Some upheld, recommendations

Summary

C had been in contact with a number of specialists at the health board as C suspected they were symptomatic of lung cancer. C said that a tumour in their lung was visible from a number of tests carried out by hospital specialists, but that this was unreasonably missed. C also said that treatment decisions and management were not reasonable and that the failure to diagnose them with lung cancer within a reasonable time had catastrophic consequences for their prognosis. C was also concerned about the way the health board dealt with their complaint.

We took independent advice from three advisers: from a consultant radiologist (a doctor who specialises in diagnosing and treating disease and injury through the use of medical imaging techniques such as x-rays and other scans), a respiratory physician (a doctor who specialises in treating and managing patients with conditions affecting their lungs) and from an orthopaedic specialist (a specialist in the treatment of diseases and injuries of the musculoskeletal system). We found that C's treatment was reasonable. C was regularly reviewed and their antibiotics were changed in order to try and improve their outcome.

However, we found that there was a significant delay in the diagnosis of lung cancer resulting from an unreasonable failure of radiological interpretation which lead to significant injustice to C; this failure would shorten C's life. We also found an unreasonable failure to follow up test results or to carry out a further scan, although we concluded that in themselves this would not have changed the outcome for C.

In relation to the standard of respiratory care and treatment provided, we found that the diagnostic process and treatment decisions were reasonable.

Finally, we found significant failings in the health board's investigation of C's complaint. While the health board identified radiological errors, they did not apologise for these or explain how they occurred and what action the health board were taking to ensure they did not happen again, nor was there any consideration of the impact of these errors on C's prognosis and treatment decisions. We upheld three complaints out of four.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failings identified in this investigation and inform C of what and how actions will be taken to stop a future reoccurrence. 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:

• Carry out an audit of x-rays and scans taken between a specified time-period to ensure there is no systemic issue which may have affected other patients.
• Ensure that test results are followed up appropriately.
• Feedback the findings of our investigation in relation to the complaint handling failures to relevant staff for them to reflect on.
• Feedback the findings of our investigation in relation to the failure of radiological interpretation to relevant staff for them to reflect on.
• Review the complaint handling failures to ascertain: how and why the failures occurred; any training needs; and what actions will be taken to stop a future reoccurrence.
• Review the failure of radiological interpretation to ascertain how and why the failures occurred and what actions will be taken to stop a future reoccurrence and inform this office of the results.

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 by the Golden Jubilee National Hospital. C underwent knee arthroscopy (a type of keyhole surgery used to diagnose and treat joint problems). Around two weeks later, C developed what was considered to be a surface infection, for which they were prescribed antibiotics and given another appointment for later in the week. Two days later, C attended another hospital's emergency department with pain and swelling. They required further surgery to wash out the joint. C complained that the decision to carry out the knee arthroscopy had been unreasonable, and that the care and treatment provided when they had an infection was unreasonable.

We took independent advice from an orthopaedic surgeon (a specialist in the treatment of diseases and injuries of the musculoskeletal system). We found that the decision to carry out an arthroscopy on C's knee had been unreasonable, as C had severe arthritis and carrying out the surgery was contrary to British Medical Journal Clinical Practice Guidelines. We upheld this aspect of C's complaint.

In relation to C's treatment when they had an infection, we found that it was reasonable for the surgeon to consider this to be a superficial wound infection rather than a deep wound infection, and the care and treatment provided for this was reasonable. We did not uphold this aspect of C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for unreasonably carrying out a knee arthroscopy. 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:

• Knee arthroscopies should not be carried out in patients such as C with degenerative knee disease, in line with relevant clinical guidelines.

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

Summary

C raised numerous concerns and complaints about repeated errors with the issuing of Movelat (pain relieving gel). C maintained the gel should be issued to them weekly but when submitting requests to receive the gel, they experienced difficulties. C received mixed responses as to why the gel was not issued. Some of the replies issued indicated the gel should be issued monthly. Other replies acknowledged that the gel should be issued weekly and explanations were offered for the error.

The evidence available confirmed that the gel was to be prescribed weekly to C. Despite this, C had to continually raise concerns in relation to ongoing errors with the prescribing frequency of the medication. It took some time before preventative steps were taken, by way of a note that was added to C's record confirming that the frequency of the prescription for the gel should not be changed.

We accepted that any delay in issuing the gel will not have had serious consequence for C, and we recognised the actions taken to minimise errors with the prescribing frequency of the gel. However, we found the administrative handling of the matter was poor. C had to unnecessarily submit repeated feedback and complaints only to receive mixed replies and for the problem with the prescribing frequency to continue longer than it needed to. As such, we upheld this aspect of the complaint.

C also complained about the decision taken by the healthcare team to discontinue a prescription for Difflam spray (an anti-inflammatory spray used to treat many painful conditions of the mouth or throat). It was explained to C that the throat spray was a short-term treatment for symptomatic relief of painful conditions of the mouth. It was noted that C had been taking the spray for several months, but there was no record to confirm the reason for that. C was reviewed by the dentist, who found no evidence of ulcers. The dentist had initially agreed to reinstate the spray but it was discontinued following a further discussion with an advanced nurse practitioner due to lack of mouth ulcers.

We took independent advice from an appropriately qualified clinical adviser, We found that the decision to stop the mouth spray had been taken in line with good practice as set out by the General Medical Council. As such, we did not uphold this aspect of C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to issue the pain relieving gel weekly, as per their prescription. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.
• Apologise to C for the unnecessary time and trouble they had to go to in an effort to get clear explanations and replies in relation to the prescribing errors with the pain relieving gel, and to get the issue resolved.

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 their late spouse (A) received from the practice. C had arranged a same-day appointment at the practice as A had been sick over the weekend. When the time approached; A was too ill to attend, therefore, C called the practice to request a house visit. A triage phone call took place that morning. A's symptoms were noted, advice provided and medication prescribed for sickness and diarrhoea. The following day, C requested a house visit as they felt that A's condition had worsened. Arrangements were made for a house visit to take place. C was concerned that A's condition was further deteriorating, so they contacted the practice to check when the doctor would arrive. The practice subsequently arranged for an emergency ambulance. A was taken to hospital but died shortly thereafter. The primary cause of death was found to be diabetic ketoacidosis (a complication of diabetes mellitus) and respiratory tract infection.

In responding to the complaint, the practice said that they could not always judge the severity of the symptoms over the phone; however, from the symptoms provided to the doctor, the appropriate action was taken in A's case. C remained dissatisfied with the care and treatment A had received and raised the matter with us. C was also unhappy that the practice's response to the complaint did not adequately cover all of their concerns.

We took independent advice from a GP. We found that, at the time of the triage phone call, there was an unreasonable failure to take an adequate history and further assess A (by way of an examination either by a house visit or hospital admission). We, therefore, upheld this aspect of the complaint. During our investigation, the practice provided us with some evidence of reflection and learning that had taken place.

In terms of C's concerns about the practice's response to their complaint, we found that they had appropriately contacted C in a timely manner in an attempt to obtain clearer information about C's specific concerns. Whilst it was not clear whether the practice attempted to get a better understanding of the complaint over the phone when C declined the offer of a meeting to discuss their complaint, we did not consider that they had failed unreasonably to respond to the complaint. We, therefore, did not uphold this aspect of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the unreasonable failure to gather sufficient information, including history, examination and testing, in order to make an informed diagnosis. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

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

Summary

C complained about the way the council had handled their reports of noise nuisance about a local village hall. The hall was leased by the council to an independent association that was responsible for managing bookings. C felt the noise caused by activities taking place at the hall breached the terms of the lease and believed the council should enforce this. C also reported the matter to the council’s Environmental Health service.

We found that the council handled C’s noise complaints satisfactorily, taking into account the status of the village hall, its lease and the powers available to the council to take enforcement action. We noted that although Environmental Health deemed that the noise was not a statutory nuisance, they continued to engage with the association to work towards an agreeable outcome. We did not uphold this aspect of the complaint.

C also complained about the way that the council handled their complaint about the service they received. We found that a number of aspects of the council’s complaint investigation were appropriate. However, we noted that the council failed to update C about the delay in the investigation and provide a revised timescale for the response. On balance, we upheld this aspect of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to update them about the delay in the investigation and provide a revised timescale for the response. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

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

Summary

C complained on behalf of their family member (A). C was unhappy with the way the council’s social work service conducted a review of A’s care package. The outcome of the council’s review was that the weekly number of hours for an element of A’s support was reduced.

We took independent advice from a social worker. We found that there was a lack of rationale within the assessment and care review documentation for the reduction in A’s support. In view of this, we concluded that the review of A’s care package was not conducted reasonably. We upheld this aspect of the complaint.

C also raised concerns about the way the council investigated and responded to their complaint. We did not identify any failings in the council’s complaint handling. We did not uphold this aspect of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C and A for the failure to conduct the review of A’s care package reasonably. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.
• Review whether the two-to-one care allowance within A’s current care package adequately meets their social needs. (The review should include provision for C to make representations in relation to this matter.) Inform C of the outcome of this review and provide them with a clear rationale for the decision.

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

• Review documentation should demonstrate that a service user’s identified needs have been fully considered during the decision making process.

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

Summary

C complained on behalf of their partner (A) after A's leg was amputated above the knee without C’s consent. We did not uphold this complaint as there was evidence of discussion with A prior to the operation and a consent form had been signed by A.

C also complained that the board unreasonably amputated A’s leg above the knee when a toe amputation would have been sufficient. A’s leg was vascularised down to their knee and there were significant problems with A’s foot. A toe amputation would not have been sufficient. It was reasonable to amputate A’s leg rather than conduct by-pass surgery. We did not uphold this aspect of the complaint.

C also complained that a Do Not Attempt Cardia Pulmonary Resuscitation (DNACPR) was put in place while A was unable to consent to it and that A was later discharged with this. We noted that there were issues relating to retaining a copy of the DNACPR on file, it but as consent was obtained once A was able to consent, we did not uphold this aspect of the complaint.

C also complained that the board changed their response to the complaint regarding consent to A’s amputation. The board had originally stated that A had been unable to consent to the amputation at the time and that it was performed out of medical necessity; however, later they located documentation to show that A had actually consented. We upheld this aspect of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to conduct an accurate investigation 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.

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

• Ensure clinical staff who have been asked to provide information relating to a complaint to the complaints team, check their understanding against contemporaneous clinical records, when giving statements for internal investigations. Ensure the complaints team ask staff feeding back comments if they have checked their understanding against contemporaneous notes.

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 sibling (A) following A's contact with a health board’s mental health service when they were in crisis. C was concerned about the standard of care and treatment provided to A. C’s concerns were wide-ranging and covered numerous aspects of the provision of care and treatment. C said this included repeated, unreasonable, failures by staff to recognise and diagnose A with psychosis and paranoia, to prescribe appropriate medication, to communicate adequately with A or their family or both, adequately supervise A, to agree a care plan and put in place appropriate discharge care, and to admit A as an in-patient at each emergency department attendance.

We took independent advice from a consultant psychiatrist and from a mental health nurse. We found that the diagnosis was appropriately assessed and reasonable conclusions reached on management and treatment of A. However, we also noted some concerns about aspects of communication with A and their family and found significant shortcomings in relation to record-keeping about a discharge from one hospital admission in particular. We upheld this aspect of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failings identified in this investigation. 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:

• Ensure relevant clinical staff at Wishaw General Hospital are aware of their responsibility to document patient management decisions in relation to General Medical Council Good Medical Practice Guidelines.

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 family member (A) who was a disabled student at the University of Glasgow. A had encountered a number of issues which they complained about. As a result of one of those complaints, A understood an action plan for the support for their learning was to be devised. A considered they, and their representatives, had asked for a copy of this action plan. C complained that the requests for a copy of the action plan had not been fulfilled. The university concluded that the action plan had not been shared with A or their representatives as the university wished to do so at a face-to-face meeting but no mutually convenient time had been identified. C was dissatisfied and raised complaints with this office about the university’s failure to provide a copy of the action plan when it was requested and about the time the university had taken to respond to their complaints.

We found that the university had not explained to A or C why they felt a meeting would be the best way to share the action plan with A, and had not provided any justification for why they felt the failure to arrange a meeting meant it was reasonable not to share the action plan with A. We decided that it was not reasonable for the university to have withheld the action plan from A in these circumstances and upheld this complaint.

We found that the matters C raised in their complaints were numerous and complex and that, consequently, there was a high volume of information that had to be considered by the investigating officer and a significant number of university staff to obtain evidence from. Taking all of this into account, we concluded that the time taken for the university to respond to the complaints was reasonable. We did not uphold this complaint but we did have a number of concerns about other aspects of the university’s handling of C’s complaints and made recommendations to address these.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C that they did not reasonably communicate with them regarding their failure to investigate C's complaints in line with timescales noted in their complaints handling procedure. 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.
• Apologise to A that they failed to provide a copy of the support action plan when it was requested. 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. The university should liaise with A to ensure their apology is provided in a format they are able to access.

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

• The university should reasonably consider requests for copies of documents and, where they feel it would be best to provide requested copies in a specific context, advise the requestor of their reasons for this. Where the university’s preferred method of providing a requested document cannot be undertaken in a reasonable timescale, the university should reconsider their position.

In relation to complaints handling, we recommended:

• The university should handle complaints in line with their 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 became a kinship carer to their family member (A) and complained that the council had failed to provide appropriate and accurate information about kinship care payments and had dissuaded C from applying. C also complained that information about the council’s policy on kinship care assistance was difficult to find and the policy provided to them in 2019 was out of date and did not include reference to changes in legislation that took place in 2009 and 2015.

The council said that C was provided with information and advice about kinship care payments, however C had decided not to pursue an application as they did not want to share their financial information.

We found evidence that C did not pursue an application for kinship care payments as they did not wish to share their financial information. We did not find any evidence that C was dissuaded from making an application. We did not uphold this complaint. However, our investigation found that the council’s policy on kinship care assistance was significantly out of date and was not updated between 2005 and 2020. Therefore, we upheld this aspect of C's complaint.

Recommendations

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

• The council should consider how they will conduct an audit of all kinship carers known them to them (informal/formal kinship carers and those or may or may not have a Section 11 Residency Order) and ensure they were given accurate information and are aware of their rights. If it is found they have not been given the information or assistance they are entitled to, this should be remedied.

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.