Some upheld, recommendations

Summary

C, a patient adviser, complained on behalf of their client (A) in relation to the care and treatment provided to A's child (B) by the board. B was diagnosed with a type of slow growing brain tumour and subsequently underwent a surgical procedure to treat build-up of fluid in the brain. B experienced a neurological deficit following the procedure and the surgeons identified that the burr hole (a small hole drilled into the skull) was not placed at the intended site. Over the following months, the neurological deficit improved but B continued to experience severe headaches following the procedure. Follow-up care was provided by paediatric oncology (specialists in treating children with cancer) and paediatric neurology (specialists in treating children with disorders of the nervous system) as well as other specialties over the following years.

We took independent advice from a consultant paediatric neurosurgeon and a consultant paediatric neurologist.

Firstly, C raised concern that the board did not obtain informed consent for the surgery and that the surgery was not performed to a reasonable standard. We found that there was limited reference to complications within the consent form and the written notes, whilst a number of known serious complications were not included in the consent form. We also found that the incorrect placement of the burr hole was unreasonable and that this likely caused the neurological deficit that B experienced. We upheld these aspects of C's complaint.

C also complained that the board did not manage B's pain reasonably following the surgery. We found that this aspect of B's care had been reasonable, with close involvement from both a consultant paediatric oncologist and a consultant paediatric neurologist over a number of years. We did not uphold this aspect of C's complaint.

Finally, C raised concern about the communication between the board and the family about B's care. We found that the documentation of discussion with B's parents about the surgical complication was poor. We found that the communication in relation to B's headaches was, on balance, reasonable. However, we noted that there should have been better communication from the paediatric oncology team. Therefore, we upheld this aspect of C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to B and B's parents for the failings identified in the consent process, in the surgical procedure and in communication with the family. 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:

• Adequate systems should be in place to ensure that technical errors are minimised.
• In accordance with the professional duty of candour, health professionals must tell the patient (or, where appropriate, the patient's advocate, carer or family) when something has gone wrong and apologise for what happened. This should be clearly documented.
• Informed consent should be obtained in accordance with the General Medical Council's guidance on this matter.

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 psychiatric consultation at Falkirk Community Hospital. They complained that they did not receive adequate support from the psychiatrist and that the psychiatrist made inappropriate comments regarding the impact of suicide on others and the best way to complete suicide. We took independent advice from a consultant psychiatrist. It was not possible to confirm from the notes the way the psychiatrist communicated with C or exactly what was discussed surrounding suicide. The board explained that it was the psychiatrist's normal practice to discuss the impact of suicide on others but refuted that C was advised of the best way to take their own life. We considered that the psychiatrist carried out a reasonable assessment and proposed an appropriate management plan. We did not uphold this complaint.

C also complained that a board run GP practice refused to continue their prescription for gabapentin (an anticonvulsant medication primarily used to treat partial seizures and neuropathic pain) until C had been seen by the psychiatrist. This medication had been prescribed overseas and C noted that it was for restless leg syndrome (RLS) and not a psychological condition. The board explained that gabapentin is a controlled drug in the UK which can only be prescribed in specific circumstances and with specialist input. They noted it is unlicensed for RLS. We took independent advice from a GP, who noted that gabapentin can be prescribed 'off-label' to treat RLS and they saw no reason for changing this if C had been taking it with good effect and was established on a reasonable dose. However, if the practice had concerns and wished to change this, it should have been gradually reduced and not stopped suddenly. We concluded that it was unreasonable to have refused to prescribe C gabapentin pending a psychiatric review. We upheld this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the stoppage of their gabapentin without a reduction regime. 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 the practice GPs familiarise themselves with gabapentin reduction regimes and the indications for the same.

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 consent process and the standard of surgery for a procedure they had received from the board. C was listed for a surgical procedure with the aim of removing a stoma (an opening in the abdomen formed during a colostomy procedure) and a para-stomal hernia (a weakness in the abdominal wall beside a stoma which allows the bowel to protrude outwards). The surgeon was unable to safely perform the procedure as planned and the decision was made to create a new stoma site. C experienced complications with the wound following surgery and was unhappy with the outcome.

We took independent advice from a consultant colorectal surgeon (a surgeon who specialises in conditions in the colon, rectum or anus). We found that C should have been informed about the risk that it might not be possible to complete the intended procedure successfully and the implications of this. In the absence of evidence that C was informed of this, we concluded that the board had failed to obtain appropriate consent for the procedure, in line with recognised guidance. We upheld this aspect of C's complaint.

In relation to the surgical procedure, we found that this was performed to a reasonable standard and the decisions made by the surgeon during the operation were reasonable. Given the findings, we did not uphold this aspect of C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C that the risks for the surgical procedure were not fully outlined as part of the consent process. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

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

• A patient's medical history should be considered to anticipate difficulties in a procedure and the likely scenarios that could emerge. Patients should receive information about the risks in a way they can understand (including side effects; complications; or failure of an intervention to achieve the desired aim), taking into account the information they want or need to know. This should be fully documented.

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 matters relating to their previous GP practice. C had been removed from the practice list as in the practice's view there had been a complete breakdown in the doctor/patient relationship due to the way C was using a prescribed antibiotic medication. The practice wrote to C to inform them of their decision.

C had concerns about the practice's decision to remove them from the list. We found that the practice had failed to provide C with a warning before removing them from the practice list. Therefore, we upheld this aspect of the complaint.

C was also unhappy with the factual accuracy of a letter sent by the practice regarding the removal decision. We did not find that the practice's letter contained inaccuracies and we were unable to conclude that it was unreasonable. We did not uphold this aspect of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failure to issue a warning before removing C from their practice list. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.
• Reconsider any application to register received from C.

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

• A breakdown in a doctor/patient relationship should be managed in line with General Medical Council guidance and the relevant legislation.

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

Ms C, a postgraduate student, complained that she had paid for classes and seminars which had been cancelled due to industrial action.

We found that the University had taken appropriate steps to minimise the academic impact of the industrial action by giving students advance notice of the industrial action and ensuring that students would only be assessed on work that they had an opportunity to cover in the course of their studies.

We noted that students may expect to learn about a particular subject and if they do not receive the teaching they are supposed to get, it is not necessarily sufficient for the provider to purely decide not to test them on it. In light of this, we also considered whether the university had taken steps to make up for the lost teaching hours and the learning opportunities these represented. We did not consider that this had to be a like-for-like replacement of the teaching hours that were lost.

During the semester affected by the industrial action, Ms C was taking three courses. These courses were formal components of Ms C’s postgraduate programme. Three of Ms C’s classes were cancelled due to the industrial action across two of the courses. Regarding two of the classes, the university offered to discuss course material with Ms C on a one-to-one basis and offered to give feedback on an essay regarding a particular topic. Regarding the third class, no steps were taken by the university to make up for the lost teaching hours. Given that the university made attempts to make up for the teaching hours lost for two out of the three classes cancelled, on balance, we did not consider the university had acted unreasonably.

We also noted that five seminars out of 22 were cancelled due to the industrial action. These seminars were academic events rather than formal components of Ms C’s course. We did not consider that the university were obligated to take steps to make up for the learning opportunities lost due to the cancellation of these seminars and we noted that the majority of the seminars went ahead. We did not uphold Ms C’s complaint in this regard.

Ms C also complained that the university failed to handle her complaint reasonably. We found that there was a delay in responding to Ms C’s stage 1 complaints and she was not informed of the reasons for the delay or provided with a revised timescale for when she could expect a response. We upheld this aspect of Ms C’s complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms C for the delay in responding to Ms C’s stage 1 complaints and that she was not kept updated or provided with a revised timescale. 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 was removed from association (no contact with other prisoners) in prison on a specific occasion. C did not believe that their removal from association had been properly handled by the Scottish Prison Service (the SPS). C submitted several complaints about specific details of the handling of their removal from association in this period. C was dissatisfied with the responses they received and made their complaints to our office.

We found that C’s removal from association was handled appropriately and did not uphold this complaint.

In relation to the handling of C’s complaints, we found that the SPS did not respond to C’s complaint that an officer was inaccurately named as having been present at a case conference until this office became involved. We also found that they did not refer to the new evidence C provided in their complaint nor clarify that the SPS’s view remained as set out in their previous responses. Given this, we upheld C’s second complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C that they did not handle their complaints reasonably. 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.

In relation to complaints handling, we recommended:

• The SPS should provide complaint responses that directly address the complaints raised, refer to any new evidence provided and, where directing complainants to previous responses, make clear whether their view remains as set out in those previous responses.

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

Mr C complained that the council failed to carry out an appropriate assessment of a planning application submitted by a recreational club that shares a boundary with his property. Mr C also complained that the decision notice, granting planning permission for the application, unreasonably failed to accurately implement the decision of the planning committee. The council concluded that they had carried out an appropriate assessment of the planning application and the planning permission reflected the decision of the committee.

We took independent advice from a planning adviser. We found that the council had carried out an appropriate assessment of the planning application. Therefore, we did not uphold this complaint.

In relation to Mr C’s second complaint, we found that the council had unreasonably failed to accurately implement the decision of the planning committee. We found that the wording of the planning condition was ambiguous and open to different interpretation. We concluded that, by not making the condition explicitly clear, the decision notice did not reflect the intention of the planning committee members accurately. Therefore, we upheld this complaint.

Mr C also complained that the council unreasonably failed to take action to ensure the club abided by what was outlined in their planning application and supporting documentation. The council considered that the actions taken by the club were in line with the planning permission granted and, as such, it was not appropriate for them to take any further action.

We found that the council had unreasonably failed to take action to ensure that the club abided by what was outlined in their planning application and supporting documentation. By including a condition that was open to interpretation, the council failed to provide a clear and unambiguous decision. As such, this enabled the club to carry out actions contrary to their stated intentions when the planning application was determined. We recognised that it may not have been possible for the council to take formal enforcement action. However, given the circumstances of this case, we concluded it was reasonable to expect the council to give further consideration to what informal steps they could take to resolve the situation. Therefore, we upheld this aspect of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for failing to accurately implement the decision of the planning committee as a result of including a condition that was unreasonably ambiguous and open to interpretation and for failing to take reasonable measures to ensure the club abided by what was the stated intention of their planning application at the time it was determined. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.
• Consider what actions can reasonably be taken to ensure the club abides by what was outlined in the proposal detailed in the Report to Committee and supporting documentation, bearing in mind that planning permission has been granted and the conditions discharged. Update Mr C with details of what actions, if any, have been carried out and provide an explanation for the decision taken. If it is concluded that further involvement would be counterproductive or may have a negative impact on existing agreements between the different parties, an explanation for this should be provided to Mr C and this office.

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

• Planning decision notices should clearly and accurately reflect the planning proposal and the contents of the Report to Committee/Report of Handling. Planning decision notices, when decided by the planning committee, should clearly and accurately reflect the intentions of the committee members.

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

Mr C complained that for over three years, the council failed to reasonably respond to his and his wife's (Mrs C) concerns about their child's (Child A) additional support for learning needs. Child A has a developmental learning disability. Mr C also said that the council unreasonably removed Child A’s 25 hours of care and support (provided by members of school staff), without first contacting him or Mrs C and that the council behaved unreasonably towards them both.

We found that the council responded appropriately to a number of Mr and Mrs C’s concerns about Child A’s additional support for learning needs. However, there was a significant failure by the council to appropriately signpost Mr and Mrs C to resolution mechanisms for disagreement regarding additional support needs. Therefore, we upheld this aspect of Mr C's complaint.

We were also concerned about the lack of notes of the meetings between Child A’s school head teacher and Mrs C, which appeared to have been a substitute for Staged Assessment and Intervention meetings and review of Individualised Education Programme targets, and we provided feedback on this point to the council.

In relation to Child A’s support hours, we found that Child A was assessed as requiring a total of 17 hours 50 minutes of support rather than 25 hours. There was no evidence that Child A’s support was unreasonably removed in the manner Mr C described, but that the head teacher contacted Mr C to inform him that the support teacher was leaving the school at around the time they became aware themselves and steps were taken to address the shortfall. Therefore, we did not uphold this aspect of Mr C's complaint.

On the matter of the council’s behaviour towards Mr and Mrs C, we found that the council referred Mr C to their Antisocial Behaviour Policy when they had been advised by their Safer Communities Team (SCT) staff that this was not the correct policy in Mr C’s case, and failed to explain their actions in this regard to our office. We were also concerned that the council failed to respond to Mr C’s complaint about the council’s treatment of the SCT staff’s advice and that their explanation about their decision not to proceed with mediation could have been clearer. Therefore, we upheld this aspect of Mr C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr and Mrs C for failing to signpost them to resolution mechanisms for disagreement regarding additional support needs; referring Mr C to their Antisocial Behaviour Policy, when they had been advised by their SCT staff that this was not the correct policy; failing to respond to their complaint about the council’s treatment of the SCT staff’s advice; and not explaining further what they meant by their consideration of ‘previous correspondence between you and the council’ when making their decision not to proceed with mediation. 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:

• Where internal advice is sought and a decision taken to act or not act on it, this should be documented; and council staff should explain their reasons not to proceed with mediation in full to parents.

In relation to complaints handling, we recommended:

• The council should appropriately signpost parents to resolution mechanisms for disagreement regarding additional support needs in cases of this type; and to respond to complaints in line with the Model Complaints Handling Procedure.

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 suffered from a gastrointestinal (stomach) disorder and was receiving treatment from the board. C complained that the treatment in response to their condition was unreasonable.

We took independent advice from a consultant hepatologist and gastroenterologist (specialist in disorders of the gastrointestinal tract, liver, pancreas and gall bladder). We found the clinicians involved in C’s care considered both the physical and psychological elements relating to C’s condition, undertook reasonable investigations into their condition and provided reasonable treatment in terms of C’s symptoms. We noted that it was reasonable in conditions such as C's, where there was no cure, to focus on the management and improvement of symptoms and prevent harm. As such, we did not uphold this complaint.

C complained that the board failed to reasonably respond to their complaint. We found that the board failed to reply to all the points raised by C. C raised a number of concerns regarding the treatment they had received. In response, the board advised that the review undertaken indicated that clinical management was appropriate; however, no details were provided to explain how they had reached that view. While we considered it was reasonable that the board focused on a way forward, to ensure appropriate treatment was carried out in the future and this was a resolution-based approach, this did not remove the requirement to respond to the points C had raised about previous treatment. There was also an unreasonable delay in responding to C’s complaint. As such, we upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to provide a reasonable response to their complaint. The apology should meet the standards 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 respond to all of the points of complaint raised by a complainant and be issued in 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 on behalf of their partner (A) about surgery they had on their hip. A, who had previously had their hip replaced, was admitted to hospital with an infection which was found to have originated in their hip and required surgery (the first surgery). The following year, A developed pain in their hip again. Scans confirmed that this would again require surgery, which was carried out later that year (the second surgery). A was discharged shortly after, but required to be readmitted twice due to pain. On the second readmission a fracture was identified above their knee, requiring additional surgery. C complained about the first surgery, the second surgery, the aftercare A received and how the board responded to their complaint.

We took independent advice from a consultant orthopaedic surgeon (a surgeon who specialises in the musculoskeletal system). We found that the first surgery was carried out appropriately. C had been concerned that the surgeon had used an incorrectly sized piece of orthopaedic equipment (a stem), however, we noted that the surgeon either used an identical, or slightly smaller stem as they decided not to remove the original cement. We found that this was reasonable.

We found that the second surgery was also carried out appropriately. The surgeon cut a small ‘window’ in the bone to facilitate removal of the cement which was established practice. We considered that this was probably the source of the fracture which A was later found to have, however, there was no indication of a fracture at the time of the surgery.

We were satisfied that the care and treatment A received after their second surgery was reasonable.

As the evidence indicated that the clinical care provided was reasonable, we did not uphold these complaints.

In relation to complaint handling, we found that there was miscommunication regarding delays and a failure to clarify all the issues of complaint. We upheld this aspect of C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for miscommunication regarding delays and a failure to clarify the confusion surrounding point two in the complaint 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:

• For the findings of this investigation to be shared with staff.

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.