Some upheld, recommendations

Summary

C complained about the care and treatment that they received from the board after they were diagnosed as having a tumour in their bowel.

C underwent surgery to remove their tumour. Following the procedure, they experienced a number of complications that led to extended hospital treatment and the need to be fitted with a stoma (a surgically made pouch on the outside of the body). It was ultimately established that their surgery failed to heal properly, possibly due to a fault with an item of equipment used to staple their bowel. C complained that the issues resulting from their surgery had life-changing consequences.

C raised a number of concerns regarding the care and treatment that they received from the board at the time of their surgery and once they had been discharged. They also did not consider that the board adequately took responsibility for the issues that affected them.

We took independent advice from a general and colorectal surgeon (a surgeon who specialises in conditions in the colon, rectum or anus). It was evident from C's complaint that they went into surgery expecting a straightforward procedure. The procedure was complicated by C's high body mass index (BMI, a measure for estimating human body fat) and took several hours longer than they had anticipated. Whilst we were critical of the board for not explaining to C that their BMI was a potentially complicating factor, overall we were satisfied that the surgery was carried out reasonably. During the procedure, the surgeon made reasonable adaptations when issues arose and there was no indication at the time of the issues that would later affect C. We were also satisfied that there was no indication at that time that there was a fault with the equipment being used during the procedure. Therefore, we did not uphold this aspect of C's complaint.

Following their surgery, C experienced a significant amount of pain. We were largely satisfied that the board's staff took this seriously and took appropriate action when it became apparent that the pain was not resolving as expected. C was ultimately found to have a leak from the site of their bowel surgery. We found that this was treated appropriately with further surgery once it was identified. That said, we found that C's symptoms should have led staff to suspect a potential leak sooner than they did. Whilst we found nothing to suggest that the outcome would have been any different for C, had staff considered a leak earlier, an earlier diagnosis could have been made and C's pain may have been relieved sooner. We upheld this aspect of C's complaint.

We found that, four months after C's surgery, the board proactively identified and investigated a cluster of patients (including C) that had experienced bowel leaks following surgery. The board concluded that there was no common factor linking these cases. Two months later, the board were advised by a medical equipment manufacturer that an item of equipment that was used during C's surgery was faulty and should be withdrawn from use. We found that there was no clear link between the faulty device and the leak that C subsequently experienced. However, we were critical of the board for not going back and reviewing the cluster of cases in the presence of the new information regarding the faulty medical device. We also found that the board could have done more to address C's questions about the situation. 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 delay in diagnosing the leak. 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 share this decision with the staff involved in C's care with a view to identifying any aspects of their care and treatment that could have been improved.
• The clinical team should review C's case with a view to ensuring their protocols for considering and diagnosing anastomotic leaks take account of all relevant risk factors.

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 concerned about the care and treatment that their late spouse (A) received at Inverclyde Royal Hospital following a surgery for a hip fracture. C complained that A did not receive appropriate post-operative rehabilitation and physiotherapy (the treatment of disease, injury, or deformity by physical methods such as massage, heat treatment, and exercise rather than by drugs or surgery). We took independent advice from a physiotherapy adviser. We found that the physiotherapy assessments and treatment were appropriate. Therefore, we did not uphold this aspect of C's complaint.

C also complained about the nursing care that A received. In particular, C was concerned that proactive steps were not taken to prevent A falling and that A was not supervised to take their medication. We took independent advice from a nursing adviser. We found that the board acted reasonably by implementing appropriate and proportionate actions to mitigate the risk of A falling. However, there was no record that A was supervised to take their medication and this was unreasonable given A's cognitive impairment and physical frailty.

In light of the above, we upheld this aspect of C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for not supervising A taking their medication. 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 provided to a family member (A) at Woodend Hospital and Aberdeen Royal Infirmary. Immediately prior to the episode of care we considered, medical investigations had been performed which indicated that A had metastatic cancer (cancer which has spread from one part of the body to another). A was then referred to the urology department (specialists in the male and female urinary tract, and the male reproductive organs).

We took independent advice from a urology adviser. In response to C's complaint, the board acknowledged that there had been a failure to request a CT scan as planned and apologised for this. We found that there was a failure to expedite a flexible cystoscopy (bladder examination using a narrow tube-like telescopic camera) and keep A informed about their care. In addition, we found that A should have been referred to oncology (specialists in the diagnosis and treatment of cancer). In view of these findings, we concluded that the care and treatment was unreasonable and we upheld C's complaint.

C also complained about the board's actions leading up to the decision whether or not to carry out a full post-mortem examination following A's death. C considered that the board had failed to follow the procedure that applied in the circumstances that the nearest family members did not agree about a post-mortem. C was also unhappy with the lack of communication about this matter. We considered a number of pieces of relevant legislation and guidance and took into account comments from the adviser. The circumstances leading to the decision about post-mortem were complex. On balance, we found that the board acted reasonably in this instance and we did not uphold the complaint. We provided feedback about good practice for the board to consider.

Finally, we found that the board's response to C's complaints could have been clearer in one respect. We also found that the board did not respond to a related complaint (about A's treatment a number of years prior) and inform C whether they would extend the timescale for accepting a complaint or not. We made a recommendation to address this finding.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the unreasonable delay in performing an urgent CT scan; the failure to ensure that A was adequately informed about the plans for a CT scan; and the lack of referral to oncology. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.
• Inform C of their decision whether or not they are extending the timescale (in relation to their complaint about A's historical treatment), and provide a reason for this.

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

• Care plans agreed at multi-disciplinary meetings should be implemented and followed up to ensure appropriate communication takes place with the patient/patient's representative and that timely investigations and referrals take place where relevant.

In relation to complaints handling, we recommended:

• Complaint responses should be comprehensive and transparent. In line with the NHS Model Complaints Handling Procedure, the timescale for acceptance of a complaint may be extended if the Feedback and Complaints Officer considers it would be reasonable in the circumstances. Where a decision is taken not to extend the timescales a clear explanation of the basis for the decision should be provided to the person making the complaint, and the person should be advised that they may ask this office to consider the decision.

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 way that the Crown Office and Procurator Fiscal Service (COPFS) dealt with their communications with them following their adult child (A)'s death by suicide. C said that the COPFS failed to deal with C's request for the return of A's property appropriately; failed to provide C with the final post-mortem report on A's death within a reasonable time; and failed to investigate C's complaint about these two matters appropriately.

It is not for this office to question decisions by the COPFS regarding the release of A's belongings, as the COPFS's decisions regarding prosecutions/whether or not to investigate Fatal Accident Inquiries are outwith the remit of this office. We therefore considered whether or not the COPFS did what they advised C that they would do in relation to the release of A's belongings and whether they acted in line with their guidance.

The records showed that the COPFS considered C's request for the return of A's property, made during a telephone call, and authorised release of some of A's belongings and that this was then communicated to the police and the belongings were released. It would appear that after receipt of an email from C in which they complained and requested the release of the remainder of A's belongings, the COPFS then authorised their release. The COPFS acknowledged that they should have responded to C's email, advised that they fed back this failing to staff and provided documentary evidence to verify that this took place at the time. We considered the remedial action by the COPFS to be reasonable and did not uphold this part of the complaint.

On the matter of the provision of the final post-mortem on A's death, the COPFS explained the difficulties they experienced with their toxicology report service provider and how this in turn impacted on the timescale for receipt of post-mortem reports by the COPFS and notification of the outcome to the next of kin. In this case, notification of the outcome of the post-mortem to C and issuing of the report on request did not take place until more than four months after the timescale stated in the COPFS's procedures. We were critical of this delay and upheld this part of the complaint. We noted that COPFS indicated that they had taken a number of steps to address the delay which was positive.

On the issue of the investigation of C's complaint, while a number of aspects of the COPFS's investigation into C's complaint and complaint response were reasonable, we found that the complaint response failed to address C's expression of dissatisfaction regarding the delay in completing A's post-mortem. We, therefore, upheld this part of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C and their family for the unreasonable delay in notifying C of the outcome of the post-mortem on A's death and providing them with a copy of the report on request and for failing to address C's concerns about the delay in providing A's post-mortem report in their complaint response. 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:

• For COPFS complaint responses to address all issues raised as part of the complaint that the COPFS are responsible for, in accordance with their complaint handling 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 to the council about the school their child (A) attends. A was transitioning from early years to primary school. As A had additional needs, a transition plan was required. C complained to the council that the school failed to put in place the appropriate transition arrangements in line with their obligations under the Additional Support for Learning (ASL) (Scotland) Act 2004; that they did not communicate appropriately with them about A's support and education and that they did not carry out an appropriate investigation of their complaint about the handling of a staged intervention meeting.

We found that the council failed to meet the required timescales when putting in place the appropriate transition arrangements for A and as such we upheld this aspect of the complaint.

We noted that there was reasonable mechanisms in place to keep C updated about A on a daily basis. While the council recognised that there were times that C's email correspondence was not responded to, we are satisfied with their overall communication with C and as such, we did not uphold the complaint. We also noted that the council carried out an appropriate investigation of C's complaint about the school's handling of a staged intervention meeting. The council consulted with all attendees and have demonstrated that they have reflected appropriately on the school's handling of the meeting. We did not uphold this aspect of C's complaint.

Recommendations

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

• The council should have appropriate measures in place to ensure that statutory timescales for putting in place an appropriate transition are met.

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, parent of A, complained to the council that during A's time at school the council had failed to address bullying and racist incidents. The complaint raised a number of incidents which C considered had not been investigated or responded to appropriately, and that as a result A was unsafe and their education had been impacted.

C also complained that the council failed to offer any assistance as promised, from an educational psychologist, which was required to help A in response to the racist bullying, including the aftermath of an assault which occurred in school.

The council, in their response to the complaint, said that records demonstrated actions taken by staff to address bullying and racist incidents reported to them were timely, appropriate and in line with council policy. The educational psychologist met with C and a commitment was given that they would meet A in person. Two appointments were arranged but A was absent for one, and for the second A was in hospital. The council acknowledged follow-up was not offered, and identified a breakdown in communication in rearranging the meeting.

We found that the school in question had investigated and taken action with respect to incidents of bullying and racist bullying. We therefore did not uphold this aspect of the complaint.

We found that there was evidence that the council had appropriately considered support for A involving an educational psychologist, however following an initial meeting the council failed to appropriately communicate subsequent appointments and failed to re-arrange the appointment for A to meet an educational psychologist. Therefore, we upheld this aspect of the complaint.

In accordance with our powers to consider complaints handling, we found that the council's response to C's complaint in relation to bullying should have been more detailed and specific and was therefore unreasonable. We made recommendations to the council in this regard.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failure to provide a full and detailed response to all issues of complaint, specifically those relating to incidents of bullying and racial harassment. 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:

• Relevant staff should be aware of the requirements of the complaints handling procedures, particularly with respect to identifying and responding to relevant issues in a complaint.

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 council's handling of their complaints about their child (A) being bullied at their school by another child. They advised that the bullying had persisted for a number of years and complained of the school repeatedly using the same strategies with little effect or of them being stopped prematurely. They also complained that the council had failed to keep proper records of the incidents of bullying. C said that this lack of documentation had contributed to the school continually using the same anti-bulling strategies despite them not working.

C made two formal complaints to the council, both of which were partially upheld by the council and which identified failings and described actions for improvement.

We found that the council had implemented anti-bullying strategies following C's first complaint which had had a positive impact on behaviour, however they did not keep this under review in line with their policies and the bullying recommenced during a period when no measures were in place. This led to C making a further complaint. Following C's second complaint, we found that the council were now monitoring the behaviour and adhering to their anti-bullying policies. However, as C had been required to make a second formal complaint to achieve this outcome, we upheld this complaint.

In reference to the council's record-keeping of the reported incidents of bullying, we found that the council had improved their documentation since C's first complaint about this and incidents of bullying were now being recorded on the appropriate systems. As this was no longer a problem at the time of C's second complaint, we did not uphold this complaint.

As C had advised of being unaware of the stage at which their complaints were being handled, we provided feedback to the council to ensure that the complaint handling procedure was clearly explained to complainants.

Recommendations

What we asked the organisation to do in this case:

• The council have been asked to apologise to C for failing to manage reports of bullying in line with their policies and procedures. 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 to us regarding the treatment that they had received from the board relating to a diagnosis of liver cancer. They told us that there had been significant delays in carrying out appropriate tests and that they considered that their care had been very self-driven, stating that they had to chase up and request treatment on a number of occasions. They told us that they had received an unreasonable prognosis when being given their cancer diagnosis, being told that they were terminally ill with only months to live. They told us that they were only referred to a liver surgeon at their request, who was subsequently able to operate successfully.

They also complained that a consultant had written an unreasonable letter to their GP about one consultation, suggesting that their appearance had given cause for concern.

We took independent advice from a consultant oncologist (cancer specialist). We found that there had been unreasonable delays in carrying out C's tests. In particular, a failure to appropriately refer on the results of a scan, resulting in C having to chase this up and request a referral through their GP, and, a failure to mark the request to carry out a biopsy as urgent, resulting in a further delay.

These failures contributed to a delay in providing both diagnosis and treatment for C which was well out with normal guidelines for cancer treatment. In addition, the fact that C was required to seek a referral from their GP to further consider the results of their scan was considered to be evidence that their care had been unreasonably self-driven. We also found that an unreasonable prognosis had been given to C, as it was clear that the consultant in question was not best placed to provide a prognosis and further consultations were required before an accurate prognosis could be given. We therefore upheld these aspects of C's complaint.

However, while we noted C's strongly held view that the consultant's assessment of their appearance had been unreasonable, we were unable to find sufficient evidence to refute the consultant's record of that consultation. We therefore did not uphold that aspect of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for unreasonably delaying investigations into C's liver lesion, for failing to refer their MRI results to the Multi Disciplinary Team (MDT), and for providing an unreasonable prognosis. 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:

• Discussions about prognosis should take place with the appropriate clinician in light of a full consideration of the treatment options available.
• Requests for liver biopsies should be marked as urgent where necessary.
• The board should ensure all investigations into possible cancer are completed within the timescales set out in guidelines, wherever feasible.
• Where appropriate, MRI results should be referred to the MDT and actioned promptly.

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 community nursing care their parent (A) received for leg ulcers which had become infected. We took independent nursing advice, which highlighted that inappropriate dressings were applied to A's wound for a period, and also appropriate supplies of dressings were not obtained in a timely manner. When the wound did not improve, there was initially a failure to escalate the matter. We noted that there was appropriate escalation later and the wound management was reasonable from this point. On balance, we upheld this complaint.

C also complained that A was discharged from University Hospital Hairmyres (UHH) with an infection still present. We noted that A was receiving antibiotics and a follow-up plan was in place, and that the discharge was reasonable even in the presence of infection. We did not uphold this complaint. C also complained that A was not reasonably assessed when they attended UHH emergency department. C was unhappy that A was assessed without removal of their bandage, and that no swabs were taken. We took independent advice from a consultant in emergency medicine. We noted that there was a reasonable focus on A's knee pain/swelling and no unreasonable omission in terms of examining the leg wound. We did not uphold this complaint.

Finally, C complained that the board's response to their complaint failed to refer to A's fall in hospital. In responding to our enquiries, the board offered assurances that A had not fallen, but rather experienced a feinting episode due to low blood pressure. We confirmed that this was supported by the medical notes. We considered the board to have reasonably explained why this was not referred to in their complaint response, and we did not uphold this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to appropriately manage A's leg ulcers for a period. 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:

• Appropriate dressing products are used for leg ulcer management with wound dressings being available at the time of dressing changes.
• Nursing staff make timely referrals to the Leg Ulcer Service if a wound is not progressing.

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 on behalf of a business, which operated out of two neighbouring premises. C complained about Castle Water Ltd's management of the business's water account. The business had been a customer of Castle Water Ltd for a prolonged period and paid a monthly direct debit for their water and waste water usage. The business began to receive invoices from Castle Water Ltd that C disputed. Over a number of months, C attempted to clarify why the invoices had been issued and what amounts were due to Castle Water Ltd. C met with a representative of Castle Water Ltd who advised that the business's account was up-to-date and that they were, in fact, in credit. However, a payment of £505.47 was subsequently taken from the business without notice. Castle Water Ltd explained that this amount had previously been overlooked and that it was owed by the business.

C complained that the business was issued with numerous invoices and credits that did not add up to the amounts taken from the business's bank account. C noted that the business had always paid the monthly amounts set by Castle Water Ltd in line with their tariffs and questioned why the business was being charged additional amounts without explanation. The business remained in dispute as to the amounts owed, due to a lack of clear explanation regarding the reasons for the additional invoices. C was also dissatisfied with the way that their complaints to Castle Water Ltd were handled.

Whilst we were satisfied that the provider handled C's complaints in line with their complaints procedure, and did not uphold this aspect of C's complaint, we were however concerned by a number of aspects of their handling of the business's account. We found that the provider began issuing invoices to the business, treating them as an unassigned premises, without realising that the business had already been paying the provider for water services for a number of years.

When C questioned the invoices, the explanations that they were given caused additional confusion rather than providing clear information as to what the charges were for. The billing situation was complex due to there being multiple premises and a mixture of annual and monthly billing schedules. We were critical of Castle Water Ltd for failing to set out their charges in a clear and understandable way. The invoices that were issued bore no relation to the amounts that the business was being charged. Whilst Castle Water Ltd's internal records of the account were accurate and the business was ultimately billed correctly, this was not evident from what was sent to their customer.

We recognised that Castle Water Ltd ultimately acknowledged and apologised for the errors in communication and the lack of clarity in their invoices. They also took steps to improve their services for future customers. However, we were critical of the fact that C had to spend a significant amount of time and effort seeking clarification of the charges that the business owed and the fact that the information provided repeatedly made the situation less clear. Therefore, we upheld the aspect of the complaint that the business's billing account was unreasonably handled.

Recommendations

What we asked the organisation to do in this case:

• Consideration to be given to making a further good will payment.

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.