Some upheld, recommendations

Summary

C complained about the way that the council had dealt with their reports of noise in their home, and the way in which the council had handled their complaint about this.

The council had previously accepted numerous failings in connection with the issues raised by C. The council acknowledged failures with respect to communication and confirmed they would carry out further investigations and undertake works to address the soundproofing in the property, particularly relating to the transference of noise from a lower level flat.

After a period of a few months, C made a further complaint to the council about failures to take appropriate action and keep C updated with respect to efforts to proceed with soundproofing. C was dissatisfied with the council's response and brought their complaint to our office.

We found that the council took reasonable actions with respect to identifying an appropriate action plan, in installing acoustic underlay, as a first step in attempting to address the noise issues. However, restrictions in response to the COVID-19 pandemic, which were outwith the council's control, resulted in delays in the council being able to carry out the proposed works. For these reasons, we did not uphold the complaint regarding delay.

However, we found that the council unreasonably failed to communicate with C throughout the lockdown period during 2020 and therefore failed to keep C appropriately updated as to the plans in place to undertake the works. We upheld this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failure to communicate effectively regarding the plans to progress agreed works. 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 communicate with C regularly to agree the purpose and scope of any additional survey, and/or agree works to be undertaken (at present installation of acoustic underlay), and arrange to complete the work agreed as soon as reasonably practicable, once Scottish Government restrictions in response to Coronavirus allow. The council should communicate with C to agree and arrange appropriate monitoring to robustly test the effectiveness of the acoustic underlay and/or any other works carried out. Should monitoring reveal that the works have not resolved the noise issues, the council should communicate with C to agree further steps, including consideration of those set out in their complaints responses, to address the noise issues at the property.

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 their housing association. C had moved from one association property to another nearby. Some months after the move, C was presented with a bill for repairs. C disputed both the need for the repairs and the cost which they considered excessive. C also said they had been overcharged rent, by four days, without adequate explanation and that their complaint had been mishandled by the association.

We found the damage had been recorded by the association following a void inspection. While it was not the SPSO's role to assess the extent of the damage, the inspection had been carried out in line with the association's procedures, and they were able to provide evidence showing the damage had been recorded immediately after the vacation of the property, in line with its published procedures. We did not uphold this aspect of C's complaint.

C noted the association had agreed to collect the keys from them, but had failed to do so. This had resulted in a four-day delay but C had not been notified this would result in additional rent charges. C noted they had moved out of the property on the day agreed and the only available paperwork supported their positions. The association accepted that they had agreed to collect the keys from C and that they could not provide evidence to show what had been agreed in this respect. They would, therefore, adjust the rent account by the days in dispute. We upheld this aspect of C's complaint.

We found the handling of C's complaint was inadequate. The association had not agreed the complaint with C or discussed it with them. As a result their response had not addressed all the issues C had raised nor obtained all relevant evidence from them. We upheld this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failure to follow their procedures, the delay in informing them of the void inspection's findings and for failing to follow their complaints procedure properly. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets
• Confirm to C in writing when their rent account has been adjusted.

In relation to complaints handling, we recommended:

• Staff dealing with complaints should be familiar with the Model Complaints Handling Procedure, understanding the importance of communication and the need to demonstrate thorough investigation of the points 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 was previously resident in England and received a package of care from the local authority to assist them with activities they are unable to do due to poor mobility and mental health needs. C chose to move to Scotland and asked their social worker to contact Fife Health and Social Care Partnership (the partnership) so their care could continue.

After moving to Scotland, C was aware that two adult protection referrals (referrals made to social work services about an adult at risk from harm) about C were made to the partnership.

The partnership assessed C and determined that they did not meet the criteria to receive a package of care. C complained that the partnership failed to support them with their move and failed in their duty to ensure continuity of care. C also complained that the partnership did not investigate or act on the adult protection referrals appropriately. C was unhappy with the way in which their complaint was handled and with the communication they received from the partnership.

As a result of their complaint investigation, the partnership found that they had failed to follow their usual process and that the correspondence from C's social worker was not responded to as it should have been. They apologised for this and upheld C's complaint. They also highlighted that it may have been helpful to connect C with non-statutory support. The partnership told us they offered to connect C with non-statutory support as a part of their complaint investigation, but that this was refused by C. They apologised that C felt the way they communicated with them about their complaint was not appropriate.

The partnership said they gave C appropriate advice before C moved, and they assessed C (including the adult protection referrals) appropriately when they were resident in Scotland.

We found the partnership's failure to follow their usual process was unreasonable and that the partnership failed to reasonably support C prior to their move to Scotland. On this basis, we upheld this aspect of the complaint.

We considered that the partnership's assessment of C's needs was reasonable and in line with the relevant guidelines and legislation applicable to Scotland. On this basis, we did not uphold this aspect of the complaint.

We found the partnership did not keep any record of their discussion with C. In this circumstance, we would expect that the partnership keep an accurate record of what happened. We found that there was maladministration on the part of the partnership when handling C's complaint. On this basis, we upheld this aspect of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to appropriately handle C's complaint. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.
• When a potential resolution is identified during a complaint investigation and set out in the final response, this should be followed up and a record kept of the action taken.

In relation to complaints handling, we recommended:

• The partnership should ensure that complaints are handled in line with the Model Complaints Handling Procedure and that they keep a clear record of any discussion with the complainant and a record of any actions taken as a result of the 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 treatment provided to their spouse (A) by the board. A underwent knee replacement surgery. After the surgery, A's health declined and A died approximately five months later. C raised a number of issues relating to the surgery itself as well as the care and treatment provided afterward.

We took independent advice about this complaint.

We considered C's complaint on how the board failed to carry out the surgery in a reasonable manner. We found the board carried out the surgery in a reasonable manner, based on the experience of the surgeon, operation note and postoperative x-rays. As such, we did not uphold the complaint.

We considered C's complaint that the board failed to provide reasonable nursing care after A's surgery. We found that while some elements of nursing care were reasonable, the main type of care provided by the board; wound care, was unreasonable. We found four key points which were unreasonable and that these could have been addressed if a referral had been made to the tissue viability service once it was clear that the wound was deteriorating. This referral was not made. Therefore, we upheld this complaint.

C also complained that the board failed to provide reasonable treatment to A after the surgery. We found that there was a delay in the provision of A receiving antibiotics and, while this was not best practice, it was not unreasonable. We found that the actions in response to A's deterioration, including transfusions, surgery and medication, were reasonable and A's condition was reasonably monitored. Therefore, we did not uphold the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to provide reasonable wound 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:

• Allergies should be consistently recorded in patient's medical records.
• Appropriate wound assessments should be carried out for patients.
• Dressings should be removed immediately if it is known the patient is allergic to them.
• Where appropriate, referrals should be made to a tissue viability nurse specialist.
• Wounds should be treated with appropriate wound care products based on the wound assessment.

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 held power of attorney for their parent (A) and complained about the management of A's medication during a hospital admission for treatment of a chest infection. A's medication Furosemide and Ramipril (both used to treat heart failure) were stopped for eight days. A was readmitted to hospital again having suffered a heart attack and died.

The board acknowledged it was not recorded who stopped A's medication and why they did so, and that there were failings in how A's medication was reviewed and managed prior to discharge.

We took independent advice from a consultant geriatrician (a doctor specialising in medical care for the elderly). After review of relevant medical records and statements, we found that while it may have been reasonable to stop A's medication at the time, there was a failure to record who made the decision and their rationale for the decision.

We also found the board did not give adequate consideration as to whether the cessation of A's medication may have had an impact on A's readmission, further heart problems and subsequent death.

We also found that A's discharge letter was not appropriately updated prior to discharge. We upheld three of C's complaints, however we concluded that the board's communication with C about the changes to A's medication was not unreasonable in the circumstances and this complaint was not upheld.

Recommendations

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

• Individual staff, particularly the consultant responsible for A's care, should show they have included this complaint in their annual appraisal as part of reflective practice.
• That it has been considered whether the failures relating to the management of A's medication had an impact on A's need for readmission and ultimate death.

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) at University Hospital Monklands. During their admission, there was an incident involving A in the early hours of the morning. The board said that A was mobilised to a commode and, at A's request, given privacy to use it. The board said that A fell during this time and sustained injuries. C was sceptical of the account given by the board of how A sustained their injuries. A remained in hospital until their death a little over a week later.

C complained to the board that A was injured, about medical treatment and nursing care after A was injured, and about the attitude of a specific doctor. In response, the board advised C of their view of what had happened, apologised that A had fallen and assured C that work was ongoing in relation to reducing the number of patient falls at the hospital. C was dissatisfied with the board's response and raised their complaints with this office.

We found that the board had not reasonably assessed A's falls risk, had not reasonably undertaken staff handovers in respect of A, unreasonably mobilised A to the commode without their hip brace and unreasonably allowed A to use the commode alone and unsupervised. We upheld C's complaint about the care provided to A in respect of their falls risk.

There was disagreement between C and the board about the circumstances of particular parts of A's care and treatment following their injury but, notwithstanding this, we found A's care and treatment following their injury was reasonable. We did not uphold C's complaints about the care and treatment of A following their injury.

In relation to C's complaint about the attitude of a specific doctor, the recollections of C and the doctor about a specific discussion are contradictory but the evidence available of board staff's communication with C shows these were reasonable. We did not uphold C's complaint about the attitude of the doctor.

Recommendations

What we asked the organisation to do in this case:

• Apologise to A's family for providing A with unreasonable care in relation to their falls risk. The apology should make clear mention of each of the failings identified and 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:

• Relevant staff should be properly trained regarding the completion of neuro observations in line with SIGN 110, the need for accurate record-keeping in line with the Nursing and Midwifery Council code, specifically around recording all conversations with families and adding times to all records and risk assessments, and the appropriate action to take, and record, regarding the administration of pain relief following injuries.
• Relevant staff should be properly trained regarding the safe positioning of commodes, and the management of delirium and the appropriate completion of the '4AT' bundle in line with the delirium toolkit.
• Relevant staff should be properly trained in the completion of care plans to reflect need in relation to cognition, mobility and maintaining a safe environment.
• Relevant staff, including allied health professionals, should be properly trained regarding assessment of mobility and risk assessment of moving and handling (including following a fall).
• Situation, background, assessment, recommendation (SBAR) transfer handovers are recorded for relevant staff regarding falls risk and safety interventions in place.
• The board should ensure their falls risk assessment procedures are compliant with the Scottish Patient Safety Programmes (SPSP) guidelines 'Prevention of falls driver diagram and change package' (2013) and include a prompt for staff regarding bathroom safety.

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 them and their child (A) by the board during their pregnancy and after A's birth. A was diagnosed with microcephaly (a condition where the head circumference is smaller than normal) and associated issues around six weeks after their birth, and C felt that the diagnosis could have occurred at an earlier point.

During our investigation, we took independent advice from a midwife, an obstetrician (a doctor who specialises in pregnancy and childbirth) and a neonatologist (a doctor who specialises in the medical care of newborn infants, especially ill or premature newborns).

In relation to the care and treatment provided to C during their pregnancy, we identified the following failings:

A lack of documentation in the care plan in relation to detail surrounding verbal discussions midwives had with medical staff during the antenatal period.

A lack of a planned schedule for obstetric reviews as per the 'Keeping Childbirth Natural and Dynamic' (KCND) pathways.

No scan carried out at 36 weeks as per the plan and no documentation to support the reasons for not adhering to this planned care pathway.

Lack of clear documentation resulting in it being difficult to accurately determine if or when an obstetric doctor saw C, and what they communicated to the midwives or C.

Lack of documentation regarding information given to C about the External Cephalic Version (ECV) procedure (a process by which a baby in the womb can sometimes be turned from buttocks or foot first to head first), delivery options, and induction.

No evidence within the files that there were discussions about risks associated with shoulder dystocia (when one or both of a baby's shoulders get stuck inside the mother's pelvis during labour) or that risk assessments in relation to previous pregnancy outcomes were undertaken.

As a result of an external Significant Clinical Incident Review (SCIR) carried out by the board, some improvement actions had been taken to address the issues identified with the lack of documentation of discussions between midwives and medical staff, and the failure to discuss induction of labour. However, we upheld this aspect of C's complaint and made further recommendations to the board.

We did not identify any failings in relation to the care and treatment provided to C during labour; C and A's discharge from hospital; or the care and treatment provided to A after discharge. We did not uphold these aspects of C's complaint.

However, we found that there was an unreasonable failure to identify A's tongue tie when still in hospital after being born. Therefore we upheld C's complaint that the board failed to provide reasonable care and treatment to A whilst in hospital after being born.

C also complained about the board's involvement in the external SCIR, and the board's handling of their complaint. We found that the board's involvement in the SCIR was reasonable and did not uphold this aspect of C's complaint. However, we considered that their complaint handling was unreasonable, as C was not informed of their right to bring their complaint to us in a timely manner, and the board did not reasonably manage the multiple streams of communication during the complaint process. We upheld this aspect of C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failure to provide reasonable care and treatment during C's pregnancy in relation to documentation, schedules for obstetric reviews and scans, communication, and risk assessments; the failure to identify a tongue tie; and the failure to handle C's complaint reasonably. 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:

• Clear documentation should be made when care plans change, which reflects the rationale for change and the new plan to be followed.
• Discussions between midwives and medical staff, and medical staff and patients, should be clearly documented.
• ECV procedure and delivery options should be discussed and documented as appropriate.
• Obstetric reviews should be scheduled in line with the KCND pathways.
• Risks associated with previous shoulder dystocia should be discussed, and risk assessments in relation to previous pregnancy outcomes undertaken.
• The names and roles of all providers of clinical care should be identified within the records, and discussions.
• Tongue ties should be identified as promptly as possible.
• Where meetings are held between patients and clinicians, the discussions should be documented.

In relation to complaints handling, we recommended:

• Complainants should be informed of their right to take their complaints to the SPSO in a timely manner.
• Efforts should be made to manage communication when there are multiple streams of communication during the complaint 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 was admitted to New Craigs Hospital following an overdose. They complained about the care provided, specifically the assessment of their condition, the suggestion to take part in a group class and a lack of access to pain medication for their migraines. C also complained about the boards response to their complaint.

We took independent advice from a consultant psychiatrist. We found that appropriate assessments were carried out and the working diagnosis was supported by the notes. The suggestion of a class was not unreasonable and C was able to decline to participate in that option. There was limited evidence about the prescription/requests for pain medication. We found the care provided to be reasonable and did not uphold this complaint.

In relation to complaint handling, we found the board did not proactively update C as often as they should have. We also found that the complaint was not fully responded to and the information given about bringing pain medication from home was not accurate. Therefore, we upheld this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to handle their complaint reasonably. 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 ensure complaints are fully responded to and the information given is accurate.

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 treatment for abnormal cervical changes. Around nine years later, a cervical smear test showed borderline changes and they were scheduled for follow-up six months later. Their next smear showed changes requiring investigation and C was seen for a gynaecology (relating to the female reproductive system) scan, at which the consultant also carried out a colposcopy (a simple procedure used to look at the cervix). Everything appeared normal but taking C's history into account they were followed up six months later. The follow-up smear showed severe dyskaryosis (change of appearance in cells that cover the surface of the cervix), prompting an urgent referral to colposcopy. C was seen six weeks later and was later informed that they had adenocarcinoma (a type of cancer), and required a radical hysterectomy (surgery to remove the uterus) and adjuvant chemoradiation (additional cancer treatment given after the primary treatment to lower the risk that the cancer will come back).

C complained that their history of three abnormal smears in the ten preceding years should have led to a referral to colposcopy after their first abnormal smear. C believes that if they had been referred to colposcopy and had a biopsy taken earlier, the need for adjuvant chemoradiation could have been avoided. They complained that the board failed to take account their medical history when considering whether to refer to colposcopy or take a biopsy. C also complained about the board dropping them from cancer tracking, and about the delay between biopsy and treatment.

We took independent advice from a consultant obstetrician and gynaecologist (a doctor who specialises in pregnancy, childbirth and the female reproductive system). We found that referral to colposcopy was not indicated earlier, explaining that the first smear was the first abnormal smear in a new episode and the recommendation for repeat in six months was in keeping with the cervical screening programme. We also found that C's examination following the second smear was satisfactory and it was reasonable not to carry out a biopsy at that time. We did not uphold these aspects of C's complaint.

In relation to the cancer tracking, the board accepted that C should not have been dropped as, given C's pathology results, they clearly required further treatment. Tracking is carried out to ensure patients are followed up timeously and within national targets. We considered that it was unreasonable to drop C from tracking, and we therefore upheld this aspect of C's complaint.

Finally, we considered that the delay in seeing C for colposcopy following their severely dyskaryotic smear, and further delay between diagnosis and treatment, was unreasonable. 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 commencing treatment, recognising the impact this matter 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:

• The board should meet national targets for the first appointment following referral with an abnormal smear, and following a positive cancer diagnosis.

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 that the board's significant clinical incident investigation and complaint investigation unreasonably failed to identify all the failings regarding the care and treatment provided to their spouse (A). We took independent advice from a general surgeon. We found that the Significant Clinical Incident Review did not identify that:

it was unreasonable that no clinical observations or clinical review took place when A developed an acute onset of pain on the surgical ward;

it was unreasonable that A's case was not discussed earlier with a consultant on the surgical ward; and

it was unreasonable that a request for an urgent CT scan was not made earlier.

We upheld C's complaint in this regard and made recommendations to the board.

C also complained that the board failed to take reasonable action to address the failings identified following the significant clinical incident investigation and complaint investigation. We took independent advice from a nursing adviser with experience of working in and managing an Intensive Care Unit. We found that the board had taken reasonable action to address these failings. While we fully appreciated that actions taken by the board will not change A and C's experience, we were satisfied that learning and improvement had taken place which should prevent the same situations from arising again. We did not uphold C's complaint in this area.

We also considered how the board had handled C's complaint. We found that the board did not provide a revised timescale for when C could expect to receive the response to their complaint and made recommendations to the board in this regard.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to carry out a clinical observations or a clinical review when A developed an acute onset of pain on the surgical ward, failing to discuss A's case with a consultant earlier on the surgical ward, failing to request an urgent CT scan at the relevant time, and not providing a revised timescale for when they could expect to receive a response to their complaint. 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:

• Deteriorating patients should be escalated to a senior clinician especially in those with ongoing low blood pressure. Where appropriate in these cases, a senior doctor should carry out a physical examination.
• Patients who have an acute onset of severe pain should be reviewed by a clinician and the findings should be documented.
• Significant Clinical Incident Reviews should be robust and, so far as is possible, identify all failings in clinical care to ensure there is appropriate learning and improvement.
• Urgent CT scans should be requested where a diagnosis of ischaemic bowel is being considered.

In relation to complaints handling, we recommended:

• Where the 20 working day timescale for a response cannot be met, the complainant must be kept updated on the reason for the delay and given a revised timescale for completion.

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.