Some upheld, recommendations

Summary

C complained on behalf of their spouse (A) about the treatment they received from the board. A was originally referred to a consultant obstetrician and gynaecologist (specialist in pregnancy, childbirth and the female reproductive system) at a different health board. Following further investigations, A's case was discussed at a multidisciplinary team meeting (MDT) which includes specialists from health boards in the west of Scotland. As Glasgow has a subspecialty in gynaecological cancers, Greater Glasgow and Clyde NHS Board took the lead in determining A's treatment plan. A was diagnosed with probable ovarian cancer and was treated with chemotherapy and surgery.

C complained about a delay in starting A's treatment, about the decision not to offer chemotherapy first and about how the board responded to their contacts during this time.

We took independent advice from a consultant gynaecological oncologist (cancer specialist). Scottish Government guidance, NHS Scotland performance against Local Delivery Plan standards, says that 95% of all patients diagnosed with cancer are to begin treatment within 31 days of decision to treat. A's treatment was not provided until 40 days later (nine days more than the guidance). Greater Glasgow and Clyde NHS Board were responsible for meeting this target, and it was not met. We upheld this complaint.

We found that while some clinicians would have treated with chemotherapy first, it was also completely acceptable practice, and indeed encouraged by relevant clinical guidelines, to provide surgery first. We did not uphold this complaint.

We considered the communication between C, A and the board. We found that while not every contact was responded to as quickly as the board said it would, and some communication was passed on without acknowledgement, the board did respond to the substantive questions C and A raised and had appointed a single point of contact to help communication going forward. We did not uphold this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to A for failing to meet the Local Delivery Plan standard. 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 a number of different aspects of the board's communication with them. Firstly, C complained about how the outcomes of two magnetic resonance imaging (MRI) scans were communicated to them. In respect of one scan, a consultant neurologist (specialist in the diagnosis and treatment of disorders of the nervous system) advised there had been “no change”. A later scan was then described as “unchanged over time”. After C obtained their medical records, they concluded that there were changes identified in both of the MRI scans.

We took independent advice from a consultant neurologist. We found that it was reasonable to describe the results as unchanged. We noted that most clinicians would, on receiving a report which described changes in a lesion which were of no clinical significance, report to the patient that there was no change. We understood why C may consider the information passed to them to be inaccurate compared to the more detailed records they obtained through a subject access request. However, we concluded that the results of the MRI scans were communicated to C in an acceptable manner and the board did not fail to carry out any follow-up actions that they should have. Therefore, we did not uphold this complaint.

C also complained about the board's communication with them following a consultation with a consultant ear, nose, throat and skull base surgeon. C had been referred by another consultant for a second opinion. Following the consultation, the consultant wrote to the referring consultant and copied in C's GP. However, C did not receive any communication about the outcomes of the consultation and their GP advised them that it is not a GP's responsibility to share results of tests initiated by a secondary care doctor with patients. In C's view, the board should have communicated the outcome of the consultation to them directly.

We found that local policies and procedures may affect how outcomes of consultations are communicated to patients. We were satisfied that the board appeared to agree that it is not a GP's responsibility to relay such outcomes to their patients. However, we would expect the patient to be copied into documentation unless there is a specific reason not to. We considered it unreasonable that the outcomes of the consultation were not communicated directly to C in some form. As such, we upheld this complaint.

Finally, C complained that the board failed to respond reasonably to their complaint. In C's view, the board's stage 2 response did not address several important points of their complaint and contained inaccuracies. We considered the board's stage 2 response to be a broadly reasonable and good faith attempt to address C's concerns. However, we concluded that there were specific aspects of the board's stage 2 response that undermined their efforts to address C's concerns. Firstly, a poorly worded statement caused it to be fundamentally inaccurate and confusing. Secondly, in some instances, the board failed to provide direct responses that tied clearly into C's complaint points. Given these shortcomings, we upheld this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to provide a reasonable response to certain aspects of their complaint and for failing to communicate the outcome of their ear, nose and throat consultation directly to 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:

• The board should ensure that the outcomes of consultations carried out by secondary care clinicians are communicated to the patient in an appropriate and recognised method. It should not be assumed that the patient's GP will forward any correspondence to them.

In relation to complaints handling, we recommended:

• In line with the Model Complaint Handling Procedure, stage 2 complaint responses should be clear and easy to understand, and address all the issues raised and demonstrate that each element has been fully and fairly 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

C complained on behalf of their spouse (A). A was urgently referred to a consultant obstetrician and gynaecologist (specialist in pregnancy, childbirth and the female reproductive system) at Forth Valley NHS Board. Following further investigations, A's case was discussed at a multidisciplinary team meeting (MDT) which included specialists from health boards in the west of Scotland. A different health board took the lead in determining A's treatment plan. A was diagnosed with probable ovarian cancer and was treated with chemotherapy and surgery.

C complained about a delay in starting A's treatment, about the decision not to offer chemotherapy first and about how the board responded to their contacts during this time.

We took independent advice from a consultant gynaecological oncologist (cancer specialist). Scottish Government guidance, NHS Scotland performance against Local Delivery Plan standards, says 95% of those referred urgently with a suspicion of cancer to begin treatment within 62 days of receipt of referral. From A's urgent referral to the start of treatment was 63 days, one day more than the guidance. As Forth Valley NHS Board was responsible for meeting this target but did not meet it, we upheld this complaint.

We found that while some clinicians would have treated with chemotherapy first, it was also completely acceptable practice, and indeed encouraged by relevant clinical guidelines, to provide surgery first. We accepted this advice and did not uphold this complaint.

We considered the communication between C, A and the board. We found that while not every contact was responded to as quickly as the board said it would, and some communication was passed on without acknowledgement, the board did respond to the substantive questions C and A raised. We did not uphold this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to A for failing to meet the Local Delivery Plan standard. 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 raised a number of concerns about the social work service provided by the council in relation to the contact between their child (A) and A's non-resident parent. At the time of the complaint, the social work service was responsible for managing contact between A and the non-resident parent.

We took independent advice from a social work adviser. C firstly complained about the way the council acted in relation to concerns they raised about what was in A's best interest. We found that the council acted reasonably in relation to a number of the concerns C raised. However, we also found that there was a failure in one instance to carry out a risk assessment timeously. On balance, we upheld C's complaint.

C also complained about the way the council handled a meeting that had been arranged to discuss A's contact arrangements. We did not identify failings in relation to this aspect of C's complaint and we did not uphold the complaint.

Finally, we considered the council's handling of C's complaint. We found that the council's complaint response did not address a number of C's points of complaint and that it failed to include an apology for a service failing the council identified during their own investigation. We made recommendations in relation to complaint handling.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to carry out a risk assessment timeously; for the service failing identified in the council's stage 2 response; and for the issues with 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:

• National Guidance for Child Protection in Scotland and the National Framework for Risk Assessment should be followed in relation to assessing risk.

In relation to complaints handling, we recommended:

• Under the Local Authority Model Complaints Handling Procedure, an investigation should explore the complaint in more depth and establish all the relevant facts. The aim is to resolve the complaint where possible, or to give the customer a full, objective and proportionate response. Where failings are identified, an apology should be offered.

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 parent (A) after A was unwell and a GP made a home visit to assess them. The GP called for an ambulance for a 'within the hour' response. The ambulance service called back later and spoke with C to advise that the ambulance was delayed and would attend as soon as possible. C later called 999 and advised that A's condition had deteriorated. This resulted in a higher priority ambulance being assigned.

C complained to the ambulance service about the failure to respond to the requests for an ambulance. In response, the ambulance service acknowledged they failed to meet the initial one-hour response requested, but explained that one-hour ambulance responses are not automatically upgraded. They said that in these circumstances they call back to explain the delay, ask if there is a change in the patient's condition and advise patients to call 999 if there is a change.

C complained to our office that the ambulance service had failed to take account of A's diagnosis provided by the GP, and had therefore not attributed the correct level of priority to the response. C also considered that there was no attempt by the ambulance service to undertake clinical triage of A, resulting in the response level not being upgraded as it should have been. C was unhappy with the investigation and response to their complaint and believed the ambulance service's response to the complaint was not plausible.

We found that whilst there was a significant delay in the ambulance attending to A, this was attributable not to failings on the part of the ambulance service in prioritising the request for an ambulance, but on the lack of available resources at the time.

However, we found that during the welfare call back, the ambulance service should have sought to clarify whether C considered A's condition had deteriorated before continuing with the call. On this basis, we upheld the complaint with respect to unreasonably failing to respond to the request for an ambulance. With respect to the complaint about the complaints investigation, we found the complaints investigation and response was reasonable and did not uphold this aspect of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to confirm whether or not A's condition had worsened before continuing with the call. 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:

• In circumstances where a call handler calls a patient, in line with the Urgent Welfare Call Back Process, they should make reasonable efforts to confirm whether or not the patient's condition has worsened. Where a call handler is unable to obtain clarification as to whether the patient's condition has worsened, the call handler should process the call through the MPDS system in line with the normal emergency call handling process.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

Summary

C complained to us on behalf of their late relative (A) regarding treatment A received from the board leading up to their death. C said that the board had failed to provide reasonable nutritional care and treatment after A was admitted to the Royal Infirmary of Edinburgh suffering from complications due to poor nutritional intake. They considered that the board had unreasonably delayed in diagnosing the likely cause of this nutritional deficit. C also said that the board had failed to reasonably communicate with A and their family, as they were only informed of the likelihood that A would die with around 48 hours' notice, previously believing A was due to be discharged.

We took independent advice from an appropriately qualified adviser. We found that the board had provided reasonable nutritional care and treatment, with no delay in diagnosis. We therefore did not uphold those aspects of the complaint.

However, we also found that the board had failed to appropriately assess A's likely prognosis and communicate this to them or to their family. As such, we upheld this aspect of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C and A's family for failing to reasonably identify and communicate their 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:

• The board should carry out reasonable and realistic assessments of a patient's prognosis, clearly communicate those assessments to the patient and, where appropriate, to their family, and make a record of these discussions.

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 support and advocacy worker, complained on behalf of their client (B) about the care and treatment their child (A) received in the early months of their life. A was born prematurely, suffered a number of medical problems following their birth and died a few years later. A was initially cared for in Aberdeen Maternity Hospital's neonatal unit. A was transferred for treatment in the High Dependency Unit (HDU) at Royal Aberdeen Children's Hospital. C asked us to investigate the standard of care and treatment that A received at Royal Aberdeen Children's Hospital. B said that A suffered a number of desaturation episodes which caused A to turn blue. They attributed this to staff being slow to react. A's feeds were increased upon admission to Royal Aberdeen Children's Hospital. B said that A's health began to deteriorate from this point. B said that A should have remained in Aberdeen Maternity Hospital's neonatal unit given A's weight at five months was still below that of many neonates, or else transferred to another neonatal unit elsewhere in Scotland. They complained that, whilst A was in Royal Aberdeen Children's Hospital, the level of supervision was insufficient, particularly over weekends.

We took independent advice from a consultant paediatrician and a paediatric nurse. We found that, while A's condition was complex, there was nothing to suggest that moving A to the HDU at Royal Aberdeen Children's Hospital resulted in a drop in the level of care and support available. We also found that the overall approach to managing and monitoring A's weight was reasonable. We did not uphold these aspects of C's complaint.

In relation to nursing supervision, we found that nursing staff reasonably monitored A throughout their time in the HDU, maintaining detailed and thorough records and appropriately escalating any issues identified to the medical team. We did not uphold this aspect of C's complaint.

In relation to medical supervision, while the nursing staff appropriately monitored A's condition and escalated A's management to medical colleagues when changes were observed, we found that these were not acted upon within a reasonable time in every case. On one occasion no medical staff attended for four hours following escalation by nursing staff. We upheld this aspect of C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to A's parents for the unreasonable delay in fulfilling a request for a medical review of A.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 have a system in place to alert a more senior member of the medical team to attend when requests for medical reviews cannot be fulfilled by the relevant medical staff within a reasonable timescale.

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 the Scottish Government had repeatedly failed to provide them with accurate information about agricultural grants that they were entitled to apply for. C said they had repeatedly visited the local office without receiving accurate information. C had complained about their experience but they had not received a response for a year. C said the Scottish Government response would not have been issued had they not repeatedly chased it up.

We found that there was very little evidence of the Scottish Government's complaint investigation. It was a matter of fact that C was responsible as the business owner for confirming that they had applied for all the entitlements they were eligible for. There was no evidence C had done this. In addition, for some of the years, C said they were poorly advised, the application had to be completed online, and C could not have been assisted with a paper application. We found the Scottish Government were not responsible for ensuring C applied for the correct entitlements. Therefore, we did not uphold this aspect of C's complaint.

The Scottish Government's response to C's complaint had, however, fallen below a reasonable standard. Appropriate records had not been kept and there was no evidence the Scottish Government had followed their complaint handling procedure. We upheld this complaint, and asked the Scottish Government to continue to provide evidence they were monitoring their complaints effectively and were able to identify delays. The Scottish Government were able to provide evidence showing the steps they had subsequently taken to improve their complaint handling.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failure to investigate their complaint in line with the Scottish Government's procedures. 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:

• Accurate and comprehensive records of complaints investigations need to be kept.

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 themselves and their neighbours. The council planned to redevelop the site of a former school, which is situated behind their properties. C raised a number of questions, concerns and objections on behalf of the local residents regarding plans for the site, maintenance of the area and the council's management of works being carried out on the site. Despite regular email and phone contact with the council, C complained that residents were not kept informed about work planned on the site or how their concerns would be addressed. C was also dissatisfied with the way their complaints about the situation were handled.

We found that the council generally recognised the impact the development had on the residents and took steps to address the issues that they raised. Whilst internally, they acted reasonably with regard to management and maintenance of the site and could show the reasoning as to why certain decisions had been reached, we found that the council's communication with C was poor. On a number of occasions, C would ask specific questions about aspects of the development, but would receive very general responses. This led to confusion and mistrust on the residents' part. While we found the council's communication to be poor, we considered that the council reasonably managed, maintained and repaired the site. We did not uphold this aspect of C's complaint.

In relation to complaint handling, we were critical of the council's handling of C's complaint. Whilst they responded to C's various calls and emails in good time, we again found that specific points raised by C were not addressed directly. We also found that, although C had direct access to a number of key members of staff, this meant that C's concerns were not escalated through a formal complaints process and largely went unresolved as a result. We upheld this aspect of C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failures identified in the council's handling of the complaint. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.
• The council should contact C to check whether there are any outstanding concerns that have not already been responded to and that these are agreed in writing and responded to in full.

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 how the council handled and assessed a planning application. The planning application related to a proposal for an extension to an existing business premises and was approved by the council. C's own business premises are located nearby and C raised concerns about how the extension would impact their business and the local area more generally. In response to C's complaint, the council acknowledged there were some failings in how the application was assessed and omissions in the Report of Handling. However, they concluded the application would have still been approved even if there were no failings in how it was assessed.

C complained that they did not think the council took appropriate action in response to the acknowledged failings and considered there to be other failings that the council did not identify in their stage 2 response. In addition to this, C complained about the council's sale of the land that the proposed extension is to be built on. In C's view, the sale of the land was not appropriately carried out by the council.

In respect of the first aspect of C's complaint, we took advice from an independent adviser with a background in planning. The advice we received, and accepted, was that there were further shortcomings in the assessment of the application and the content of the Report of Handling that were not identified by the council. While a number of C's outstanding concerns related to disagreements with the council's decision, we considered there to be examples of the council either failing to appropriately consider certain matters or not recording them in sufficient detail in the Report of Handling. As such, we upheld this complaint.

In respect of the second complaint, C was of the view that the land sold was classed as common good land and should not have been subject to sale. They also considered the council's sale of the land not to be in line with the European Commission's state aid rules. We concluded that the evidence did not support either of these conclusions and, therefore, did not uphold this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to consider certain matters appropriately in their assessment of the planning application and for the fact that the Report of Handling did not contain sufficient detail about parts of their decision-making. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.
• Given the failings identified in both the council and our investigations, comment on their view remains that there are no grounds or good planning reasons to revoke the planning permission. Provide justification for the decision reached to both C and this office.

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

• Planning applications should be assessed thoroughly and in line with relevant guidelines. Reports of Handling should be appropriately detailed and contain clear justifications for the conclusions reached.

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.