Some upheld, recommendations

Summary

Mr C complained that the Scottish Prison Service (SPS) had failed to clarify his circumstances in relation to his fitness to work and was reported for not working. He was also concerned about the handling of his representations about this.

During our investigation the SPS provided evidence that Mr C had seen a prison doctor, who had deemed him fit to work, although not with machinery, before he was reported for not working. The prison doctor had also considered the risk assessments for the workshed Mr C was allocated to and deemed it to be suitable.

While we were satisfied that in general the SPS had dealt with Mr C's complaints in line with the complaints process, we were concerned that when Mr C had asked for assistance at a number of internal complaints committee (ICC) hearings, this was not always acknowledged on the paperwork. We also noted that three committee members were not always present at the ICC as required. During our investigation the SPS reminded staff of the need to follow the correct procedures in relation to providing the relevant paperwork to a prisoner. They also agreed to remind staff of the need to follow the process when a prisoner requires assistance at a ICC. We, therefore, made only one recommendation.

Recommendations

We recommended that the SPS:

• remind staff of the need to ensure that at least three members are present at the ICC in line with guidance.

Summary

Mr C had suffered prostate problems since his forties and his prostate health was regularly monitored. Until 2011, the tests had shown that although his prostate was enlarged, he was not suffering from cancer. Early in 2011, Mr C's blood test results began to indicate that he might have prostate cancer. Tissue samples were taken but these showed no sign of cancer. Mr C was given an appointment for a review within 12 weeks. However, this was cancelled and Mr C was not seen again until December that year. Following this appointment Mr C was diagnosed with advanced prostate cancer, which was incurable.

Mr C complained that the delay in rescheduling his review appointment was unacceptable. He felt that this happened because staff did not follow departmental procedures properly and because the board failed to appropriately implement a new appointment management system. Mr C said he believed the delay had adversely affected his treatment options and that when he complained the board did not handle his complaint reasonably or appropriately.

We took independent advice from a medical adviser on the clinical aspects of Mr C's case, and upheld most of his complaints. We found that the delay in rescheduling the appointment was unreasonable. The board did not give a reason for the delay and our adviser said that they should have explained why he needed the review appointment. Their failure to do so meant that Mr C did not pursue a rescheduled appointment after the original was cancelled. We did not uphold the complaint that his treatment was adversely affected, however, as our adviser said that it was likely that the cancer had already spread outside the prostate and the delay in rescheduling the appointment did not affect Mr C's prognosis or the available treatment.

We upheld Mr C's other complaints. The board could not show that they had implemented their appointment management system correctly, or that they had identified learning from the failures in Mr C's case. Their handling of his complaint was inadequate and there was no evidence that they had since introduced robust complaints handling procedures to stop these mistakes happening again.

Recommendations

We recommended that the board:

• review the urology department procedures, to ensure that patients are informed of the reason for a follow-up appointment and the timescale for this;
• provide us with evidence that they have identified the causes of the delay in manually transferring appointments during the introduction of the Patient Management System to prevent a reoccurrence, including the checks carried out to ensure that all patients were manually transferred at the time;
• provide evidence that the new Patient Management System will alert medical staff when appointments are cancelled;
• provide evidence of the steps they have taken to improve the accuracy of complaint responses;
• provide evidence that all staff have been reminded of the importance of using appropriate language when corresponding about patients;
• audit their new complaints process to ensure complaint investigations are conducted with appropriate rigour and that adequate records of the investigation are be maintained; and provide us with a copy of the findings; and
• apologise in writing for the failings our report identified.

Summary

Mr C complained about the end of life care and treatment provided to his late mother-in-law (Mrs A) in Glasgow Royal Infirmary. Mr C said that the family found it distressing to see Mrs A in the latter stages of her illness, and that the board failed to provide reasonable pain relief and refer her to the palliative care (care provided solely to prevent or relieve suffering) team within a reasonable time. He also said healthcare professionals failed to take account of the views of Mrs A's daughter, who held welfare power of attorney (a legal document appointing someone to act or make decisions for another person), and that there were failures in communication and record-keeping, particularly around the provision of a morphine pump. Finally, Mr C complained about the the way the board handled his complaint, saying that they failed to carry out an objective and transparent investigation.

Having taken independent advice from a medical adviser and a nursing adviser, we upheld some of Mr C's complaints, as we found that while the frequency of communication between healthcare professionals and the family was reasonable, the board did not ask Mrs A's family about power of attorney (particularly in light of Mrs A's incapacity) or formally discuss the medical procedures in advance with Mrs A's daughter. Having said that, we found that the board's records of several conversations with the family about the provision of a morphine pump were reasonable in that they reflected the views of the clinicians concerned. We accepted advice that Mrs A's pain relief and end of life care were generally reasonable and that Mrs A's symptoms were adequately managed by the medication prescribed. We were not, however, satisfied that the board's complaint investigation was carried out in accordance with the NHS complaints procedure, as it appeared from the board's responses that it was done by the members of staff who were the subject of the complaint.

Recommendations

We recommended that the board:

• review their patient profile and documentation and its completion in light of our nursing adviser's comments;
• bring the failures our investigation identified to the attention of the relevant healthcare professionals concerned;
• ensure the relevant healthcare professionals appropriately consider referrals to the palliative care team at the earliest opportunity, in light of our medical adviser's comments;
• bring the failures identified in complaints handling to the attention of relevant staff; and
• apologise to Mr C for the failures this investigation identified.

Summary

Mr C complained on behalf of his wife (Mrs C) about the care she received from the maternity triage service at Forth Valley Royal Hospital immediately prior to the birth of her daughter. Mrs C had phoned the service twice for advice about coming into hospital as she was concerned about the progress of her contractions, and felt she was dissuaded from going to hospital after speaking to a midwife during her second phone call. Around an hour later, Mrs C gave birth to her daughter at home with the assistance of her husband. She suffered heavy blood loss, paramedics attended and she was transferred by air ambulance to another hospital.

We took independent advice on this case from one of our medical advisers, who is a specialist in midwifery. Our adviser was critical of the midwife's actions during the second phone call, as they should have asked Mrs C to attend hospital for assessment of whether or not she was in active labour, given that she had experienced complications during a previous birth. We also found that the maternity triage phone template did not prompt staff to ask women about their previous medical history. We, therefore, upheld Mr C's complaints about the advice Mrs C had received by phone, and the lack of adequate documentation of the advice given.

In responding to Mr C's complaints, the board agreed to make triage staff aware that patients should not feel as if they need permission to attend hospital, and acknowledged that the midwife had not documented any advice she had given Mrs C about coming into the hospital. They also took steps to introduce a new national maternity triage template to ensure that appropriate information is captured, and introduced peer review.

Although we took the view that the board made reasonable improvements to shortcomings in the triage process, we did not find that the structure in place at the time was inadequate. We also concluded that it was not unreasonable for the board to have staffed the maternity triage service with a labour ward midwife, given they are qualified to determine if admission is necessary or not. We did not uphold those aspects of Mr C's complaint.

Recommendations

We recommended that the board:

• ensure that the midwife reflects on our adviser's comments as a learning tool;
• ensure midwifery triage staff appropriately document advice they provide; and
• apologise to Mrs C for the failings our investigation identified.

Summary

Ms C complained to us on behalf of her client (Ms A). Ms A met with a health visitor after registering with a local GP. Ms A advised the health visitor that her child had issues with feeding and as a result, had not really been introduced to solid foods. The health visitor noted that Ms A's child was well above the range of weight and length expected for a child of that age. A number of issues relating to the family resulted in the health visitor making contact with the social work department. Ms A's child was voluntarily put into the care of the child's father following a meeting with a social worker and a paediatrician.

Ms A complained about the health visitor's actions and said that she held the health visitor predominantly responsible for the child being removed from her care. Ms A also complained about the way that the board handled her complaint. The board said that the health visitor had carried out her role appropriately and explained that a health visitor cannot be responsible for the removal of a child from its mother's care as they do not have this statutory duty.

We took independent advice from one of our advisers, who is a health visitor. Our investigation found that the health visitor's actions were reasonable on the basis of the information available to her. Some issues around record-keeping were highlighted for professional development but the adviser had no concerns about the health visitor's actions. We did, however, find that the board's handling of Ms A's complaint was unreasonable as they had not fully addressed all her concerns in their response and had not followed their complaints handling procedure.

Recommendations

We recommended that the board:

• highlight the issues regarding record-keeping to the health visitor for professional development;
• apologise for failing to follow their complaints handling procedure in this case; and
• take steps to ensure the investigation and written response to a complaint is in line with their complaints handling procedure.

Summary

Mrs C complained to us about the care and treatment of her son (Mr A) at the Royal Edinburgh Hospital. Mr A was admitted to hospital under a short-term detention certificate when he was having an acute reaction to stress. He was discharged nine days later, but had ongoing contact with psychiatric services. He was readmitted to hospital the following month, and was an in-patient for a month. After he was discharged he continued to be in the care of psychiatric services, and engaged to varying levels with community based staff. Around ten weeks after his discharge Mr A committed suicide.

Mrs C complained that her son's care was not sufficiently coordinated between professionals and teams. She was also concerned that her son had been discharged without a care plan in place and with no support, and said that staff were unwilling to provide her with enough information for her to be able to support her son.

We took independent advice from two of our advisers - a psychiatric nurse and a psychiatrist. The advisers reviewed Mr A's care and treatment and said that Mr A's care had been appropriately coordinated. They said that information about a patient's care and treatment could not always be shared with all family members, but that information was passed on appropriately during Mr A's care. Mr A was given appropriate medication, but at times he had been reluctant to take this. The advisers also explained that, while the medication prescribed may have slowed Mr A down, it would not have lowered his mood. In relation to Mr A's discharge, the advisers said that the discharge process was properly planned and cohesive. On the basis of this advice, we did not uphold the complaint about Mr A's care and treatment.

Mrs C also complained that she had not received a full response to her complaints within a reasonable timescale. She had chased the board for responses, and felt that her concerns were not addressed honestly. She also met with board staff in an effort to get answers. It was nearly two years from when Mrs C first wrote to the board when they finally told her she could contact us. The NHS complaints procedures says that complainants should be told that they can approach us after 40 business days, even if the board have not provided a final response to the complaint by then. We upheld this complaint, as the timescales were not in line with the NHS complaints procedures. We also found that the responses lacked the detail that Mrs C was expecting and did not address all her concerns, which was not in line with good complaints handling.

Recommendations

We recommended that the board:

• apologise to Mrs C for their failure to address her complaints in a timely and appropriate manner.

Summary

Ms C, who is an independent advocate, complained on behalf of her client (Miss A) that the medical practice did not respect Miss A's wish to use an advocacy service. She also complained that the quality of communication from the practice was poor, and that they unreasonably removed Miss A from their patient list.

We took independent advice from a medical adviser and a mental health adviser. The mental health adviser said that Miss A had a right to use an advocacy service and that the evidence showed that, although the practice had tried to engage with Ms C, they had not properly understood the role of the advocacy service and had not respected Miss A's wishes. The medical adviser said that the standard of correspondence fell below a reasonable standard. Letters from the practice were emotive and unprofessional and the practice failed to maintain a professional level of distance. The mental health adviser said that in his view they had not taken enough account of Miss A's mental health issues. We, therefore, upheld the complaints about the practice's engagement with the advocacy service and that the standard of their communication was below that which Miss A had a right to expect. We also found that they failed to direct correspondence to Ms C, despite Miss A's clearly stated wish that this should happen.

We took the view, however, that the practice's decision to remove Miss A from their patient list was reasonable, noting that they had complied with the terms of the standard general medical service contract, by giving written warning to Miss A that they intended to take this action unless she provided them with an emergency contact phone number. We did not find this unreasonable, and did not uphold the complaint as we found that they acted in accordance with national guidelines.

Recommendations

We recommended that the practice:

• provide evidence that all staff have been reminded of the role of independent advocates;
• remind all staff of the need to use appropriate language when communicating in writing with patients;
• review their complaints handling procedure to ensure that complaint correspondence is clearly identified and that it signposts complainants to SPSO at the appropriate stage; and
• apologise for the failings that our investigation identified.

Summary

Mr C requires regular blood sampling due to the medication that he is prescribed. At one appointment there was difficulty obtaining a blood sample and Mr C was in pain. He attended his GP who referred him to a neurologist who diagnosed nerve damage, possibly caused by the attempt to take blood. Mr C complained that the board had not provided him with a reasonable standard of care and that they had not properly responded to his complaint.

We took independent medical advice on this complaint from our nursing adviser. Our investigation found that the board had apologised for the distress caused and had made arrangements for Mr C to have future blood samples taken by another team. We considered these actions to be reasonable and did not uphold the complaint. However, we did not consider the time taken by the board to respond to Mr C's complaint to be reasonable, so we upheld this aspect of his complaint and recommended that the board apologise to Mr C for the delay.

Recommendations

We recommended that the board:

• apologise to Mr C for the time taken to respond to his complaint.

Summary

Ms C complained that the association had not responded to her online enquiry form submissions and had not told her what was going to be done about the landscaped area in front of her property. Ms C also said that they had not kept her updated about her status on the housing transfer list or reminded tenants of their responsibility for their pets, following a noise complaint.

The association said that they had had problems receiving online form submissions, and recognised that one of Ms C's emails was received but not acted on. They went on to say that they had new gardening contractors and would be discussing with them the best way to manage the landscaping. The association said that they had sent Ms C reminder letters about her status on the transfer list, but as they were not responded to, they had removed her. They had, however, reinstated her once they became aware she wished to remain on the list. They confirmed that they had sent letters to tenants about their pets.

We found evidence that the association had written to tenants about their responsibilities for their pets, and we considered their actions about the landscaping reasonable. We, therefore, did not uphold these two complaints.

We recognised that the association had experienced problems with how they were managing incoming emails and the steps they had taken to correct that. However, it would have been appropriate for them to have apologised to Ms C for not following up on the email they had received from her. We also found evidence that they had incorrectly sent the transfer update letters to Ms C's previous address. We made recommendations to address these issues.

Recommendations

We recommended that the association:

• apologise to Ms C for failing to apologise to her in the original complaint response;
• apologise to Ms C for incorrectly addressing her transfer update letters;
• restore Ms C's position on the transfer list to the point she would have been at if she had not been removed; and
• update systems to ensure the correct address is used when issuing letters to tenants.

Summary

Mrs C's mother (Mrs A) had a history of urinary problems. She was referred for a CT scan of her kidneys in 2011 which highlighted a mass on her kidney. Further tests diagnosed cancer, and a plan was made to discuss this with Mrs A at her next scheduled appointment. Before this could happen, however, Mrs A became unwell and was admitted to Gartnavel Hospital, where a doctor told her about the cancer. A cystoscopy and uteroscopy (examinations of the tubes that carry urine and the kidneys, using a narrow tube-like telescopic camera) were performed but it was not possible to obtain tissue samples for further analysis. Mrs A was discharged home and attended follow-up clinics. Following a multi-disciplinary team discussion about Mrs A's case, it was decided that she should have surgery, but the operation she needed was not routine. Before it could be arranged, Mrs A was admitted to hospital again, as she had suffered a suspected stroke. A scan showed an acute intracerebral bleed (where blood suddenly bursts into brain tissue). Staff felt that this was indicative of a brain tumour, so they started radiotherapy (a treatment using high-energy radiation) and postponed treating Mrs A's kidney tumour. It was later found that Mrs A did not have a brain tumour. Mrs A died shortly afterward.

Mrs C complained that there were delays in diagnosing and treating Mrs A's kidney tumour. She also complained about the misdiagnosis of a brain tumour, explaining that this diagnosis caused Mrs A to enter a deep depression.

After taking independent advice from two of our medical advisers - a cancer specialist and a kidney specialist - we found that Mrs A's clinical treatment was largely good. We did find that there were unacceptable delays to two diagnostic scans, but there was nothing to suggest that this had any impact on Mrs A's overall prognosis (the forecast of the likely outcome of her condition). We accepted advice that, based on the evidence available to the clinical team, the diagnosis of a brain tumour was reasonable and that it was reasonable to start radiotherapy. That said, we were critical of the board's communication with Mrs A about her diagnosis and the treatment she received.

Recommendations

We recommended that the board:

• apologise to Mrs C that the overall time from the first suspicion of cancer to proposed treatment exceeded 62 days in her mother's case; and
• apologise to Mrs C that her mother was not advised sooner of the scan results.