Some upheld, recommendations

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.

Summary

The complainants (B & C) raised concerns about the practice following the suicide of their child (A). A and B had attended the practice two weeks prior to A’s death and B & C told us that they held concerns regarding the manner of the GP they saw, which A and B had found to be dismissive and unsupportive. While they did not consider that the doctor could have predicted the extent of A’s distress, they considered that the doctor’s demeanour may have contributed towards A feeling unsupported.

B & C also held concerns regarding the way in which the practice had cared for them following A’s death, as they had concerns about a prescription for Diazepam (a drug which belongs to a group of medicines called benzodiazepines and usually used to treat anxiety) they both received, the lack of other support offered, and the way in which the practice carried out a Significant Adverse Event Review (SAER) into what had occurred.

On investigation, we found that the doctor in question had already accepted that their body language had been inappropriate and apologised for this, when responding to B & C’s original complaint. We took independent advice from a GP on the care and treatment offered and we considered that the support provided by the doctor at the appointment was otherwise reasonable. Therefore, we did not uphold that element of the complaint.

We considered that the handling of the prescription of Diazepam and the bereavement support otherwise offered to B & C had been inappropriate. We also found that the SAER had been unreasonably delayed. Therefore, we upheld these complaints.

Recommendations

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

• Patients should be appropriately consulted before being prescribed benzodiazepines; patients should not be prescribed benzodiazepines for longer than is appropriate; the practice should consider whether prescribing benzodiazepines is appropriate for grieving families, given this may impair their grief reaction; and grieving families should be contacted with offers of support.
• Significant Event Analysis Reviews should be completed in a timely manner and identify any failings in treatment, as appropriate.

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 member of the Scottish Parliament, complained on behalf of one of their constituents (A) about the care and treatment they received from the board.

Initial investigations carried out diagnosed A with atrial fibrillation (AF, a problem of the heart characterised by irregular and often faster heartbeat). While waiting for a cardiology (the branch of medicine that deals with diseases and abnormalities of the heart) appointment, A suffered a heart attack and was admitted to Hairmyres Hospital.

C raised concerns that the hospital’s cardiology department knew A had a problem with their heart two weeks before they suffered the heart attack and that aspects of A’s care and treatment during their admission were unreasonable. In particular, they complained that A was placed in a bed next to a disruptive patient who was suicidal while in the Acute Assessment Unit (AAU), that there was a delay in carrying out a coronary angiogram procedure (a type of x-ray used to examine blood vessels), and that communication by hospital staff was poor. C also complained that A’s follow-up rehabilitation treatment after discharge was unreasonable.

We took independent advice from a cardiology adviser. We found that while there were issues identified initially with A’s heart, there were no concerning features associated with their AF that would raise suspicion that A might have a heart attack.

While we acknowledged that being in a bed next to a disruptive patient in AAU, must have been very distressing for A at a particularly difficult and anxious time, we found that this reflected the status of AAU as a communal assessment ward and was consistent with standard practice.

Regarding C’s concerns about the delay in the carrying out of the coronary angiogram, we found that it was reasonable for staff to delay this procedure in the context of staff being required for other urgent and emergency procedures.

We acknowledged C’s concerns about staff communication and how this made A feel, in particular, surrounding the delayed angiogram procedure. While A had expected some face-to-face contact with their consultant, and although this did not occur, we did not find sufficient evidence to show that there was a failure in communication. However, we provided feedback to the board about this.

In terms of the care provided following A’s discharge, we found this was of a reasonable standard.

We found that the overall care and treatment provided to A was reasonable. As such, we did not uphold this complaint.

C also complained that the board did not respond reasonably to A’s complaint. We upheld this complaint on the basis that the board did not address all aspects of A’s complaint in their response.

Recommendations

What we asked the organisation to do in this case:

• Apologise to A for failing to address all aspects of A's complaint in their response letter. 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:

• Complaint responses should address the issues raised by the complainant, 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, an advocacy worker, complained on behalf of (B) about the care and treatment provided to B's family member (A) before their death. Around three months prior to A’s death, they attended their GP with back pain, nausea and feeling generally unwell. They subsequently attended Accident and Emergency (A&E) at Inverclyde Royal Hospital on two occasions, before being admitted to the Royal Alexandra Hospital via A&E there. A was diagnosed with a rare and aggressive type of cancer and died a short while later. C complained on behalf of the family that A was not investigated more thoroughly given their symptoms and medical history, and that the family was not included in discussions about A’s care.

We took independent advice from a consultant in emergency medicine. With regards to care and treatment, we found that appropriate investigations were carried out during A’s hospital attendances and reasonable management plans were put in place. While we considered that there could have been closer attention to pain measurement recording, and a referral to an out-patient clinic could have been made by A&E staff directly (rather than relying on A to re-attend their GP for this purpose), we accepted that improvements in these aspects of care would not have altered the outcome for A. On balance, we did not uphold this aspect of C's complaint.

Regarding communication with A’s family, we noted that A was a competent adult and it is not expected practice to involve family members in treatment decisions when the patient has capacity. The records indicated that medical staff did speak with A’s family on occasion and we were satisfied that they were not deliberately excluded from discussions. As we found no significant omissions in communication, we did not uphold this aspect of C's complaint.

C also complained about the board’s handling of the complaint. We found that the complaint was not responded to in a timely and robust manner. An initial meeting was held with A’s family but the board did not follow this up in writing. Additional questions and concerns developed during A’s family’s wait for a written response. Delays were not proactively explained and revised timescales were not communicated to C. We upheld this aspect of C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to A's family for the identified failures in the handling of their complaint. 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 board 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’s sibling (A) received care and treatment from the board in response to symptoms of pain and urinary issues. A was later diagnosed with bladder cancer and died. C complained that the treatment provided to A prior to their diagnosis was unreasonable. Dissatisfied with the board’s response to their complaint, C brought their complaint to our office.

We took independent advice from a consultant urological surgeon (a doctor who specialises in the male and female urinary tract, and the male reproductive organs). We found that the board failed to carry out a general anaesthetic cystoscopy (passing a thin viewing tube called a cystoscope along the urethra (the tube that carries urine out of the body) and into the bladder) in a reasonable timescale. This was accepted in the board’s own complaint investigation. However, we considered that there were opportunities to pick up and correct the delay which were missed. As such, we upheld the complaint.

In relation to a complaint about pain management, we found that while there were elements which could have been improved, overall the board reasonably managed A’s pain. We considered that the board could have enquired about pain with A and did not do so, however, there was also no record that A had reported pain which had not been responded to. As such, we did not uphold this complaint.

We considered that the board had failed to diagnose A in a reasonable timescale. We found, which the board had previously acknowledged, that due to the delay in carrying out the general anaesthetic cystoscopy there was an unreasonable delay in diagnosing A with cancer. We also considered that the lack of follow-up for one of A’s symptoms following a botox injection was a failing. As such, we upheld this complaint.

Finally, C complained that the board had failed to reasonably respond to their complaint. We found that, overall, the board’s responses to C’s complaint were accurate and the board took action to discuss C’s concerns at a meeting and provide explanations as to what happened during A’s care. While there were delays in responding to C’s contact, the board reasonably responded to the complaint. As such, we did not uphold the complaint.

Recommendations

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

• Patients with a potential malignancy should be kept moving through the pathway, even where staffing and capacity issues exist.
• Procedure-specific patient information leaflets should be provided.

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 relative (A). A was admitted to hospital with an ongoing Clostridium difficile infection (bacteria that can infect the bowel and cause diarrhoea). A remained in hospital until their death.

C raised concerns with the board about the level of clinical and nursing care provided to A. The family were particularly concerned that staff took the decision to implement the nil by mouth protocol, meaning A would not be given any foods or fluids. The board acknowledged failings and agreed to review relevant practice.

We took independent advice from appropriately qualified advisers. In relation to the clinical care provided, we found that clinical staff took detailed consideration of A’s health and were aware how frail they were when admitted to hospital. The records indicated that a good level of investigation took place along with frequent blood tests and x-rays, when appropriate. We considered that the clinical care A received was reasonable. We did not uphold this aspect of C's complaint.

In relation to the nursing care, we found that important information from A’s family with regards to the requirement to provide thickened fluids was handled poorly by nursing staff. We found that it was unreasonable to carry out the appropriate swallow test with A using water instead of thickened fluid. In addition to this, risk assessments and person-centred documentation were never completed throughout A’s time in hospital. Had this documentation been completed, then failings might have been avoided in A’s case, meaning medications and fluids would have been provided. We upheld this aspect of C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to A’s family for failing to provide a reasonable level of nursing 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:

• National guidance and standards of care for older people in hospital should be implemented appropriately by the board by demonstrating that appropriate guidance is available for staff when undertaking compromised swallow tests; measures are in place to maximise patients receive their medications; and important documentation is completed on admission and from that, an appropriate person-centred plan of care will be devised.

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.