Some upheld, recommendations

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.

Summary

C complained about the council's handling of a planning application submitted by their neighbour. The planning application was for a number of alterations to C's neighbour's property. C objected to the application, as they had a number of concerns about the proposed alterations, including what they considered to be inaccurate plans and information submitted by the neighbour. Despite C's objections, the council approved the planning application.

C complained to the council about their handling and assessment of the application. They stated that there were inaccuracies within the Report of Handling and that the council had not addressed the points raised in C's objection appropriately. The council acknowledged that there were a number of failings in how they handled and assessed the planning application. However, they concluded that their decision on the application would have been the same had these failings not taken place.

In C's complaint to us, they explained that they were not satisfied with the council's response and that the council should have taken further action in response to the aspects of the complaint they upheld. C also had further concerns about the council's handling of the application and the assessment that led to their decision.

We took independent advice from a planning adviser. We found that the council's stage 2 complaint response provided a reasonable explanation for why the decision to approve the planning application was appropriate. Furthermore, the council's decision-making was in line with relevant guidance and legislation. Although C disagreed with the council's decision on the planning application, we were satisfied that this was a decision the council were entitled to reach. However, we did identify one failing in respect of the application validation process that was not addressed in the council's response. In light of this, and the failings already identified by the council, we upheld this complaint.

C also complained that the council had failed to take reasonable and appropriate action in relation to the drainage provisions that were part of the planning application. C said that there was a lack of detail in the planning application in relation to drainage and that the council had been unclear about whether this was a matter for the planning department or building standards. The council stated that the information contained within the planning application was sufficient to allow an appropriate assessment of the application. They also clarified that a development of this nature would not require a building warrant.

We found that the information provided in the council's complaint response was accurate. As such, we were satisfied that the nature of this development meant that more detailed information, plans or drawings were not necessary. We also accepted that building standards would not have a role in this matter should the development lead to unexpected water run-off. While acknowledging that the council's Report of Handling contained inaccurate information, we concluded that the council acted appropriately and did not fail to carry out any actions they were obliged to. Therefore, we did not uphold this complaint.

Recommendations

What we asked the organisation to do in this case:

• Given the failings identified in both the council's stage 2 investigation and our investigation, consider whether it is expedient to revoke the planning permission granted for the application and require a new application to be submitted.

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

• Reflect on how this planning application was validated, handled and assessed. Consider whether there are any learning and improvement points that can be put in place.

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 home visit to attend to their late spouse (A) concerning A’s PEG (a tube into the stomach to enable non-oral feeding) which was leaking. A family member of C had called the district nurses and was put in touch with an enteral feeding (a method of supplying nutrients directly into the gastrointestinal tract) nurse who agreed to visit the next day. The nurse advised C that the leak appeared to be due to constipation. C complained that the nursing care provided to A was unreasonable. The nurse also filed an Adult Support and Protection Referral (ASPR) with social work due to concerns about A’s safety. C complained that the ASPR was not appropriate.

We took independent advice from a community health nurse. We noted that the partnership's pathways and referral process indicated that unscheduled care from the community enteral feeding team should be provided within four hours (or an alternative care plan identified). We found that an urgent response was required in this case as A was bedbound and dependent on the PEG for providing all nutritional needs, including administration of medications essential for managing long-term conditions. Any malfunction of A’s feeding and medication regimes would result in detriment to their wellbeing. The visit to A should have been classed as ‘unscheduled care' and A should therefore have been seen within a four-hour time period in terms of the process. In relation to the overall nursing care, we were critical that there was no detailed documentation of the assessment and examination during the visit, and no treatment plan recorded (other than advising the family to contact the GP to arrange an x-ray). However, we noted that the nurse followed up with the GP, which was good practice. We also noted that a subsequent hospital scope indicated that the nurse’s diagnosis of constipation appeared reasonable. In view of the lack of detailed records or care plan, and the failure to comply with the partnership’s own timeframes for reviewing A, we considered that the care and treatment was unreasonable and we upheld this complaint.

In relation to C’s complaint that the ASPR was not appropriate, our role is not to decide whether the concerns raised in the ASPR were justified (that is, whether or not A was in fact at risk); rather, we had to consider whether the nurse’s decision to make the referral was reasonable, based on their knowledge of the situation and their concerns. We found that the nurses' concerns were appropriate and sufficient reason for making the referral. As such, we did not uphold this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the poor record-keeping and for failing to meet their timeframes for unscheduled 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:

• Unscheduled care should be provided within the timeframes in the partnership’s policy, with clear records of the examination, findings and treatment plan.

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 to us on behalf of their client (B) about the care and treatment the board provided to B's spouse (A). During our investigation, we took independent advice from an adviser in respiratory and internal medicine.

In 2011, A's GP referred them to the board, after an x-ray showed irregularities in their lungs. For around two years, A was followed up at the respiratory medicine clinic with chest x-rays. Medical staff concluded the lung irregularities were unlikely to be cancerous and A was discharged. Around that time, A was diagnosed with rheumatoid arthritis (a long-term condition that causes pain, swelling and stiffness in the joints). In late 2017, A was diagnosed with small cell lung cancer at Ninewells Hospital that had already spread to their liver. A died shortly afterwards.

C complained that between 2011 and 2013, the board failed to diagnose A with lung cancer. We found A was given appropriate follow-up with chest x-rays and it was reasonable the lung irregularities were not considered to be cancerous. We did not uphold this complaint.

C complained that between 2013 and 2017, A was experiencing symptoms of lung cancer that were wrongly attributed to rheumatoid arthritis. We found that it was reasonable A was diagnosed with rheumatoid arthritis. We found A had not reported cancer related symptoms at their rheumatology reviews. We also found that as small cell lung cancer is very aggressive, the symptoms would usually develop over months and not years. We did not uphold this complaint.

C also complained that A's discharge letter from Ninewells Hospital was unreasonable, as it contained incorrect information about A's condition. The board acknowledged there was an error in the discharge letter. We found the discharge letter was unreasonable due to the error and we upheld this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to B for the failings in the board's complaints handling. 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' discharge letters should contain accurate information about their condition and the outcome of investigations.

In relation to complaints handling, we recommended:

• Complaints should be handled in line with the Model Complaints Handling Procedure (MCHP). The MCHP and guidance can be found here: https://www.spso.org.uk/the-model-complaints-handling-procedures.

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 complained about the care and treatment she received from the board for her ongoing health problems. She said that the board initially failed to appropriately diagnose and treat her health condition and then failed to provide her with appropriate care and treatment for her condition. Ms C said she was advised by the board that she had multiple sclerosis (MS) and she never had any reason to doubt the diagnosis, until ten years later she discovered she had a condition which inhibited the absorption of vitamin B12, when she found that supplementing her diet with liquid vitamin B12 resulted in her experiencing improvements in many of her symptoms.

We took independent medical advice from a consultant neurologist (a specialist in the diagnosis and treatment of disorders of the nervous system). We found that Ms C’s initial diagnosis of probable MS was appropriate. The evidence suggested that the description given to Ms C of the level of certainty of her MS was reasonable and in line with the actual status of her diagnosis at that time. We found that vitamin B12 deficiency would not be expected to have presented with the pattern of relapsing–remitting disease in Ms C’s case. We considered that there was no indication to have administered vitamin B12 injections in the early stage of Ms C’s illness, as there was no evidence that her condition related to vitamin B12 deficiency. Therefore, we did not uphold this part of the complaint.

In terms of Ms C’s subsequent treatment, Ms C raised a number of issues, including that the board did not order a further spinal MRI to compare with the spinal MRI done at the time of her diagnosis. We found that the main purpose of MRI scans in a case such as this was to secure the diagnosis, rather than to monitor progress and there was, therefore, no clear indication to repeat the scans any more regularly than was actually done. We considered that the board provided Ms C with appropriate subsequent care and treatment and did not uphold this part of the complaint.

Ms C also complained that the board failed to respond to her complaint about her diagnosis and treatment appropriately. We found that the board’s responses to Ms C’s complaint failed to address all the issues raised; the responses were issued outwith the timelines set out in the NHS Model Complaints Handling Procedure; and the board failed to keep Ms C updated on the reason for the delays and give her revised timescales for completion. We, therefore, upheld this part of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms C for failing to address all the issues raised in their responses to her complaint; for issuing the responses outwith the timelines set out in the NHS Model Complaints Handling Procedure and for failing to keep her updated on the reason for the delays and give her revised timescales for completion. 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’s responses to complaints should address all the issues raised, be issued within the timelines set out in the NHS Model Complaints Handling Procedure and keep the complainant updated on the reason for the delays and give revised timescales for completion.

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

Summary

C attended A&E at Wishaw General Hospital complaining of chest tightness, sweating, nausea and palpitations (a noticeably rapid, strong, or irregular heartbeat due to agitation, exertion, or illness). C felt that their concerns were not fully listened to and concerns about side effects of medication were not taken into account.

We took independent advice from a consultant in emergency medicine. We found that the assessment C received was of a reasonable standard for a patient presenting with chest pain and appropriate investigations were carried out. We did not uphold this aspect of the complaint.

C also complained about the response they received to their complaints. We found that while some of the board's actions were reasonable (a resolution was sought; C spoke with the consultant about their concerns; C was offered to add their account to the medical record), overall the board's complaint handling was unreasonable. We found that the board had not responded to all of the points that C raised as complaints, and the board acknowledged this failing in a later complaint response. We also found that the board should have been clearer when advising C of which stage of the complaints process they were at and should have managed C's expectations about the next steps if a resolution could not be reached. Therefore, we upheld this aspect of the complaint.

C also complained about the board's application of their Unacceptable Actions Policy (UAP). We found that the board had acted in line with process. While they had warned C that they had a UAP and why they considered C's actions were unreasonable, they did not formally restrict C's contact with them through the UAP. We did not uphold this complaint.

Recommendations

In relation to complaints handling, we recommended:

• The board should ensure that complaints communications are clear.

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.