Some upheld, recommendations

Summary

C complained to us on behalf of their parent (A) who has dementia. A was admitted to Glasgow Royal Infirmary (GRI), after falling at home. A's condition improved and they were discharged home. After a few days, A was readmitted to GRI and treated for pneumonia (inflammation in the tissue of the lungs). Although A responded well to the treatment, their family was concerned about their mobility and pain when moving. A was referred for imaging of their pelvis and hip, which did not find a skeletal injury. Later that month, A was transferred to Stobhill Ambulatory Care Hospital. Around a week later, A was given a lumbar x-ray, which found a vertebral wedge fracture (a fracture of the bones commonly called the lower back). C raised concerns about A's medical care and their nursing care at both hospitals.

We took independent advice from a consultant physician in geriatric medicine (a specialist in medicine of the elderly). We did not consider that there was an unreasonable delay in carrying out A's lumbar x-ray. In particular, we found that it was appropriate that the medical staff had focused on ruling out A having fractures that might be treatable with surgery. We did not uphold this aspect of C's complaint.

We also took independent advice from an acute nursing specialist. We found that A's pain was not assessed appropriately, as nursing staff did not use the correct tool for someone with cognitive impairment (a condition that affects the ability to think, concentrate, formulate ideas, reason and remember). We also found that A fell at a time that they should have been under enhanced supervision by nursing staff due to their high risk of falls. 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 in A's nursing care. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

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

• Patients with cognitive impairment should have their pain levels assessed using an appropriate tool so it can be managed appropriately.
• When patients are considered to require enhanced observations in a cohort room, there should be appropriate nursing staff (in terms of both skill mix and staffing levels) to implement this.

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 made a complaint on behalf of their partner (A), who had a cancer diagnosis. C complained that there was a failure to keep A reasonably informed about appointments for treatment. C considered that the board had failed to ensure that they had A's address correctly recorded on the patient database. C also raised concerns about a delay in responding to the complaint, and a failure to provide a consistent explanation about why A was not reasonably informed of appointments for treatment.

We found that the board were able to provide copies of letters with the correct address, and whilst these had not been received by A, it was not possible to say that they had not been sent. In addition, whilst A turned up for an appointment that A did not know had been cancelled, the consultant did see A to carry out a full consultation. We did not uphold this aspect of C's complaint.

We found that the board provided conflicting accounts of what address information was held on the databases for C and for SPSO and whether or not this required to be corrected/had been corrected.

We also found that there was a delay in responding to C's complaint. We noted that the complaints department had moved, but we considered that it was reasonable to expect that the board would have in place a mechanism to forward the mail addressed to the complaints department to the new location within a reasonable period of time. We upheld these aspects of C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for (i) a failure to ensure they had correctly recorded on their patient databases A's address which he had lived at since August 2015, (ii) a failure to provide a response to C's complaint within a reasonable period of time and (iii) a failure to provide a consistent explanation regarding why there was a failure to ensure A was reasonably informed of appointments for treatment. The apology should meet thestandards 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:

• Ensure patient addresses are accurate on all databases.

In relation to complaints handling, we recommended:

• Ensure complaint correspondence received is directed to the correct department.
• Ensure a thorough investigation is carried out before a stage 2 response is sent to a complainant.

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 local secondary school. They referred to a number of incidents which they reported to the school. They complained that the school failed to investigate these incidents adequately. They also complained that the council failed to investigate their complaint about the handling of the reports of bullying appropriately.

We found that the school took steps to investigate the incidents in line with the relevant guidance and were helpful and supportive. However, in some instances it appeared that the school failed to speak to the pupils being accused of the bullying, failed to keep records of the steps taken in this regard and to provide C with follow-up contact in line with the relevant guidance. We also found that the council failed to respond to C's complaint about the handling of the bullying allegations in line with their complaints handling procedure. Therefore, we upheld these aspects of C's complaint.

C also complained that the council failed to appropriately handle administrative aspects of their appeal against the council's decision, following C's placing request for A to attend another school. We did not find evidence of any failings in this regard and did not uphold this aspect of C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C and A for failing to handle C's complaints about bullying in accordance with their guidelines. Additionally, apologise for failing to acknowledge and respond to C's complaint timeously and address all the issues raised by C in their complaint and identify emails from C to the school as complaints and deal with them under the Complaints Handling Procedure (CHP), or escalate the matter to the council to deal with under the CHP. 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:

• Complaints about bullying should be handled in line with council guidance. In particular, where appropriate, pupils accused of bullying should be spoken to, records made of the steps taken in this regard kept and parents who reported the incidents provided with follow-up contact, in accordance with the guidelines.

In relation to complaints handling, we recommended:

• The council should acknowledge and respond to complaints in line with the timescales set out in the CHP, address all the issues raised in complaints and demonstrate that each element was fully investigated, in line with the CHP and correctly identify emails from pupils' parents which are complaints to be dealt with under the CHP, or escalate the matter to the council to deal with under the CHP.

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 failure of emergency mental health services to treat them during crisis admissions. C stated that they had been brought to the hospital on multiple occasions by police but that an assessment was not always carried out. C also complained that they had not been allocated a psychiatrist (a medical practitioner who specialises in the diagnosis and treatment of mental illness) or a community psychiatric nurse.

The board responded by advising that services treated C appropriately when they attended and completed assessments when required. They also stated that C previously was supported by a psychiatrist but disengaged from this service and did not re-engage with services in the intervening period. C was unhappy with this response and brought their complaint to us.

We took independent advice from a psychiatric adviser and a mental health nurse. We found that the medical records showed that the board had acted reasonably and occasions where full assessments were not completed were appropriate and in keeping with strategies put in place to treat C. We considered that the plan to manage C's crisis contacts was in their best interests and we found no evidence of mental health assessment's being unreasonably withheld. Therefore, we did not uphold this aspect of C's complaint.

In relation to the allocation of a psychiatrist, we found that C had disengaged with services. However, proposed actions suggested by a psychiatrist to re-engage and support C did not appear to be actioned and records showed an unexplained gap in contact between C and services of around 18 months. Therefore, we upheld this aspect of C's complaint.

C requested a review of our decision and the case was reopened for further consideration. Details of this are explained below.

C was admitted to A&E at the Royal Infirmary of Edinburgh (RIE). After being transferred to an acute medical unit (AMU) from A&E, they left the ward and returned to their home. The police were contacted and they visited C at their home. C was detained under the Mental Health (Care and Treatment) (Scotland) Act 2003 (the Act) and returned to the RIE the following morning. C complained that the assessment carried out following C being detained and taken to hospital was unreasonable.

We took independent clinical advice from a consultant psychiatrist. We found that, while the board met the minimum requirement of the Act in terms of undertaking a medical assessment, there was no clear documentation detailing the mental state examination. We considered, given the complexity of the case, the lack of recent review and the presentation of C at the time, a formal assessment undertaken by an appropriately trained clinician from psychiatric services would have been reasonable and this did not take place. As such, we upheld this aspect of C's complaint.

C also complained that the assessment that was undertaken into their capacity was unreasonable. We found that there was no evidence to suggest that C did not have capacity to make their own decisions at the time. We noted that informal assessments are undertaken in every clinical interaction and we would not expect a formal capacity assessment to have been undertaken when clinicians considered C retained capacity. The psychiatric team had advised that in terms of C's mental health they considered C had capacity to make decisions on their care. The focus was then on whether C's physical injuries required care but C had consented to treatment for the same. Therefore, it was determined that there was no reason to detain C or undertake a formal capacity assessment. As such, we did not consider the lack of a capacity assessment to be unreasonable in these circumstances. We did not uphold this aspect of C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to undertake a formal assessment of them by an appropriately trained clinician from psychiatric services. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.
• Apologise to C that the agreed actions and proposed strategies were not pursued. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/leaflets-and-guidance.

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

• Individual clinicians will reflect on the outcome of this investigation as required within their annual appraisal process.
• The board should take steps to ensure that treatment plans devised are effectively followed through, in order to try and foster trusting relationships, minimise a sense of rejection, demonstrate service consistency and reliability and show a willingness to work in an open, engaging and non-judgemental manner.

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 their relative (A) about the treatment A had received from the board. A had emergency surgery to repair a dissected aorta (a tear in the heart) and was discharged following treatment. A developed an infection in their surgical wound and was readmitted to hospital for further treatment. C complained that in treating A's infection, the board incorrectly administered A with penicillin (an antibiotic) to which they are allergic. Following intravenous Co-Amoxiclav (antibiotic used for bacterial infections), A developed a skin rash. C also complained that A was administered ibuprofen which should not have been prescribed to A due to the heart medication they were taking.

We took independent advice from a clinical adviser. We found that there was no evidence in A's medical records of a penicillin allergy prior to the development of their skin rash following intravenous Co-Amoxiclav. We also found that the board's use of a penicillin derivative was reasonable and an appropriate choice of antibiotic for A's wound infection. We noted that the potential adverse effects of taking ibuprofen did not mean that it could never be used in patients taking A's heart medication. In A's case, the use of ibuprofen postoperatively had not been sufficiently documented, therefore we were not able to determine whether its use was appropriate. On balance, we found that the board had provided a reasonable standard of treatment to A and did not uphold this aspect of C's complaint.

C further complained that the board had not provided A with clear information regarding their cardiology (area of medicine concerning diseases and defects of the heart and blood vessels) rehabilitation and aftercare, resulting in a delay in A receiving appropriate follow-up appointments.

We took independent advice from a cardiologist. We found that the board had not correctly processed A's referrals for cardiology follow-up and cardiac rehabilitation or done so in a timely manner. The board had not correctly identified a discrepancy in A's nutritional assessment scoring or followed this up at the time. Therefore, we upheld this aspect of C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to A and A's family for not correctly processing the referrals for their cardiology follow-up and cardiac rehabilitation, and for providing A with aftercare that fell below a reasonable standard. 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:

• Ensure a process or system is implemented so that discrepancies with patient malnutrition universal screening tool (MUST) scores/nutritional assessments are easily identifiable so that follow-up dietetics reviews can be requested.
• Ensure appropriate referral pathways are in place to ensure patients receive timely cardiology and cardiac rehabilitation follow-up as noted in a patient's post-surgical discharge summary.

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 underwent surgery for removal of a complex cyst on their right ovary. C complained that during the surgical procedure the board unreasonably removed their left ovary despite their express wishes it should be retained. They said that in the absence of a fully informed pre-surgical consultation, the board had not understood their surgical choices and had unreasonably prepared them for surgery. They said that following surgery, the board had failed to provide them with adequate pain relief and had withheld their medication. C also complained that the board's handling of their complaint was inadequate and that there were delays and inaccuracies in their response.

We took independent advice from an appropriately qualified adviser with experience in obstetrics and gynaecology (pregnancy, childbirth and the female reproductive system). We found that the surgical procedure performed was in line with the recommendations of a multidisciplinary team (MDT) and that the board had acted on what they believed were C's express instructions and for which written consent had been obtained. As such, we did not uphold this part of the complaint.

We found that despite reasonable attempts to include C in the pre-surgical decision-making and consent process, the board had failed to clarify with C their understanding of the proposed surgical plan and the circumstances in which C's left ovary was to be removed. We also found that the board had not telephoned C following the MDT team meeting as had been agreed, and some of the pre-surgical discussions that had taken place between the parties were brief or had not been documented in the clinical records. Therefore, on balance, we upheld this part of the complaint.

Following C's surgical procedure we found that there were two occasions where analgesia (pain medication) had been delayed after being requested, and on one of those occasions where it appeared to have been an inadequate dose. However, we found that C's usual pain regime medications had been administered regularly and their acute pain medications administered when requested. As such, we found that C had been provided with appropriate pain relief and did not uphold this part of the complaint.

We found that the board's complaint handling in this case was poor. There was a failure by the board to update C on the progress of the investigation and there were delays in a number of their responses. The board's final response contained a number of factual inaccuracies and it had not adequately addressed all of C's concerns. As such, we upheld this part of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to clarify their understanding of the proposed surgical plan, the circumstances in which their left ovary was to be removed and for failing to handle their complaint reasonably. Also apologise for not sufficiently documenting the discussions that took place between the parties at the initial consultation, for failing to contact C by telephone following the MDT meeting, and for failing to document the pre-operative discussions which took place between the parties on the morning of C's surgery. 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:

• Ensure all discussions between patients and clinicians are clearly documented as part of the consent process.
• All relevant clinical staff should be reminded of the need to ensure all reasonably practical steps are taken to clarify a patient's understanding of a proposed surgical plan prior to consent being obtained and that patients are fully counselled on the nature of borderline ovarian cancer results.

In relation to complaints handling, we recommended:

• The board should ensure all complaints are handled in line with the NHS Model Complaints Handling Procedure, particularly in terms of the requirement to respond in writing and in a timely manner. Where a response to a complaint cannot be provided within an agreed timescale, complainants should be provided within an updated timescale as to when they can expect to receive a response. The board should ensure all responses are accurate, reflect the available evidence and information, and address all points raised. Where there has been a delay in providing a response beyond the normal timescale, the board's stage 2 response should include an apology.

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 submitted a housing application to the council and complained about how this was handled. C complained that the council unreasonably suspended their application while investigating their personal circumstances, that they ignored their medical conditions, and that they did not respond to C’s concerns appropriately. The council said they considered C’s application was handled appropriately and they noted that C has since accepted an offer of permanent housing.

We found that, while C did record their medical conditions on the housing application, they did not indicate that they required any specific adaptations, therefore the council handled the application appropriately. We did not uphold this aspect of C's complaint. While we considered the council handled C’s application appropriately overall, and they gave appropriate advice in response to C’s queries, we did conclude that the council’s housing allocations policy was not clear about the circumstances that an application will be suspended. As such, we upheld the second part of C's complaint and asked the council to review their policy to ensure it is clear and transparent with regard to when housing applications will/will not be suspended.

Recommendations

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

• Housing applicants should be informed promptly if/when their housing applications have been suspended, in accordance with the council’s policy.
• The council’s policy should be clear on the circumstances where a housing application will or will not be suspended.

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 their late parent (A) who died following surgery to remove cancerous tissue. C said that the care and treatment that A received in hospital was not reasonable, and that A’s cancer should have been detected earlier. C believed there were failings in the management of A’s care which caused A pain, distress and discomfort and this was worsened by the standard of nursing care.

We took independent advice from two appropriately qualified advisers. We found that the diagnosis concerning the spread of cancer was reasonable and did not uphold this aspect of C's complaint.

In relation to nursing care, we found that there was a lack of accurate and appropriate pressure assessments, and a lack of timely interventions led to the development of severe pressure damage. There was inappropriate wound management causing deterioration to wounds and poor observation of urinary output. We also found that the standard of record-keeping was unreasonable, that national pressure ulcer prevention standards and relevant policy were not followed and there was delay in referring to specialists. 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 standard of nursing care provide to A, for failing to carry out appropriate assessments to prevent severe pressure damage, failing to provide appropriate wound management, failing to appropriately monitor urine output, delaying referrals and failing to follow relevant standards and policy. 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:

• A wound chart should be completed for each wound detailing size, tissue type present, treatment and treatment objectives.
• Fluid balance charts should be completed to acceptable standard for early recognition of fluid balance issues.
• Pressure ulcer risk assessments should be calculated properly on admission and reassessments recorded at least weekly and when clinical condition changes.
• Sufficient information should be given to a patient and or their family to allow them to make an informed choice when deciding to decline pressure relieving interventions. This should be recorded in the case notes.
• Tissue viability referrals should be made in line with the relevant national guidance.

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 their child (A) who has a background of low mood and anxiety. C complained about the assessments of A by two paediatric consultants. C also complained that the Child Adolescent Mental Health Service (CAMHS) unreasonably rejected referrals from A’s GP due to social work’s involvement with the family.

We reviewed the relevant medical records and took independent advice from a consultant paediatrician and registered mental health nurse. We concluded that the assessments by both paediatricians were reasonable and appropriate tests and follow-up were arranged. We did not uphold this aspect of C's complaint.

However, we considered that it was unreasonable for CAMHS to reject the referrals on the basis that they failed to risk assess A in accordance with the board’s guidance. On that basis, we upheld this aspect of C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C and A for failing to accept the initial referrals to CAMHS and for the subsequent delay in treatment and the distress caused. 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:

• Ensure staff have reflected and learned from the findings of this investigation.
• The CAMHS service correctly follows the board’s suicide prevention guidance and pathway.

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 their spouse (B) complained about events during two periods of hospital treatment for their child (A). A has complex medical needs. They are cared for by C and B at home, however they have required multiple and prolonged spells in hospital. C and B complained about the care and treatment A received, communication by the board, communication within the board and how their complaint was handled.

In response to C and B’s complaints, the board acknowledged a number of failings in A’s care and treatment and the way in which they had communicated with C and B. They also said that consideration should have been given to earlier involvement of social work and the community children’s nurse.

We took independent advice from a consultant paediatrician and a social work adviser. We found that the care and treatment A received on their first admission were unreasonable. We considered that there was inadequate dietetic support, an unreasonable reliance on C and B's assessment as to whether intake was sufficient, and a lack of information and help for the family when A required emergency care after a gastro-jejunal tube (G-J tube, a tube used to vent the stomach and small intestine) procedure. We upheld this aspect of the complaint.

In relation to A's second hospital treatment, we considered the care and treatment to be reasonable. We did not uphold this aspect of the complaint.

We also found a lack of reasonable communication with C and B about A's care and treatment and a lack of reasonable communication between the board’s staff during A's second admission. We upheld these aspects of the complaint.

Finally, we found that the board failed to handle C and B's complaint reasonably. We upheld this aspect of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C and B for the lack of information on what to do if they had concerns following the procedure, for wrongly informing them that the child concern form (CCF) would be removed from A’s medical records (and explain the reasons why this cannot be done) and for the failings identified in complaint handling. 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:

• All relevant staff should be aware of the local guidance for the management of fabricated or induced illness (FII) for multi-agency use, of the guidance for the completion of CCFs, of their roles and responsibilities in such cases; and of the GMC guidance: Protecting children and young people 2012 (in particular Sections 56 and 57).
• Children with feeding tubes should have a de-escalation plan individualised for each child advising of the feeding regimen if the tube dislodges. This should be shared with parents, tertiary and local centres. There should be clear documentation of advice regarding fasting for procedures and a checklist to identify those who may be at risk of fasting. Consideration should be given to carrying out such procedures on an in-patient basis if the patient is considered at increased risk.

In relation to complaints handling, we recommended:

• Complaint investigations and responses, including acknowledgement of receipt, should be in accordance with the board’s Complaints Handling Procedure. The board should keep a complainant regularly updated about their complaint including when they should expect to receive a response to their communication and if there is going to be a delay in providing this.

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.