consultant initially accepted and apologised for the fact that A's bladder was likely perforated during surgery, the board subsequently backtracked and suggested that there could have been a number of causes. C did not consider that their family had been given a clear explanation as to how A's bladder had been perforated.

A subsequent review of A's case established that they had cancer invading their bladder muscle. The cancer could not be treated with chemotherapy or radiotherapy and staff had discussions with A regarding the difficulties associated with attempting surgery in light of their other existing medical conditions. A was readmitted to hospital via A&E the following month, due to bladder spasms and catheter (a flexible tube used to empty the bladder and collect urine in a drainage bag) pain. A CT scan was carried out and A was admitted to a ward for ongoing monitoring and treatment. A's pain worsened and further scans showed that the cancer had spread to their lungs. Surgery was no longer an option and A died shortly afterward.

C complained that the communication from the urology staff (specialists in the male and female urinary tract, and the male reproductive organs) during A's hospital admissions was poor and that there was an unreasonable delay to A and other family members being told the extent of A's condition.

We took independent advice from a consultant urologist. We considered that, when responding to C's complaint, the board sought to provide a detailed description of events and a clearly set out explanation as to the potential causes of A's bladder perforation. That said, we found that information provided by C was not taken into account and, had it been, a clearer explanation could have been provided by the board. Therefore we upheld this aspect of C's complaint.

We found that A did not require routine input from urology. Their day-to-day care in hospital was managed reasonably by gastroenterology (specialists in the diagnosis and treatment of disorders of the stomach and intestines), with input from urology as required. We were satisfied that A's urology investigations took place in good time and a reasonable management plan was put in place for their ongoing urology input. Overall, we found that the communication from the urology staff to be reasonable. We did not uphold this aspect of C's complaint.

A had a rare and aggressive form of cancer. We accepted evidence from the board that earlier scans showed evidence of changes that were visible, but not identified. We concluded that, whilst the treatment options available to A may not have been any different, had the changes been identified earlier, they may have been given details of their cancer and prognosis sooner and this may have given A more time to prepare and make arrangements. Therefore, we upheld this aspect of C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C and their family 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/information-leaflets.

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 the board. C had experienced severe nausea but initial investigations found no definitive cause for their symptoms and a presumed diagnosis of irritable bowel syndrome (IBS, a condition of the digestive system that can cause stomach cramps, bloating, diarrhoea and constipation) was made. C said that they were provided with medication but this had little effect.

C developed severe abdominal pains later the same year which required immediate surgery and initially appeared to recover well. However, their abdominal pains returned a few months later and they required a hospital admission. Further surgery was carried out, establishing and resolving the root cause of the pain.

Whilst C's pain resolved following the second surgery, they raised a number of concerns regarding the care and treatment provided by the board, delays to diagnosing the cause of their symptoms and inaccurate documentation of the procedures that they had had.

We took independent advice from a consultant gynaecologist (a doctor who specialises in the female reproductive system). We found that the initial view that C's symptoms were being caused by a bowel condition was reasonable and that IBS was a reasonable working diagnosis while tests were carried out to confirm or rule out other possible causes of their nausea. We were satisfied that the working diagnosis and the focus of investigations changed when C's symptoms escalated. We were also satisfied, following the recurrence of their abdominal pain, that the board followed a reasonable and recognised pathway to establishing the cause of C's pain. Therefore, we did not uphold these aspects of C's complaint.

We were critical, however, of a number of errors in C's medical records, including details of another patient's procedures being misfiled in C's notes. We upheld this aspect of C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the issues highlighted in this decision. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

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 that nursing staff failed to provide them with adequate personal care following an enema (an injection of fluid into the lower bowel by way of the rectum to expel its contents, to introduce drugs or to permit X-ray imaging) at University Hospital Monklands. C also complained about the provision of toilet facilities on a ward. They said that their experience had caused significant trauma. We took independent advice from a nursing adviser. We found that there was insufficient evidence to suggest that that the board provided C with inadequate personal care. We did not uphold this complaint.

C also complained that the board had failed to communicate effectively with them after they had a laparoscopy (an examination of the abdominal organs using surgical methods to determine the reason of pain or other complications of the pelvic region or abdomen) at a private hospital under a waiting list initiative. They said that this had caused delay to their treatment. We found that there had been a delay in communicating the results of the laparoscopy to C and this caused delay to C's treatment. The board were wrong to consider that C's GP should have discussed the results of the laparoscopy with them. The board requested the laparoscopy and it was their responsibility to discuss this with C. We upheld this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failure to adequately communicate the results and/or findings of the laparoscopy with C. The apology should meet the standards set out in the SPSO guidelines on apology available atwww.spso.org.uk/information-leaflets.

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

• Staff should be aware of their responsibility to directly discuss the outcomes and/or findings of tests or procedures they have requested with their patients.
• They will ensure that mistakes are rectified.

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 adult child (A) during two admissions to Aberdeen Royal Infirmary where they had been admitted for investigation and treatment of persistent vomiting and weight loss. We took independent advice from a nurse and asked for their comments on A's care and treatment during both admissions.

During the first admission, C complained about A being given incorrect medication, comfort and observation charts being completed inaccurately, and of the poor level of cleanliness in the ward's bathroom. We found that there were failings in these areas, which the board had acknowledged in their own complaint investigation and had identified actions for improvement and learning. Therefore, we upheld this aspect of C's complaint and asked the board to provide evidence of the actions that they had said they planned to take.

During the second admission, C complained that A was given the wrong nasogastric feed and failed to take proper action when A self-harmed; was provided with the wrong type of feeding tube; staff failed to communicate properly with C or A during the admission; and A was not given medication on discharge.

We found that the care of A's enteral feed (feeding tube leading into the stomach) to be reasonable, however we found that the planning and documentation of A's care after they had self-harmed was unreasonable. We also found that A had been given the wrong length of feeding tube and that the procedure went ahead despite this being known. Therefore, we upheld these aspects of C's complaint.

We found that communication with A had been reasonable and we did not uphold this aspect of C's complaint. In relation to communication with C, we found this to be mostly reasonable, however there had been a serious oversight in communicating with C when A had self-harmed. Therefore, on balance, we upheld this aspect of C's complaint.

In relation to A's discharge, we found this to be reasonable and we did not uphold this aspect of C' complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to A and C for the failings we have 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 ensure staff are aware of how to report and respond to incidents of self-harm when they occur within acute care settings.
• The board should ensure the correct type of feeding tube is used according to the planned procedure.

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 the board during an in-patient stay at Forth Valley Royal Hospital. C was admitted to the hospital while in the early stages of labour. C gave birth a few days later and was discharged to their home the following day. After discharge, C's health began to deteriorate and were later admitted to a different hospital, where they received a blood transfusion and treatment for an infection.

C complained that the board had failed to inform them that they had a yeast infection and failed to provide them with any treatment for this. C also complained that a clinician knowingly recorded an inaccurate pulse rate on their records and that the board failed to appropriately treat their post-natal high blood pressure and/or blood loss.

We took independent advice from an obstetrician (a doctor who specialises in pregnancy and childbirth). We found that the board had failed to inform C that they had a yeast infection. Therefore, we upheld this aspect of their complaint.

We found insufficient evidence to establish that an inaccurate pulse rate had been recorded on C's records. We also found that C's blood pressure and/or blood loss were within normal limits when they were discharged from hospital. Therefore, we did not uphold these aspects of C's complaints.

However, we did find that clinicians failed to reasonably respond to C's high pulse rates at one point during their admission. While this issue was not raised by C in their complaint, we considered that it was reasonable to make recommendations to the board in relation to this matter.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failure to adequately monitor and respond to their condition. 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:

• Clinicians should closely monitor Modified Early Warning Scores (MEWS) and appropriate action should be taken in light of them.
• When a candida (yeast) infection is identified, patients on the ward should be informed.

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.