Some upheld, recommendations

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.

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.