Some upheld, recommendations

Summary

C was referred to the board's plastic surgery department with a suspected sebaceous cyst (a common non-cancerous cyst of the skin) as a routine referral. It was found that C had a squamous cell carcinoma (a type of skin cancer). After diagnosis of the cancer C subsequently underwent treatment to remove it. After surgery the board's district and community nurses managed C's wound in the community. C complained about the treatment provided by the board and subsequent wound care.

We took independent advice from a consultant plastic surgeon. We found that the board's investigation, diagnosis and treatment of C was reasonable and met the waiting times specified by the Scottish Government in 'Better Cancer Care, An Action Plan'. While there had been some communication failings, the treatment provided was reasonable. We did not uphold this aspect of C's complaint.

We took independent advice from a nurse regarding C's wound care. We found that the wound care provided by the board was unreasonable. It was not evidenced that C's wound had been seen and assessed by an appropriate clinician before agreeing how the wound would be cared for. The board accepted there was a lack of documentation relating to C's wound care. 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 provide reasonable wound care to them. 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:

• Wounds should be assessed by an appropriate clinician before determining the best course of treatment.

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 on behalf of his daughter (Ms A) in relation to charges for treatment provided to Ms A in Victoria Hospital. Ms A was visiting the UK from overseas and attended A&E with palpitations (noticeably rapid, strong or irregular heartbeat). Following assessment in A&E, Ms A was admitted to an acute medical ward before she was later discharged. Ms A reattended the hospital the following week for a check-up and at this time an interview to assess charges for overseas visitors was also performed. Ms A subsequently received an invoice for the admission. Ms A had extensive contact with the board's finance and patient feedback teams in relation to the invoice. She remained dissatisfied with the board's final response and Mr C brought the complaint to us.

Mr C firstly complained that the board failed to inform Ms A that she would be charged for treatment when she attended A&E. We found that, due to the timing of the attendance and discharge from the hospital, it was reasonable that Ms A was not informed she would be charged for treatment until the interview performed in the week following the admission. We did not uphold this complaint.

Mr C also complained that the board failed to charge and invoice Ms A appropriately for treatment provided. In response to Ms A's complaint, the board identified and apologised for issues with the invoicing process. We found that the board's documentation of the assessment of liability for charges was poor. We were unable to determine that the board had followed the correct process for establishing liability and fully established that no exemptions applied to Ms A's treatment. On this basis, we upheld the complaint.

Finally, we identified a number of failings in the board's handling of Ms A's complaint. We noted that there had been a delay in signposting Ms A to the complaints procedure; that the board's correspondence contained inaccurate information; and that the final response did not address all the points raised. We upheld this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms A for the failings identified in assessment and complaint handling. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.
• Seek further information from Ms A (as needed) and reassess her liability for charges using overseas visitors' liability to pay charges for NHS care and services: a guide for healthcare providers in Scotland – CEL 09 (April 2010). Inform Ms A if she is deemed exempt or liable for charges, and provide a reason for this.

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

• Patients from overseas should be assessed for liability for charges in accordance with the board's internal procedure and the Scottish Government guide. An assessment of liability should be recorded in line with the board's procedure.

In relation to complaints handling, we recommended:

• Complaints should be handled in line with the requirements of the NHS Scotland 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 attended an appointment at Victoria Hospital to have a stent (a splint placed temporarily inside a duct, canal, or blood vessel to aid healing or relieve an obstruction) removed. The procedure, scheduled for the morning, was not performed until the evening, and when C was transferred to a ward they had not eaten for over 24 hours or drunk for around 18 hours. The board accepted that C had been fasted of food and liquid for longer than guidelines recommended. The board apologised for this and committed to reviewing their fasting guidelines and discussing these with staff. C had also not received all of their regularly required medication during this time in the hospital. The board apologised for this and explained that a full medication history should have been obtained via discussion with C and took steps to improve medicines management. During the process of complaining about their experiences, C agreed with a patient relations officer that a meeting to discuss their complaints, as offered in the board's first response to them, would be arranged. C subsequently received a second response from the board but no further communication about the expected meeting.

We investigated C's complaints about these matters. We upheld C's complaint about being fasted for an unreasonable length of time and found the actions that the board had committed to had not been undertaken. We upheld C's complaint about the failure to provide their regularly prescribed medication, given these had not been provided and there was no evidence a medication history had been completed as per normal processes. The board explained that they had decided the second response was the appropriate way to provide the clarification that a meeting would have delivered. Given C had reached a similar conclusion and had not pursued the matter further with the board, we did not uphold their complaint about the board's failure to complete the arrangements.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to provide them with their regularly prescribed 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:

• The board to complete a medication history for all patients as per normal processes.
• The board to fulfil their commitment to reviewing fasting guidelines and discussing these with all 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

Miss C complained about the care and treatment provided to her late father (Mr A). Mr A had been diagnosed with advanced prostate cancer and was admitted to a community hospital for rehabilitation and intensive physiotherapy after he had undergone chemotherapy and radiotherapy. Mr A's care and treatment was provided by a team of medical professionals including a GP and nursing staff. Mr A's condition deteriorated and he died during his admission.

We took independent advice from a GP and a nurse.

Miss C was concerned that there was a failure to diagnose and treat Mr A's lower respiratory tract infection and pneumonia and questioned the administration of an antidepressant medication to Mr A. We found that the infection was identified appropriately and appropriate treatment was provided. In addition, it was reasonable to have prescribed the medication and that there was no connection between this and Mr A's deterioration and death.

Miss C also raised concerns about the physiotherapy and rehabilitation provided to Mr A and the input from the dietician service. We found that the records documented Mr C had received reasonable physiotherapy and dietary care.

In relation to Mr A's end of life care, we found that it was not required that a GP attend Mr A in the 24 hours before he died. We also found that appropriate nursing care was provided to Mr A.

For the reasons outlined above, we did not find evidence of unreasonable failings in the care and treatment provided to Mr A and, as such, we did not uphold this complaint.

Miss C further complained that there was a lack of reasonable communication with her and her family about Mr A's care and treatment. While we found there was evidence of appropriate communication about Mr A's care, including about Mr A's end of life care, we took account of the board's complaint response to Miss C which identified areas for improvement and learning and accepted that unintended distress was caused to Miss C and her family. Therefore, on balance, we upheld this complaint.

Miss C also considered that the board had failed to handle her complaint reasonably. We found that there was a reasonable and proportionate effort by the board to answer the issues raised by Miss C. We noted that the board offered to meet with Mr A's family. As such, we did not find that the board's handling of the complaint was unreasonable and, therefore, we did not uphold this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Miss C and her family for the failings identified by the board's complaint investigation in communication, in particular, around the end of life care provided to Mr A. 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

Ms C returned to her GP after being discharged from the board's community psychiatric nursing (CPN) service as she was experiencing coping difficulties and anxiety. A further referral was submitted to the service but was refused. The local mental health team's view was that ongoing support for Ms C would not be appropriate or required because it was unlikely that she would derive any therapeutic gain.

In her complaint to the board, Ms C said she was unreasonably discharged from the service and that this had not been communicated to her clearly. She also complained about the decision to refuse the further referral to the service. The board said that Ms C's discharge from the service was well planned and discussed with her. It was also noted that Ms C had received extensive input from the service so it was felt she would not gain anything further and no plans were made to see her again after her GP referral. Ms C was unhappy with this response and brought her complaint to us.

We took independent advice from a mental health nurse. We found that Ms C's discharge was reasonably planned and phased and took place with her agreement and input. However, we were unable to identify a crisis plan within the records. A plan of this nature would have been helpful to all stakeholders in their efforts to support Ms C when her emotions fluctuate. It was unreasonable that no such plan appeared to be in place for Ms C. With that said, whilst it was clear from the GP's referral letter that Ms C was experiencing an increase in anxiety, there was no evidence to suggest that she was in crisis at that point. Given the evidence available, we concluded that Ms C's discharge from the CPN service was reasonable and that it was communicated to her appropriately. We also found that the local mental health team's response to her GP's referral was reasonable. Therefore, we did not uphold Ms C's complaints.

Ms C also complained that the board failed to handle her complaint reasonably. We found that there were delays in corresponding with Ms C and she was not kept up to date on the progress of her complaint. We also found that the board should have followed up with Ms C following a meeting were a number of action points were agreed. We upheld this aspect of Ms C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms C for failing to handle her complaint reasonably. The apology should meet the standards set out in the SPSO guidelines on apology available at: www.spso.org.uk/information-leaflets.
• Write to Ms C to confirm the steps taken to progress the identified outcomes recorded following the meeting.

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

• 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

Miss C complained about the care and treatment the board provided to her late father (Mr A). Her concerns related to the board's out-of-hours service and care provided at Dumfries and Galloway Royal Infirmary.

Mr A had been unwell and the board's out-of-hours service was contacted. Mr A was subsequently admitted to hospital with signs of infection but later discharged himself. He was then readmitted after it had been identified that he had staph aureus bacteraemia (SAB, an infection). Subsequently, Mr A suffered a gastrointestinal bleed (bleeding on the digestive tract, and a symptom of a disorder), and developed kidney failure. Mr A then also developed severe heart failure. He was discharged for palliative care and died shortly thereafter.

We took independent advice from a GP, a consultant in acute medicine and a nurse. In relation to the treatment provided by the board's out-of-hours service, we found that it was reasonable that a GP did not visit Mr A at home, based on the situation and what was known at the time. We did not uphold this complaint.

In relation to Mr A's admissions to Dumfries and Galloway Royal Infirmary, we found that during Mr A's first admission staff had provided reasonable reviews, tests and treatment for Mr A, and the level of clinical care and his treatment was reasonable. However, it had been identified after Mr A left hospital that he had SAB and we found that there was a failure to recognise or act on the seriousness of the SAB result and start proceedings to bring Mr A back to hospital and obtain treatment. In relation to Mr A's second admission, we found that Mr A was given intravenous potassium too quickly and that there was a delay in receiving a transoesophageal echocardiogram (an ultrasound test that uses sound waves to produce moving, real-time pictures of the heart) though it would not have changed his treatment. As such, we found that there were unreasonable failings in the clinical care and treatment provided to Mr A. We upheld this complaint.

In relation to the nursing care provided to Mr A, we found that there was a lack of evidence of day-to-day nursing care, significant failures in record-keeping by nursing staff and a scarcity of relevant nursing records. There were some areas of concern in relation to Mr A's fluid balance and shortcomings in the pressure care provided to Mr A. We also found failings in communication between nursing staff. Therefore, we found that there were unreasonable failings in the nursing care provided to Mr A. We upheld this complaint.

Miss C further complained that the board failed to communicate reasonably with her about Mr A's care and treatment. We found that medical staff had communicated reasonably with Miss C. However, we found there were shortcomings in how nursing staff communicated. In particular, there were limited references to communication, and where they existed, they were prompted by Mr A's family, not by staff. We therefore found there was a failure by nursing staff to communicate reasonably with Mr A's family. As such, we upheld this aspect of Miss C's complaint.

Miss C also complained that the board had failed to respond reasonably to her complaint. We found that there were a number of failures by the board in their handling of Miss C's complaint. We found that there was an unreasonable delay in acknowledging Miss C's complaint, a repeated failure by the board to meet their own timescales to finalise the complaint response letter or request a further extension and a lack of clear communication with Miss C. We upheld this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Miss C for the failings this investigation has identified. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

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

• A SAB result should prompt staff to review the patient, repeat blood cultures, give consideration to the investigations needed to find the source, and provide treatment. Relevant staff should be aware of the correct rate for administering intravenous potassium. Where a transoesophageal echocardiogram is planned, this should be carried out as soon as possible.
• The board should have systems in place to ensure the quality of day-to-day nursing care and record-keeping.
• Ward nursing staff should communicate with a patient and their relatives and ensure that any communications are appropriately recorded in the nursing notes.

In relation to complaints handling, we recommended:

• Complaint investigations and responses, including acknowledgement of receipt, should be in accordance with board's complaints handling procedure. The board should, whenever possible, inform a complainant about when they should expect to receive a response to their communication and if there is going to be a delay in providing this.

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 agreed to specialist reconstructive surgery, underwent their treatment, but experienced urinary incontinence thereafter. C said that they had believed the surgery would be of a routine nature and felt that they had not been not provided with adequate information about it; in particular, that a possible side effect was incontinence.

The board said that they could not comment on the information provided about the procedure as it was care provided by another board. We found that, while the procedure itself was carried out in another health board area, it was clear from the board's records that the procedure in question was discussed with C at a consultation within Borders NHS board and their agreement to proceed with the procedure was obtained.

We took independent advice from a urology (specialists in the male and female urinary tract, and the male reproductive organs) adviser. We found that the board failed to provide adequate information to C about the planned procedure prior to obtaining their consent. Therefore, we upheld this complaint.

C also complained that the board failed to provide them with reasonable aftercare in that they had to arrange follow-up care independently and had to undergo a further unnecessary test. The board said that C's discharge letter, outlining need for aftercare, was not copied to them by the board who carried out the procedure and acknowledged that C had to arrange follow-up care independently. We found that the board did not receive information about required aftercare from the other board and that the further test was necessary. Therefore, we did not uphold this complaint.

C also complained that the board failed to handle their complaint reasonably. We found that the board did not respond to a specific concern raised in C's complaint and as such we upheld this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to provide them with adequate information about the procedure and its recognised complications prior to obtaining their consent and for failing to handle their complaint reasonably. 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 consent process should follow national guidelines. Consent should be taken, where possible, prior to the day of surgery. As part of the consent process, there should be a clear discussion of the risks and benefits (of having the surgery and not having the surgery) and of any alternative options; and those discussions should be clearly documented.

In relation to complaints handling, we recommended:

• Staff should handle complaints in line with the Model Complaints Handling Procedure, which includes responding to all aspects of complaints.

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 said that mail sent to him by recorded delivery, which arrived at the prison, had not been received by him. Mr C said that he did not sign the mail log. This is a document used by the prison to record that a prisoner has received recorded mail items that have arrived for them. Mr C believed the signatures shown were forged.

The prison concluded that all recorded delivery mail addressed to Mr C, and received at the prison on the dates in question, had been signed for by him.

Mr C said that the prison failed to handle his mail appropriately. He also complained that their handling of his complaints was unreasonable. Mr C was unhappy with the time taken to investigate the matter and felt no information was shared with him during the investigation. Mr C also said that no relevant investigation was carried out. He felt an expert should have been asked to analyse the signatures shown on the mail log.

We could not determine one way or the other whether the signatures shown on the mail log sheets in question were Mr C's and considered a proportionate investigation had been carried out. There was no evidence to cast doubt on the findings of the Scottish Prison Service's (SPS) investigation. On balance, and with the absence of any further reliable corroborating evidence, we concluded that Mr C's mail appeared to have been handled appropriately by the SPS. We did not uphold this aspect of Mr C's complaint.

In relation to the handling of Mr C's complaints, we felt that the investigation carried out by the SPS was reasonable and proportionate. However, we concluded that steps should have been taken at an early stage to notify Mr C that the investigation of his complaint would not be completed within the timescale set out in the Prison Rules. He should also have been advised of a new timescale and of any further delays in finalising the investigation of his complaint. In addition to this, we concluded that although several discussions were said to have taken place between staff and Mr C to keep him informed of the ongoing investigation, no record of when those discussions, or their content, were kept. In light of this, we upheld this aspect of complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for not handling his complaints reasonably. 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:

• SPS should handle complaints in line with prison rules and complaint handling guidance.

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 on behalf of her adult son (Mr A) regarding two specific matters. The first concerned child protection procedures that been instigated following concerns for children in Ms C's care. Ms C complained that the council unreasonably requested a police report on Mr A. The guidance for the protection of children in Scotland means that it was reasonable for the social work department, as lead agency, to request any police check on an adult in Ms C's home, given the information that had been reported to them by the children's school. We did not uphold this aspect of the complaint.

Ms C also complained that there was a failure to document the basis on which a police report was requested. Section 91 of the Child Protection guidance states that when information is shared, a record should be made stating the purpose and form in which the sharing occurred. The social work records did not contain any information on why the request was made and we considered this to be unreasonable. The police request was in a standard form but it did not include parameters on the request limited to the alleged incident and we considered that it would have been reasonable to expect that this information should have been documented. We upheld this aspect of Ms C's complaint.

The second matter related to communication and access to social work services. Ms C complained that, despite being advised Mr A had a new social worker, there was a failure to advise Mr A of their name. Mr A was not transferred to adult services and therefore he would not have a named social worker. Mr A was not made aware of this and he was under the impression he would have access to a named social worker rather than the duty social worker. We found there was an unreasonable failure to communicate this. On balance, we upheld this aspect of the complaint.

Ms C also complained that there was a failure to refer to adult services and carry out an assessment for Self-Directed Support, despite stating this would be done. The decision not to refer Mr A to adult services under the children with disabilities and adult services transition arrangements was reasonable; however, the failure to document and explain this to Mr A was unreasonable. We upheld this aspect of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr A for (1) failing to document why the police report was requested in the social work records and failing to ensure the actual request was confined to parameters relevant to the alleged incident; (2) failing to advise Mr A how he could access social services and providing him with incorrect information that he had been allocated a new social worker when this was not the case; (3) failing to document an assessment which showed that Mr A did not meet the criteria for transfer to adult services and assessment for Self-Directed Support, and advising Mr A that he would receive an assessment by adult services including a Self-Directed Support assessment when this was not the case; and (4) failure to confirm to Mr A that he was not eligible to transfer to adult services and why he did not meet the criteria for referral to adult services under transition arrangements. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.
• Clarify how long the 2.5 hours per week provided to Mr A will be funded by children's services and how this is being monitored and reviewed. Clarify with Mr A how he can continue to access this service at present.
• Provide Mr A with details of how he can access an adult services assessment by self-referral so that it can be determined whether the council has an obligation to meet eligible needs.

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

• Ensure there is a clear transition process between children with disabilities and adult services. This should include information for families of children with disabilities telling them how they can access adult services. This should include what the process is, how decisions are made and how they are communicated with families and who the contact point is.
• Ensure assessments are adequately recorded on social work files.
• Ensure contemporaneous notes are recorded on social work files documenting why child protection concerns have been raised and reasons for seeking information from the police.

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 had concerns in relation to changes to the recycling system introduced by the council. Ms C told the council that she had a disability and needed reasonable adjustments in relation to the recycling system. The council took steps to visit Ms C and explain the changes to the system. Ms C remained unhappy and complained to the council. Her complaint was not upheld and the council concluded that there was no failure to provide reasonable adjustments under the Equality Act 2010. Ms C was dissatisfied with this response and brought her complaint to us.

Ms C complained that the council failed to consider her request for reasonable adjustments appropriately. Although we noted that council officers had attempted to assist and engage with Ms C, it was not apparent from the evidence available that the council had appropriately taken into account how Ms C's disability impacted on her ability to use the recycling system. We did not find evidence that the council considered the adjustments in a systematic way. We upheld Ms C's complaint.

Ms C also complained that the council had not carried out an appropriate equality impact assessment in relation to the changes to the recycling system. We found that the council had performed equality impact scoping exercises at two stages during the implementation of changes to the recycling system. These assessments did not identify that the proposals would result in negative impacts on people with disabilities. We found that the council has acted in accordance with their guidance in relation to equality impact assessments. While we did not identify failings, we suggested that the council may wish to review their assessments in light of the evidence about Ms C's experience of the recycling system. We did not uphold this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms C for failing to appropriately consider making reasonable adjustments. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.
• Contact Ms C to seek further information about how her disability impacts upon her capacity to use the recycling system. Refer to the Equality Act 2010 Statutory Code of Practice Services, public functions and associations (2011) and reconsider whether or what reasonable adjustments can be made. Inform Ms C of their decision and provide reasons.

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

• Officers should be aware of the duty to consider reasonable adjustments. Evidence of this consideration should be documented.

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