Some upheld, recommendations

Summary

C complained that the board failed to provide reasonable physiotherapy care and treatment to their child (A) and failed to maintain reasonable clinical records.

We took independent advice from a physiotherapist. We found that some aspects of A’s care were reasonable, particularly in relation to ongoing treatment at school, and the adjusting of equipment and personal care access was in line with normal practice. However, it was unreasonable that no paediatric physiotherapy programme was provided and delegated to school staff initially to support classroom and curriculum access and that clinical notes only mentioned a programme taught to support staff in school following the change in physiotherapist. Therefore, we upheld this part of C’s complaint.

In relation to the clinical records, we found that there were omissions in the completion of documentation and poor physiotherapy clinical record keeping. Therefore, we upheld this part of C’s complaint.

C also complained about the board’s handling of their complaint. We found that the board’s actions in relation to the handling of C’s complaint were reasonable and did not uphold this part of C’s complaint. We also noted that the board had taken learning and improvement action which we welcomed.

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.

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

• Clinical notes should be comprehensive as set out by the Charted Society of Physiotherapy (CSP)/Health and Care Professional Council (HCPC) standards and include action plans. Senior managers should be aware of their role in relation to monitoring the quality of record keeping (in line with the Records Management Code of Practice).

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

Summary

C complained about the care provided to their adult sibling (A) when they attended A&E following an accident. C also complained that the board failed to reasonably investigate A’s symptoms when they attended hospital with headaches on two further occasions the following year. A was later diagnosed with a brain tumour and C feels that there were missed opportunities in identifying this earlier.

We took independent advice from a consultant emergency physician and a GP. We found that the board undertook appropriate assessments and provided reasonable treatment to A when they attended A&E following their accident. We did not uphold this part of C’s complaint.

In relation to A’s first attendance at hospital the following year, we found that the board failed to investigate A’s symptoms. There were clear flags identified in the GP’s referral letter, indicating further investigations should have been carried out, specifically a head CT scan, and this did not occur. Therefore, we upheld this part of C’s complaint.

In relation to A’s second attendance, we found that the board reasonably investigated A’s symptoms as they presented at the time, with appropriate investigations undertaken and follow-up advice provided. Therefore, we did not uphold this part of C’s complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to undertake reasonable investigations when A attended hospital and for the poor handling of C’s complaint about this matter. 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:

• Junior doctors are aware of the importance of considering relevant clinical information from all available sources to guide clinical assessment. Clear red flags outlined in patient referrals and clinical questions resulting in patient referrals should be clearly documented in patient notes and communicated to senior reviewing clinical staff.

In relation to complaints handling, we recommended:

• Complaint responses should be accurate and based on all of the relevant evidence.

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 nursing care and treatment provided to their parent (A) who was admitted to hospital after a fall.

We took independent advice from a registered nurse. We found that there were unreasonable time gaps between care and comfort checks, making it impossible for the board to provide assurance that appropriate checks were completed. We found that the necessary risk assessments and care documentation were not completed to the required standards, with no person-centred care plan in place for A. We also found that the standard of record-keeping was unreasonable. Therefore, we upheld this part of C’s complaint.

C complained that the board had failed to provide them with timely updates on A’s care and treatment. The board accepted that C was not provided with appropriate updates regarding changes to A’s health. We upheld this part of C’s complaint.

C also complained about the board’s communication in response to their complaint. C said that the board had not investigated their concerns about A’s dementia diagnosis and reduced capacity, and had referred in the complaint response to allegations by nursing staff about C’s behaviour which detracted from the complaint. We found that the board had shared the issues for investigation with C, inviting correction. We also found that it was reasonable for the board to take into account the experiences of the relevant nursing staff when responding to concerns C had raised. Therefore, we did not uphold this part of C’s complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the specific communication and process failings 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:

• Patients should be appropriately assessed by nursing staff, in particular in relation to continence and cognition issues, and nursing care provided in line with the assessments carried out and in a timely manner. Records about a patient’s care and treatment and decisions made should be clearly and accurately documented, in accord with the relevant professional standards and guidelines, and reflect a person-centred approach. Patient records should include clear details explaining why a decision about care and treatment has been made.
• Family members should be communicated with in a timely and appropriate 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 is the grandparent of A and B, whose parents were separated. C complained about the actions of the council after A and B’s parent (X) submitted an authorised absence request from school to spend some time abroad. C considered that the council failed to check with A and B’s other parent (Y) that they were in agreement with the proposed absence from school and that the council failed to reasonably assess the risks when granting the authorised absence request.

C complained that the council failed to reasonably assess the authorised absence request. We found that the council failed to reasonably assess the authorised absence request as relevant paperwork was not completed or a rationale documented to support their decision. We upheld the complaint.

C also complained that the council unreasonably failed to inform Y of the request. We found that the council reasonably followed their policy in relation to communicating with Y. We did not uphold this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to follow procedure in considering the authorised absence request. The apology should meet the standards 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:

• When considering authorised absence requests appendix 4 should be completed along with a copy of the pupil’s attendance record.

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 social work assessment of their adult child (A). A had fragile-X syndrome (a genetic condition that causes a range of developmental issues), which affected them in a variety of ways. A’s long-standing care worker had retired and A was experiencing difficulties which were putting them and their family at risk. C believed that unreasonable assumptions were made about A’s ability to function independently because of the level of support their family provided for them.

A had been referred for assessment by a psychologist and the partnership's social work department. A was assessed by social workers as not eligible for support. C challenged this, because A’s psychology assessment recommended that they receive support. The partnership refused to alter their decision, saying that the psychology report was inappropriately worded, and that they would seek to have it reworded. C complained to the SPSO that this was unacceptable and that the partnership had failed to handle their complaint properly.

We took independent advice from a registered social worker. We found that the assessment of A by social workers was reasonable. We did not uphold this aspect of the complaint.

Although the partnership wrote to C saying that they would seek to have the wording of A’s psychological assessment reworded or redacted, there was no evidence that they had asked for this. We found that the psychological assessment was inappropriately worded, as A’s eligibility for support could only be assessed by social workers. Social work raised reasonable concerns about this with the psychology team. We found that C’s complaint was handled unreasonably, as the partnership failed to discuss it with C, and consequently did not address all the points of concern C wished to raise. We upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to contact them about their complaint, to clarify the points of concern and the outcomes being sought. The apology should meet thestandards set out in the SPSO guidelines on apology available atwww.spso.org.uk/information-leaflets.

In relation to complaints handling, we recommended:

• Complaint responses should consider and respond fully to the issues raised in accordance with The Model Complaints Handling Procedure. They should consider any relevant national or local guidance in both the investigation and response and identify and action learning.

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

Summary

C complained on behalf of a relative (B), about the care and treatment provided by the board to B's late spouse (A).

When A first felt unwell, they visited their GP on three occasions where they were prescribed antibiotics and told they had a chest infection. Following an x-ray, A was prescribed medication to increase the amount of urine produced, with a plan to carry out a follow up x-ray. A visited the GP again with breathlessness and was referred to the hospital where they were admitted and diagnosed with COVID-19. Blood tests showed that A had an infection and a chest x-ray reported fluid on the right side of A’s chest. A was initially treated for infection with COVID-19 and a suspected bacterial infection. A was discharged from hospital with a plan to repeat the x-ray as an outpatient. A few days later, A was readmitted and diagnosed with lung cancer and was showing signs of spinal cancer.

A was further told that there was a cancerous tumour pressing on their lungs. A’s breathing worsened, they had severe weight loss and they were not eating. Only one family member at a time was permitted to visit A. Staff said that more of A's family would be able to visit if their condition deteriorated. A remained in hospital until their death a week later.

In considering C’s complaint, we took independent advice from a consultant in general and respiratory medicine and a senior nurse. We found that the decision to discharge A from hospital was reasonable and did not uphold this aspect of C's complaint. However, we found that it was unreasonable that A's pleural effusion (fluid build up) was not treated on or shortly after admission. Therefore we upheld the complaint that the board unreasonably failed to carry out further investigations whilst A was on the ward.

We also found that A was unreasonably left sitting and sleeping in a chair during their admission, that A’s family were not given any additional time to visit when A was at end of life and that there was a failure by the board to notify A’s family that their condition was rapidly deteriorating. We upheld these aspects of C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the specific failings identified in respect of these complaints. 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:

• Further investigations should be carried out in line with the expected standards for management of pleural effusions in the context of acute admissions.
• In such circumstances, staff should contact the family promptly to inform them of a patient’s deterioration.
• Relevant staff should be aware of changes to guidance.
• The person-centred care plan should be fully completed for each patient and updated with a changing deteriorating picture. When a patient is nursed in a chair it should be clearly documented that this is an informed choice to ensure person centred decision making and regular skin checks completed. Recliner chairs should be obtained promptly where required.

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 that they received from the dentist during a period of eight months. C is a bariatric patient and is unable to recline due to their medical condition. C attended for an examination with the dentist and complained of a broken front tooth and decay on the upper left second molar. Treatment options were discussed and it was agreed that at the next visit, the dentist would apply fillings to both teeth.

C attended for treatment to both teeth 11 weeks later. The dentist explained to C that a referral to the Public Dental Service (for individuals who cannot access an independent dentist) would likely be the best option going forward as they were unable to gain proper access to treat C. C agreed to a referral and the next examination was scheduled for six months’ time. C attended for an emergency appointment six weeks later, complaining of pain. The tooth was filled and the dentist made a referral to the Public Dental Service, resending it six weeks later.

C emailed complaints to the practice on two occasions but did not receive a response to either.

C attended for a further examination complaining of ongoing pain. Treatment options were discussed and the dentist booked C in for an appointment for treatment.

C emailed the practice to ask for a response to their previous two complaint emails. C was advised by the practice to speak with the dentist during their appointment the following day. However, C decided to cancel future treatment as they had lost faith in the dentist.

C received a complaint response from the dentist and contacted the practice the following day to express their dissatisfaction with the response. The dentist issued a further response in an undated letter. C wrote to the practice again and the dentist subsequently issued a further letter to C saying that they believed they had already addressed all of C’s concerns.

In considering C’s complaint, we took independent advice from a dentist. We found that overall, the care and treatment provided to C by the dentist was reasonable and that there was no unreasonable delay in referring C for treatment. We did however find that C’s complaints were not appropriately identified and responded to in line with the complaint handling procedure and upheld this complaint. We also provided feedback to the dentist in relation to communication.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the specific failings identified. 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:

• The dentist should ensure complaint investigations conform to the NHS Model Complaints Handling Procedure, particularly in terms of the requirement to respond in writing and in a timely manner. They should review their handling of this complaint with a view to identifying areas for learning and improvement.

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 partner (A) who was admitted to hospital due to abdominal pain, severe lower back pain, weight loss and reduced appetite. A CT scan identified a left hepatic vein thrombosis (a blood clot in the vein draining the liver). A was commenced on anticoagulant (blood thinning) medication. A further CT scan showed that A had new thrombus in the portal vein (the main vein draining into the liver). Following discussion with haematology (specialists in conditions of the blood), A’s anticoagulation medication was changed.

Several days later A complained of a headache and vomiting and was given pain medication. The following morning A was found to be unresponsive by nursing staff. Levetiracetam (an anticonvulsant medication) was administered and A was taken for a CT scan which showed extensive intracerebral haemorrhage (bleeding into the brain tissue). Protamine (medication that partially reverses the effects of the anticoagulation medication) was administered and advice sought from neurology (specialists in conditions of the nervous system) who said that on review of the scans, the extent of the bleeding was not survivable. A died shortly after.

C complained that the board unreasonably failed to warn A of the risks of anticoagulation medication and unreasonably administered protamine and levetiracetam shortly before A's death. C complained that the board unreasonably failed to include anticoagulation medication on the death certificate and failed to communicate to A’s family that it was a cause of death.

We took independent advice from a consultant in acute medicine. We found that the use and timing of both levetiracetam and protamine was reasonable. We did not uphold this part of C's complaint. However, we found that the board failed to warn A of the risks of the anticoagulation medication before commencing the treatment. We also found that the board unreasonably failed to include the anticoagulation medication on the death certificate and failed to communicate that it was a cause of death to A’s family. Therefore, we upheld these parts of A's 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 inthe SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

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

• Patients prescribed anticoagulation medication should be given appropriate information on the risks and benefits of anticoagulants, in line with relevant clinical guidance and this should be clearly documented within the patient records.
• Relevant information about a patient’s death should be effectively communicated to their family.

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 failed to provide their sibling (A, a prisoner) with medication in a reasonable manner. C complained that the injection for A’s condition was not administered in line with the prescribing consultant’s instructions and that the board’s view that the acknowledged delays did not negatively impact A was unreasonable. C was also unhappy with the way that A’s other medications were managed.

We took independent advice from a GP. We found that there was an unreasonable delay when one of the injections was administered and guidance did not support the board’s view that no detriment would have been caused by this delay. We also found that the record keeping for the other medications administered during that period did not indicate that other medications were provided at regular intervals. This was unreasonable. Therefore, we upheld this part of C's complaint.

C also complained that the board unreasonably failed to arrange or rearrange hospital appointments for A. We found that some elements of this complaint were outwith the board’s control, in relation to third party organisations being involved in transportation. Whilst there were instances where A’s transport requests were not sent within the timeframes set out by guidance, overall we considered that the board’s efforts to schedule transport were reasonable. Where an appointment was cancelled due to transport issues, the board took quick action to reschedule the appointment and rearrange transport. This was reasonable. Therefore, we did not uphold this part of C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to provide A with medication in a reasonable manner. 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:

• Medication should be prescribed in line with specialist advice.
• When there are multiple delays in administering medication action is taken to avoid the issue repeating.

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 social work service during the pre-adoptive process of their child (A). C complained about the council’s decision to temporarily suspend A’s nursery placement and about the council’s communication of their decision. C complained that the council failed to have an appropriate level of contact with A during the pre-adoptive process, and that the council failed to reasonably prepare and submit a report which is required from an adoption agency for court, regarding the suitability of the prospective adoptive parents.

The council apologised for failing to communicate information about A’s suspended nursery placement at a time when open and honest communication could take place.

We took independent advice from a social worker with experience in fostering and adoption. We found that the council’s decision to temporarily suspend A’s nursery placement was made without consultation with A’s pre-adoptive carers or nursery, who should have been part of the decision-making process. We upheld this point of C’s complaint. We found the council’s social work visits to A did not meet the frequency or timing set out in the council’s policy or legislation. We upheld this point of C’s complaint. We found the council prepared and submitted the required report within the statutory timescale and reasonably communicated with C about the report. We did not uphold this point of C’s complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to the complainant for the failings identified by this investigation. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/meaningful-apologies.

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

• Social workers should visit children in pre-adoptive placements in line with their statutory requirements as per the Looked After Children (Scotland) Regulations 2009, and the council’s procedure.
• The social work department should appropriately consult with key partners in pre-adoptive placements (such as carers and nursery) on decisions related to a child’s care, and communication with partners should be timely.

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.