Some upheld, recommendations

Summary

C applied for a Collaborative Doctoral Award (CDA) programme. One of the key features of a CDA is the opportunity to work with an industry partner (IP) as well as academic staff. C complained that their supervision had been flawed and that there had been a lack of engagement with the IP. They also complained about how their complaint was handled.

We considered the information both C and Glasgow School of Art (GSA) provided in support of the complaint. We found that C had regular supervision meetings which were documented as required. There is also evidence that C’s supervisors were readily available by email and responded promptly to C’s contacts. However, according to associated guidance from the Arts and Humanities Research Council Training Grant Funding Guide and their guide on CDAs, GSA should have set out the structure of the collaboration and the expectations of those involved. They did not define what a CDA is or the expectations of the IP and student. The student did not receive an induction at the IP’s business address nor was a supervisor appointed at the IP. We upheld this complaint.

We were satisfied GSA had provided a reasonable response to C's complaint, which was about a number of different issues as well as supervision, and did not uphold that 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.

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 attended A&E at Perth Royal Infirmary following a knee injury. They were diagnosed with a soft tissue/tendon strain and advised to attend their GP for follow-up. C said that their knee did not settle and attended the hospital again six months later. C was then told that they had a meniscal tear (a partial or full tear in the cartilage of the knee). As their condition did not improve, C underwent an operation. C said that they experienced no relief following the operation and their GP made a further referral to orthopaedics (specialists in the treatment of diseases and injuries of the musculoskeletal system). They were advised that further surgery would be unlikely to help and, therefore, there was no clinical reasons to operate further.

C complained about the care and treatment they were given by the board. C said that there was a delay in providing appropriate treatment and diagnosis, that their care was poor and that the board did not deal reasonably with their complaints about this.

The board said that C’s initial care and treatment had been appropriate and although they were aware of C’s view that they should have been x-rayed when they first attended the hospital, to have done so would not have shown the subsequent diagnosis they received. The board added that scans and x-rays were not routinely carried out for knee injuries and that C had been given appropriate advice.

We took independent advice from consultants in emergency medicine and in orthopaedics. We found that, overall, C’s care and treatment had been reasonable. However, there was a failure to carry out an x-ray when they first attended hospital which was contrary to accepted guidance regarding when an x-ray of a knee should be undertaken following trauma. For this reason, the complaint was upheld.

In relation to complaint handling, we found that C was kept fully apprised of the progress of their complaint and given a new target date for a response which was met. We did not uphold this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failure to x-ray their knee in accordance with the Ottowa knee rules. 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:

• When presented with knee injuries in A&E, clinicians should take into account the relevant guidance (in this case the Ottowa knee rules).

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’s late partner (A) tested positive for COVID-19. A week after testing positive, A called 111 as they were still feeling very ill. They explained that they had had a fever for a few days and were having difficulty regulating their temperature. A was advised by a nurse practitioner to remain hydrated, continue taking paracetamol, and to continue to self-isolate until they had no fever for 48 hours. They were also advised to call back if they had any further concerns about their symptoms.

C called 111 again a few days later as they were concerned A’s breathing was becoming laboured. C had to wait around 20 minutes before the call was answered. During the call, the call handler repeatedly asked to speak to A to take information directly from them, even though C kept answering for A as A was confused. The call lasted around 30 minutes. The call handler contacted Scottish Ambulance Service and requested an ambulance on an emergency basis, but by the time paramedics arrived A had stopped breathing and could not be resuscitated. C complained about the clinical assessments of A’s condition on both instances.

We took advice from an advanced nurse practitioner with experience of assessing patients with similar presentations. We found the assessment on the first instance to be reasonable, and we therefore did not uphold this complaint.

We considered it unreasonable for the second call to have lasted 30 minutes before an ambulance was called. We noted that the call handler was following the protocol correctly, but were of the view that if the protocol took 30 minutes to establish that an emergency response was required, it was not fit for purpose. We considered that rigid following of the protocol led to a delay in obtaining medical attention for A. Therefore, we upheld this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failings we have identified. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

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

• Protocol is reviewed so that in patients with shortness of breath as the primary presentation there is a clear escalation route to a medically trained clinician.

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 various aspects of the care and treatment their late spouse (A) received from the board.

A had a history of vascular (relating to a vessel or vessels, especially those which carry blood) surgery and was admitted to hospital for the removal of a benign tumour. The procedure took place, however, A’s condition deteriorated and they were moved to an infectious diseases unit with suspected sepsis (blood infection). A’s condition deteriorated further and they were transferred to a vascular and critical care ward in a different hospital on an emergency basis. Later that day, A underwent surgery to remove an infected synthetic artery graft (a piece of living tissue that is transplanted surgically).

A experienced an abdominal bleed and was transferred to a critical care unit. After treatment, A was reviewed by a consultant and returned to the vascular and critical care ward. A experienced a fall on the ward. A later developed a lung infection/sepsis and died.

C complained that the board failed to screen, manage or treat A’s infection. C said that A had been discharged from the critical care unit onto the ward too soon. C also complained that the board had failed to properly assess A’s fall risk or treat A properly after their fall.

We took independent advice from a consultant geriatrician (a doctor who specialises in medicine of the elderly) and a registered nurse. We found that the screening, management and treatment of A’s infection and their discharge from the critical care unit was reasonable. We did not uphold these complaints. However, we found that the board had failed to adequately complete risk assessments, including a falls risk assessment, for A. We upheld this complaint.

We also considered that the board made an error of communication while responding to C’s complaint when they referred to MRSA (a bacterial infection that is resistant to a number of widely used antibiotics) instead of MSSA (a bacterial infection which is not resistant to certain antibiotics). We provided feedback to the board about this.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for wrongly referring to MRSA rather than MSSA when responding to C’s complaint and for their failure to complete A’s Falls Risk Assessment; bed rails and 4AT delirium assessments in line with organisational 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:

• Falls Risk Assessments and bed rails/4ATdelirium assessments should be carried out in line with the board’s stated policy.

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 referred urgently to the gynaecology department (medicine of the female genital tract and its disorders). During the vetting procedure the board requested the referral be downgraded to routine and the GP complied with this request. Following a consultation with the first consultant, C was scheduled for an operation. During the pre-operation examination by the second consultant, a cervical tumour was found and the operation cancelled. When informed of this, C made a verbal complaint about their treatment since being referred.

Biopsy results confirmed the tumour as malignant. C lost faith in the clinicians involved and requested a second opinion. A consultant oncologist (cancer specialist) met with C to discuss this and took steps to arrange a second opinion. C also took steps to obtain the second opinion using personal contacts. The second opinions provided concurred with that of the board. C complained to the board in writing regarding their experiences. A significant clinical incident (SCI) investigation was undertaken and following this, the board responded to C’s complaints. C was dissatisfied with the board’s responses and brought their complaint to this office.

We took independent advice from a consultant gynaecological oncologist. The SCI investigation had found that the board failed to give advice, contrary to relevant guidance, to C’s GP regarding the referral submitted as urgent. We upheld C’s complaint about this and accepted advice received that the board’s revised guidance had addressed the identified failings. However, the board had not apologised to C for these.

The board concluded the time taken between C’s referral by their GP and a correct diagnosis being reached was unreasonable and also accepted the time taken to respond to C’s complaint was unreasonable. We upheld C’s complaints about these and found that the board had not reasonably apologised to C for the delay in diagnosis.

We found that C’s verbal complaint had not resulted in reasonable action being taken as there was no evidence of any consideration regarding the complaint until C made a written complaint over two months later.

We accepted the advice we received that the board provided reasonable care and treatment to C following their diagnosis and that there were no concerns about how the SCI investigation had been carried out in relation to the board’s policy. We did not uphold these complaints.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the specific failings identified. The apology should make clear mention of each of the failings identified as well as include a clear stated apology for the delay in C’s diagnosis. 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 take all reasonably practicable steps in the present circumstances to ensure that they comply with the Treatment Time Guarantee.

In relation to complaints handling, we recommended:

• The second consultant should take action to ensure that all complaints are appropriately recognised, acknowledged and actioned, including verbal complaints.

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 an admission to Forth Valley Royal Hospital two weeks after undergoing emergency bowel surgery there. C was admitted with a fever and vomiting and spent many hours on a trolley in A&E in severe pain. They were diagnosed with an abdominal abscess (a painful swelling caused by a build-up of pus). C complained that the abscess was drained by a surgeon while they were still on the trolley in unsterile conditions and with no anaesthetic. C complained that they were left with the wound open and that they did not receive antibiotics until later that evening, after they were transferred to the Surgical Assessment Unit. C complained that they were left with a soaked dressing and a foul-smelling wound until the following morning. They complained that failings in their care and treatment led to development of an MRSA infection (a bacterial infection that is resistant to a number of widely used antibiotics) and a hernia at the wound site.

We took independent advice from a consultant in emergency medicine. While acknowledging the length of time C had to wait for a bed, we found that generally C’s care and treatment were reasonable. We found that C was assessed appropriately and received reasonable treatment for their condition within an acceptable timescale. However, we noted that there had been a delay in C receiving antibiotics which was unreasonable. Whilst recognising how difficult C’s experience had been, on balance, we did not uphold the complaint about the standard of care and treatment in A&E.

We also took independent advice from a general surgeon. We found that C had generally been treated appropriately and that the development of MRSA and a hernia had not occurred as a result of any failings in care and treatment. Despite there being no significant clinical failings, we acknowledged C’s extremely poor patient experience including the board’s apparent failure to ensure that C was kept clean with their wound dressing changed in a timely manner. On balance, we upheld the complaint about the standard of care and treatment in the Surgical Assessment Unit.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the delay in providing an adequate wash and changing of their dressing, with recognition of the impact these matters have had on them. 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:

• Staff ensure that patients are kept adequately clean and dressings changed when needed.

In relation to complaints handling, we recommended:

• Complaints are responded to as comprehensively as possible, particularly in situations in which complainants have requested that specific matters are investigated.

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

Concerns were raised during C's time on community work placement. Investigations were carried out and having considered the information available, the risk management team (RMT) at Prison A took the decision to return C to closed conditions (Prison B).

C considered that Prison A failed to seek relevant evidence as part of their investigation, and dismissed relevant evidence, prior to taking the decision to return C to closed conditions. We found that the RMT at Prison A appropriately considered the circumstances of C's case, taking relevant information into account, prior to reaching the decision to return C to closed conditions. Therefore, we did not uphold this aspect of C's complaint.

C also complained about the way the Scottish Prison Service (SPS) handled their complaint. They said that no Internal Complaints Committee (ICC) hearing was convened and the recommendation put forward by them was unachievable.

We found that C escalated their complaint to the ICC around the time the Scottish Government requested everyone to stop non-essential contact and travel due to the COVID-19 pandemic. C's complaint was passed from Prison B to Prison A to respond at ICC stage because the matter related to actions taken by the RMT at Prison A. Whilst an ICC hearing was not convened because of restrictions in place, Prison A did appoint a representative to consider C's complaint. However, we found that Prison A failed to share their findings and recommendation in relation to C's complaint with Prison B to ensure the matter could be given further consideration. We considered that the ICC failed to handle C's complaint reasonably and upheld this aspect of C's complaint.

In relation to the recommendation put forward by the ICC, we found this to be reasonable. 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 handle their complaint appropriately. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.
• Provide written confirmation to C in relation to the current status of the First Grant of Temporary Release application.

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, a solicitor, complained on behalf of their client (A). A is elderly and has multiple disabilities. They live in their own flat and have care provided by the partnership. A number of support needs assessments were carried out over several years. The partnership proposed to reduce A's in-person care provision and put in place a telecare system. C complained about this and then complained to our office about a delay in receiving a response to that complaint. Our office made a discretionary decision to progress the complaint in light of significant complaint handling delays. We decided to consider the substantive matters, as well as the complaint handling process.

We took independent advice from a social work adviser. We found that the assessments of A's needs were reasonable and evidence showed that A's views and those of their carers were taken into account. The partnership were entitled to review care arrangements and consider how they use their resources. The partnership also proposed a trial period, phasing in the changes, which we found to be reasonable. Therefore, we did not uphold this aspect of C's complaint.

In relation to complaint handling, we found that there were significant delays in responding to C. We noted that the partnership's information about what they would and would not consider a complaint, was unhelpful. 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 the delays in responding to the complaint, giving unhelpful information about what they would and would not consider a complaint and for speculating on whether their complaint handling failings had caused detriment or injustice to the complainant. 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:

• Complaints should be handled in line with the Model Complaints Handling Procedure. Complaints should be responded to within 20 working days or, where this is not possible, adequate explanation must be given alongside a reasonable timescale for the 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 actions of a consultant during an appointment to assess them for adult Attention Deficit Hyperactivity Disorder (ADHD, a behavioural disorder that includes symptoms such as inattentiveness, hyperactivity and impulsiveness). They also questioned the basis upon which the determination that C did not meet the criteria for ADHD had been made.

We took independent advice from a psychiatric adviser. We found that the clinical records were detailed and comprehensive and clearly showed that the consultant who assessed C had acted in accordance with relevant guidance. We found that the evidence demonstrated that the clinical records contained relevant information to provide a clear opinion as to whether or not C had ADHD which was informed by appropriate historical, clinical and questionnaire based information. We also found that the decision to discharge C back to their GP practice was appropriate and reasonable, particularly as the evidence demonstrated the consultation had been a second opinion appointment. We found no evidence that the consultant had acted unreasonably at the clinic consultation and we did not uphold this complaint.

C also complained about the response they received to their complaint. We found that the response from the partnership was unreasonable as it contained the personal views of a senior manager unrelated to the information in the case record. There was also a failure to address aspects of C's complaint regarding specific questions which had been asked during the consultation. As such, we upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for including personal opinions in the complaint response which were not relevant to the outcome of the investigation and for failing to address all aspects of C's complaint in their 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:

• Staff should be reminded of the partnership's complaints handling policy. In particular, in relation to the necessity for those dealing with complaints to remain objective, impartial and independent, and the requirement to address all the issues raised.

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) in A&E. We took independent advice from an accident and emergency adviser. We found that A waited an unreasonable amount of time for a clinical review on their attendance to A&E and this did not meet the triage category standards assigned to A. We also found that sepsis (blood infection) should have been considered at an earlier stage during one of A's attendances to A&E given their low blood pressure and increased respiratory rate. We upheld this aspect of C's complaint.

C complained that the board failed to provide A with reasonable care and treatment regarding a chyle leak (an accumulation of lymphatic fluid in the abdominal cavity). We took independent advice from a surgical adviser. We found that A was provided with reasonable care and treatment for the chyle leak, that their pain and discomfort was appropriately investigated and responded to and that reasonable action was taken in relation to the prevention of blood clots. As such, we did not uphold this aspect of C's complaint.

Finally, C complained that A's mobility was not fully investigated while they were in hospital. We took independent advice from a physiotherapy adviser (a person qualified to treat disease, injury, or deformity by physical methods such as massage, heat treatment, and exercise). We found that A was provided with reasonable care by physiotherapists in the assessment and management of their mobility. 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 not considering sepsis at an earlier stage during A's attendance to A&E given their low blood pressure and increased respiratory rate. 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 should receive a clinical review within triage category timescale.
• Sepsis should be considered in A&E patients who present with low blood pressure and increased respiratory rate.

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.