Some upheld, recommendations

Summary

C complained about the care and treatment provided to them by the board when they presented with abdominal pain. C complained that they were repeatedly unnecessarily catheterised, their symptoms and clinical context were ignored, and they were misdiagnosed as having a bladder tumour instead of an ovarian tumour.

We took independent advice from a nurse, a 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 urologist (a doctor who specialises in the male and female urinary tract, and the male reproductive organs), and a sonographer (a healthcare professional who performs diagnostic medical sonography, or diagnostic ultrasound). We found that both nursing and urology care and treatment provided to C was reasonable. However, we found that an ultrasound scan incorrectly interpreted a mass as being a bladder tumour, when in fact the mass represented a large ovarian tumour. Though this was a misinterpretation of the scan, we found that given the clinical information available at the time, this misinterpretation was not unreasonable. We did not uphold this aspect of C’s complaint.

C also complained about the board's handling of their complaint. We found that there were significant complaint handling failings, including failure to advise C in a timely manner which aspect of the complaint they would investigate; failure to update C in a timely manner throughout the investigation; incorrect information being contained in the complaint response and no apology being given for this. We therefore upheld this aspect of C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the unreasonable 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:

• Staff should be aware of the scope of a complaints investigation and the relevant standards and processes that apply. Staff should be able to appropriately obtain and evaluate the evidence obtained and use this to give reasons for decisions reached; and complaints should be handled in line with the model complaint handling procedure. SPSO have issued a guidance tool to support investigations staff. This can be accessed here: www.spso.org.uk/how-we-offer-support-and-guidance. The model complaints handling procedure and guidance can be found here: 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

Mr C complained about the care and treatment provided to his partner (Miss A) at Aberdeen Maternity Hospital. Mr C said that when Miss A attended a pre-caesarean section assessment, the doctor failed to identify that she was in the early stages of labour. Mr C also complained that the board failed to explain why their baby required antibiotics and a breathing tube after they were born, and that the board's handling of his complaint was unreasonable.

The board acknowledged that the doctor assessing Miss A had failed to carry out a full assessment. The board noted that the reasons why their baby required antibiotics and a breathing tube had been explained to Mr C by hospital staff and later in email correspondence. The board also carried out a comprehensive review of their handling of the complaint and identified areas for learning and improvement.

We took independent advice from a consultant obstetrician and gynaecologist (a doctor who specialises in the female reproductive system, pregnancy and childbirth). We accepted the board's view that the doctor failed to carry out a full of assessment of Miss A's condition when she attended for the pre-caesarean section appointment and that their handling of the complaint was unreasonable. We upheld these complaints on that basis and made further recommendations for learning and improvement. We concluded that there was reasonable evidence it had been explained to Mr C why his baby required antibiotics and a breathing tube at the time of the event and later in email correspondence. Therefore, we did not uphold this aspect of the complaint.

Recommendations

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

• The board should have a guideline in place for the management of patients attending the pre-caesarean section clinic. This should include standard questions to ask all patients such as about presence of vaginal bleeding, fetal movements, as well as contractions and leaking fluid vaginally.
• The board should have guidelines in place about the turnover time for issuing letters following debrief meetings.
• The board should have in place template letters which can be used when inviting patients for debrief meetings that make the purpose of the meeting explicit.

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 provided to her by the board in relation to rheumatology (the branch of medicine that deals with rheumatism, arthritis, and other disorders of the joints, muscles, and ligaments), radiology (medical discipline that uses medical imaging to diagnose and treat diseases), and respiratory (the branch of medicine that deals with conditions affecting the lungs) care and treatment.

We took independent advice from a rheumatologist, a radiologist, and a respiratory physician. We found generally that the care and treatment provided to Ms C was reasonable. However, we identified that there was a scan which had been reported inaccurately, and this was unreasonable in that it missed acute inflammation. Therefore, we upheld Ms C's complaint about radiology but did not uphold her complaints in relation to her rheumatology and respiratory care and treatment.

Ms C also complained about the board's handling of her complaint. We found that there was an inaccuracy in the complaint response and upheld her complaint on this basis.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms C for her scan being reported inaccurately and the response to her complaint being inaccurate. 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:

• Scans should be reported to a reasonable standard.

In relation to complaints handling, we recommended:

• Complaint responses should be accurate.

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 support and advocacy worker, complained about the University of Dundee on behalf of their client (A). A was a disabled student at the university. The university terminated A's studies on the basis that A had not met the required academic standard. C made a number of complaints about how the university handled matters. C complained that the university did not provide A with reasonable adjustments during their studies.

We took independent advice from an equalities adviser. We found that the university had appropriate regard to their obligations in terms of the relevant equalities legislation and guidance and that they took reasonable action to address A's concerns regarding equipment issues. We did not uphold C's complaint regarding the reasonable adjustments provided to A.

C complained that the university did not provide A with a first and second supervisor and with supervision meetings. We noted that the university appeared to have done most of what was required of them regarding the provision of supervisors and supervision meetings. However, we found that:

for a four-month period, A did not have at least two supervisors

the supervisors did not record the substantive outcomes of all A's scheduled supervision meetings

not all the supervision meetings that took place were recorded on the university's system.

Given that these were requirements in the university's procedures, we upheld C's complaint about the supervision provided by the university.

C complained that the university unreasonable terminated A's studies and unreasonably time-barred A's academic appeal. We did not find any evidence of administrative or procedural failings regarding the university's actions. We noted that, in the particular circumstances, the university had the discretion to decide whether to terminate A's studies and whether to time-bar the appeal. We did not uphold these aspects of C's complaints.

C complained about the way the university communicated with A. We found that the university did not:

set out their position to A after a deadline had passed without submission

explain to A that a particular email would be treated as an extension request

explain to A why the position regarding the extension request changed from being refused to approved within a few days.

We upheld C's complaint that the university failed to communicate reasonably with A.

Lastly, C complained about the way that the university had handled A's complaint. We found that the university did not give appropriate consideration to whether the outcome A said they were seeking should have been dealt with under the appropriate appeals procedures, rather than under the complaints handling procedure. We, therefore, upheld this aspect of C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to A for the university's communication with them regarding the extension and for not giving further consideration to whether the outcome A said they were seeking should have been dealt with under the appropriate appeals procedures, rather than under the complaints handling procedure. 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:

• Communication with students regarding extensions should be clear, particularly where the position regarding an extension request changes.
• Procedures regarding the supervision of students should be followed.

In relation to complaints handling, we recommended:

• Consideration should be given to the outcome a complainant is seeking and whether that outcome would be more appropriately explored through the appeals procedures or other appropriate mechanism.

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

Summary

C complained about the social work service provided to their family by the council. A social worker first had contact with the family after the police charged C's child (A) with an offence. Social work, as part of a multi-agency group, contributed to risk management plans. Under these plans, A's contact with peers and access to school and extracurricular activities was limited.

C complained that the risk plans were too restrictive and disproportionately impacted on A's educational attainment, wellbeing and social relationships. The council did not uphold C's complaint. We took independent advice from a social work adviser. We found that the social work service acted reasonably in the course of making and managing the restrictions. We found evidence of reasonable support and engagement with the family and social workers being responsive to the concerns, including reducing the restrictions when it was considered appropriate. We did not uphold this aspect of C's complaint.

C also raised concern that the service inappropriately shared confidential information about A with a health professional. We were not critical of the council's rationale for sharing the information. However, having reviewed the relevant guidance on information sharing, we considered that, before sharing the information, the council should have informed A's family of the intention to share information and provided reasons for this. We also found that the council's record-keeping of the information disclosure was insufficiently detailed. We upheld the complaint and made recommendations.

Finally, C was unhappy with the way the council handled their complaint. In particular, C raised concern that there was an unreasonable delay in responding and a conflict of interest given the involvement of a manager in the investigation. We found that the council took reasonable steps to extend the timescale to 40 working days, although it appeared they then missed the revised timescale by a small number of days. We did not find failings in relation to the investigation performed. On balance, we concluded that the council handled the complaint appropriately. We did not uphold the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C and A for failing to inform them about the intention to share the information or the reason for this; and failing to fully document the information disclosure. 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:

• Information sharing should be conducted in line with the relevant legislation and guidance. Where information is shared, an appropriate record of this should be maintained.

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) following A's admission to University Hospital Hairmyres with drowsiness. There was an indication that A may have taken too much of their prescribed medication at home. C raised concerns that a period of deterioration during A's admission was due to poor care.

We took independent advice from an appropriately qualified adviser. We considered that A's deterioration was related to infection, and were unable to identify anything to suggest that their deterioration was due to poor care. We did not uphold this aspect of the complaint.

C complained that their concerns about A's deterioration were ignored, and that when they asked to speak to medical staff, this was not arranged. The board noted that C had been given the telephone number of the consultant's secretary, and that two doctors were on the ward during the day on weekdays and were available to speak to patients and relatives. We considered that nursing staff should have arranged for the ward doctors to speak to C, rather than providing a number to make an appointment with the consultant. We considered that this would have been simpler, quicker and more effective. We upheld this aspect of the complaint.

C also expressed concern about the arrangements in place for A's medication on discharge, including that they were not given a dosette box to assist them in managing the medication at home. We noted that there was concern that A's medication may have caused the symptoms which led to their admission, and as such they considered that the discharge medication should have received more care and attention. Therefore, we upheld this aspect of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C and A for not giving more care and attention to A's discharge medication. 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:

• Care and attention should be given to arrangements for discharge medication, especially where there is evidence of a patient having had previous problems taking (or relatives having had problems administering) the correct medication.

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 to us about the care and treatment provided to her late partner (Mr A) by Raigmore Hospital during an admission. Mr A was assessed and a crisis plan was agreed; Mr A was then discharged home, but soon after he died. Ms C complained that the board unreasonably discharged her partner home. She also raised concerns about the significant adverse event review (SAER) carried out by the board into Mr A's care and treatment.

We took independent advice from a mental health nurse and from a consultant psychiatrist (a medical practitioner who specialises in the diagnosis and treatment of mental illness). We found that the board carried out an appropriate and systemic risk assessment. We found that a coherent short-term crisis plan was agreed with Mr A, until he could engage with his local mental health services. We found that the decision to discharge Mr A home was reasonable. We did not uphold this aspect of Ms C's complaint.

We found that the board's SAER process and report was reasonable; and it identified appropriate learning. However, we noted that when Ms C complained to the board, they said that they would address her concerns through the SAER. In the circumstances and given the time it took to complete the SAER, we considered that the board should have kept Ms C updated more regularly on its progress. We upheld this aspect of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms C for failing to keep her appropriately updated. 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:

• If the board decides to address a complaint through their SAER, they should then keep the complainant appropriately and regularly updated on its progress.

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

Miss C complained about the care and treatment her late mother (Mrs A) received at Raigmore Hospital after she was admitted with symptoms of bleeding from her stoma (an artificial opening made into a hollow organ, especially one on the surface of the body leading to the gut or trachea). Mrs A died around three weeks later following surgery to revise the stoma (resected ileostomy). Miss C raised concerns that the surgery was unnecessary and Mrs A had not properly consented to it; that the nursing care was poor (in terms of wound management, personal care, repositioning Mrs A and cables that had tied down her hands); and that the board did not handle Miss C's concerns through the NHS Model Complaints Handling Procedure (MCHP) appropriately.

We took independent advice from a consultant general and colorectal surgeon (a surgeon who specialises in conditions in the colon, rectum or anus). We considered that the decision to operate was reasonable on the basis that Mrs A had multiple admissions in the period immediately prior to this admission and required blood transfusion. In addition, Mrs A had undergone appropriate investigation to identify the source of gastrointestinal blood loss and that the pathology report of the resected ileostomy had confirmed that it was the source of bleeding. In addition, we were of the view that although Mrs A had experienced a rare complication of the surgery, there was no evidence that it had fallen below a reasonable standard. However, we found that there was insufficient evidence to show that any of the recognised risks of the surgery had been discussed with Mrs A. We considered this unreasonable and not in accordance with guidance. Therefore, we upheld this aspect of Miss C's complaint. We noted that the board's investigation had accepted that the documentation regarding communication was of an unreasonable standard and that the staff involved had reflected on their practice for learning and improvement. The board also took steps to amend the surgery consent form to ensure that the recognised risks of surgery are clearly captured.

In terms of nursing care, we found this to be reasonable and appropriate. We did not uphold this aspect of Miss C's complaint.

In relation to complaint handling, we found that the board should have summarised the issues for investigation and checked whether Miss C wanted to provide any further information before they issued their response to the complaint. Therefore, we upheld this aspect of Miss C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Miss C for the failings identified in terms of the documentation of communication; the surgery consent process; and the handling of her 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 surgical staff understand their responsibilities in ensuring important events and communications with the patient or supporter is recorded; and involving patient supporters in decisions about treatment in accordance with the Good Surgical Practice guidance.
• Ensure the current standards of consent are followed as outlined by the Royal College of Surgeons.

In relation to complaints handling, we recommended:

• Ensure complaints are handled in line with the NHS MCHP: 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

C complained to the board about the decision to move them to another ward and the manner in which they were discharged while they were a patient at Royal Edinburgh Hospital. The board explained that beds are allocated according to clinical need and, due to extreme pressures on hospitals at that particular time, it was felt appropriate to move C to another ward as they were clinically stable. The board said appropriate referrals were made following C's discharge, however, as C did not return to the ward following an overnight pass, they were unable to complete their assessment for home treatment.

We took independent advice from a mental health nurse. We found that it was unavoidable that a patient had to be transferred to another ward due to the pressures on the wards at the time, and that the board followed a reasonable process in selecting C as a suitable candidate. We did not uphold this aspect of the complaint.

However, we found that while appropriate assessment was carried out, the board failed to appropriately manage C's discharge as they did not ensure that Intensive Home Treatment Team supports commenced when C left the hospital. We upheld this aspect of C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to ensure that the planned post-discharge inputs by the Intensive Home Treatment Team commenced at the point of discharge. 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 take steps to ensure that planned post-discharge inputs by community-based services are followed through at the point of discharge and that said community-based services are timeously notified that discharge has taken place. This is especially important in circumstances where discharge has occurred in irregular circumstances which elevate the risk of the person becoming lost to follow-up.

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 he was unreasonably removed from the boards waiting list when he did not attend an appointment. We took independent advice from a dental adviser. We found that it was reasonable to remove Mr C from the waiting list without offering him another appointment in the clinical circumstances. We did not uphold this aspect of Mr C's complaint.

Mr C also complained that the board did not communicate reasonably with him. We found that the board's letter to Mr C did not inform him that, if he contacted the service within four weeks, he may be offered another appointment. This was contrary to the NHS Lothian Standard Operating Procedures for Waiting Times Management. We also found that there was no written record of Mr C's call to the board. We upheld this aspect of Mr C's complaint.

Lastly, Mr C complained about the way the board handled his complaint. We did not find evidence that the board had handled Mr C's complaint unreasonably. Therefore, we did not uphold this aspect of Mr C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for failing to inform him that if he contacted the service within four weeks he may have been offered another appointment and for failing to record Mr C's call to the board. 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.