Some upheld, recommendations

Summary

Mr C made a number of complaints to us about care and treatment he had received after he attended the Royal Alexandra Hospital with back pain. He was subsequently diagnosed with metastatic prostate cancer. He was transferred to the Beatson West of Scotland Cancer Centre and was given radiotherapy (a treatment using high-energy radiation). Mr C considered that the primary treatment at that time should have been surgical.

We took independent advice on the complaints from an emergency medicine consultant, an orthopaedic consultant (a specialist in the treatment of diseases and injuries of the musculoskeletal system), a consultant oncologist (a doctor who specialises in the diagnosis and treatment of cancer) and a neurosurgery consultant (a specialist in the diagnosis and treatment of disorders of the nervous system, especially the brain and spinal cord).

Firstly, Mr C complained that there was a delay in carrying out an MRI scan. We found that he should have had an MRI scan within 24 hours, but there was a delay in carrying this out. We upheld this complaint.

Mr C also complained that when he attended A&E at the Royal Alexandra Hospital, he was inappropriately referred to the orthopaedics team. We found that it had been reasonable to refer him to the orthopaedics team and we did not uphold this complaint.

Mr C complained that there had been a failure to communicate effectively and to discuss the result of the MRI scan with the neurosurgery team. We did not find any failings in relation to this and we did not uphold the complaint.

Mr C complained that he was unreasonably given radiotherapy without consent being obtained for this appropriately. We found that it had been appropriate to give him radiotherapy at that time, given his deteriorating neurological symptom. We did not find any failings in relation to this matter and we did not uphold the complaint.

Mr C also complained that staff failed to communicate reasonably with him. We found that staff had not met his needs in relation to communication and upheld this complaint. However, we noted that the board had acknowledged and apologised for this failing.

Mr C complained that medical staff failed to adequately communicate to nursing staff that he should have been given Clexane (medication that helps to reduce the risk of blood clots) before an operation. We found that it was unreasonable that medical staff failed to communicate this adequately and upheld this complaint. The board said that they had already taken action in relation this complaint and we asked them for evidence of this.

Finally, Mr C complained that there was an unreasonable delay in deciding that surgery should be carried out after the MRI scan was reviewed by a spinal surgeon. We found that the timescale was reasonable and did not uphold this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for the unreasonable delay in carrying out an MRI scan. 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 consider developing a standardised pathway for the management of Malignant Spinal Cord compression based on NICE Guidance and including access to urgent MRI scans within 24 hours. This should also take bank holidays into account.

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, who has diabetes, damaged their foot. C was diagnosed with a broken 4th metatarsal (one of the long bones in the foot). A scan was taken and C was seen at a fracture clinic. C was unhappy with the assessment and the lack of further scans at the fracture clinic appointment.

We took independent advice from an orthopaedic surgeon (a medical expert who treats patients with problems in their muscles, bones, joints and other related structures). We found that, due to C's diabetes, C had a high risk of developing a delayed or non-union of the fracture and that this was not recognised by the doctor. Scans should have been taken at the clinic appointment to monitor healing and C was unreasonably discharged before the fracture was healed. Therefore, we upheld this aspect of the complaint.

C also complained about the management of their diabetes while they were awaiting surgery on their foot. We took independent advice from a nurse. We found that the management of C's diabetes was reasonable. C had a libre device which monitored their blood sugar levels. While the documentation of the management of C's diabetes should have been clearer, it was reasonable for C to continue to monitor their blood sugar levels on the ward and report the results to staff. We did not uphold this aspect of C's complaint.

Lastly, C complained that there was an unreasonable delay in their surgery being carried out. We found that the initial surgery was delayed due to equipment being unavailable. The surgery was a planned procedure and therefore the equipment should have been ordered prior to the day of surgery. When C's surgery was rescheduled, C was unreasonably placed on the trauma list when they should have been placed on the urgent planned list, where there would have been less likelihood C's surgery would be cancelled. We upheld this aspect of C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failings as identified in the appointment and for the delay in carrying out surgery. 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:

• Diabetic fracture healing should be appropriately assessed.
• Ordering/procurement systems are in place to ensure necessary equipment is available in advance of operations.
• Surgery should be scheduled on the appropriate list.

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 both the health visitor and hospital care provided to her child (Child A) in the context of child protection safeguarding. Ms C felt that there had been a lack of action taken by the health visitor when she reported Child A had ongoing diarrhoea and had a hard and bloated stomach. Ms C was also concerned that child protection procedures should not have been instigated and that the process was not properly communicated to her or reasonably followed in terms of the alleged facial markings on Child A.

In responding to the complaint, the board considered that the actions and care provided by staff were appropriate in terms of Ms C's complaints.

We took independent advice from a registered health visitor and from a consultant paediatrician.

In terms of the care provided by the health visitor, we considered that the care provided to Child A was appropriate and that it was correct to instigate child protection proceedings. However, we upheld this complaint on the basis that there was a failure to either reasonably communicate the decision about instigating child protection proceedings to Ms C or to record the decision not to communicate this to her.

We found that the care provided by the hospital was reasonable, therefore, we did not uphold this complaint on the basis that child protection procedures were appropriately followed.

However, we were critical of the board's original complaint response to Ms C as it provided limited detail of their complaints investigation in relation to the actions of the health visitor.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms C for not following the National Guidance for Child Protection in Scotland. 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:

• Staff should document that they have either communicated the decision to instigate child protection procedures to the family or to record the decision not to do so, in line with the National Guidance for Child Protection in Scotland.

In relation to complaints handling, we recommended:

• Complaint responses should address the issues raised, in line with the Model Complaints Handling Procedure.

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

Summary

C complained about a failure on the part of the board to discuss their eye conditions and possible treatments before they were referred to another board for an operation.

We found that, whilst the referral to the other board was reasonable, the fact that C was not involved in a discussion, or advised about possible options for treatment prior to the referral, was unreasonable. Therefore, we upheld this aspect of the complaint.

C also complained about a failure on the part of the board to transfer all relevant medical information to the other board prior to the operation.

We found that it was reasonable practice for the board to state that the other board could contact them for relevant information if they considered it necessary to do so, given they had already met with C and had notes about their condition. We did not uphold this aspect of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for (1) failing to explain to them why the doctor considered it necessary to refer them on to the other health board and (2) failing to send them a copy of the letter to their GP stating why the referral was being made. 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:

• To ensure patients receive information about why a referral has been made for them to see another clinician.

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

Mrs C complained to the board on behalf of her son (Mr A), who had a diagnosis of autism. Mrs C was unhappy with aspects of the care and treatment provided to Mr A by the mental health service at Queen Margaret Hospital.

Mrs C firstly raised concern about the communication surrounding the prescription of a medication. The board upheld Mrs C's complaint and apologised that the information provided about the dose was not clear.We found that Mr A had taken a greater dose than intended; however, the dose taken was still within the safe limits of prescribing for this medication. We concluded that the board had taken reasonable action in light of the matter. We upheld the complaint but did not make recommendations.

Mrs C was also unhappy with the psychiatric care and treatment provided to Mr A more generally. We took independent advice from a consultant psychiatrist. We found that there was a reasonable level of assessment, treatment, and clinical management of Mr A during his consultations with the service. We did not uphold this complaint.

Finally, Mrs C raised concern about some of the language used in the board's complaint response. We considered that the use of one term or another was a matter of preference and we did not conclude that there were failings in the language used. However, we did consider that the time taken for the board to respond to Mrs C's complaint was excessive. On balance, we upheld this aspect of the complaint.

Recommendations

In relation to complaints handling, we recommended:

• In line with the NHS Scotland Complaints Handling Procedure, the person making the complaint should receive a full response to the complaint as soon as possible but not later than 20 working days, unless an extension is required. Delays in the investigation should be minimised.

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 has a family history of bowel cancer polyps (abnormal growths) on the colon and was admitted to hospital on several occasions over many months with abdominal pains and vomiting. C complained to the board that, despite their family and medical history, the board unreasonably delayed to perform a scan, which resulted in a delayed diagnosis of bowel cancer. C also complained that the board failed to accurately report on a scan, as a subsequent review identified the presence of cancer.

The board advised that a scan was not indicated when C first presented to hospital. They also advised that the initial report on the scan was adequate, and it was only when additional clinical information became available (blood test results), that a second review changed the diagnosis.

We took independent advice from a consultant colorectal (bowel) surgeon. We found that there was insufficient consideration given to C's own medical history and that an x-ray taken was not appropriately followed up or acted upon. We concluded that there were several missed opportunities to perform a scan or colonoscopy (an examination of the bowel with a camera on a flexible tube) when C had attended hospital. We upheld this aspect of the complaint.

However, we concluded that the initial report on the scan was adequate. We did not uphold this aspect of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to take proper account of their medical history and for failing to carry out a CT scan when they first presented to hospital. 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 consultant with overall care for the patient should receive feedback from the case in a supportive way and the feedback is used for reflection as part of their annual appraisal.
• This case should be discussed as a delayed diagnosis and be reported and investigated as an incident in the organisation.

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

Mrs C was listed for a procedure to decompress a nerve in her foot. This procedure was agreed by a consultant but they resigned so Mrs C was transferred to another consultant (consultant 2) whose preferred treatment was non-surgical. Mrs C expressed concern at the treatment proposed for her so she met with a third consultant (consultant 3). It was agreed that she would be listed for surgery. Mrs C understood the procedure would involve removal of a bone spur (bony lumps that grow on the bones of the spine or around the joints) along with decompression of the deep peroneal nerve (a nerve that runs from the leg to the top of the foot). After surgery, Mrs C became aware that the procedure carried out by consultant 3 involved only the removal of the bone spur. Mrs C complained that the board unreasonably changed the original treatment plan agreed for her and that they inappropriately failed to carry out the procedure she consented to. She also complained that the board unreasonably failed to arrange a follow-up appointment with a different consultant.

We took advice from a consultant orthopaedic surgeon (a specialist in the treatment of diseases and injuries of the musculoskeletal system). We found that consultant 2's preferred treatment was reasonable although we did note that pre-operative investigation was limited with no apparent x-rays being arranged until Mrs C was seen by consultant 3. We found that consultants can have differing opinions in relation to proposed treatment and therefore, it was reasonable to change the original treatment plan for Mrs C given her care was transferred between different consultants. Therefore, we did not uphold this aspect of Mrs C's complaint.

In relation to consent for the surgery, we found that the consent form signed by Mrs C and the letter issued by consultant 3 confirming the proposed surgery did not match the surgery she received. It may have been the case that removing the bone spur released pressure on the nerve anyway but this should have been explained clearly to Mrs C. We found that whilst the procedure may have been clinically appropriate, the communication surrounding the procedure was unclear and inconsistent so we upheld this aspect of the complaint.

In relation to arranging a follow-up appointment for Mrs C with a different consultant, we saw evidence that Mrs C had clearly communicated that she was unhappy with the response provided to her complaint and she asked that her follow-up appointments be with someone else other than consultant 3. We saw evidence that consultant 3 wrote to Mrs C offering to facilitate her receiving an opinion from someone else. Mrs C said she did not receive that letter. The board told Mrs C that because she did not have an open referral, she should return to her GP to discuss further treatment options.

We found that it would have been reasonable for the board, as part of its handling of Mrs C's complaint, to offer her the opportunity to meet with a different consultant. Doing so would have demonstrated a willingness to try to better understand and resolve Mrs C's ongoing concerns about her surgery. We upheld this aspect of Mrs C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C for failing to clearly and consistently communicate with her in relation to her surgery and for not offering her the opportunity to meet with a different orthopaedic consultant as part of their final complaint response. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets
• Clearly communicate to Mrs C details of the surgery including the procedure consented to and the procedure actually carried out detailing whether that involved decompression of the deep peroneal nerve.
• Consider offering Mrs C the opportunity to meet with an orthopaedic consultant to discuss her concerns about the surgery.

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 works as part of a team of peer tutors within the prison. This includes him working with individual prisoners, or small groups of prisoners, within residential halls. Mr C understood a timetable for when peer tutoring could take place was agreed between the learning centre manager and prison senior management. However, there were occasions when prison staff refused to facilitate Mr C's requests to leave his cell to carry out peer tutoring sessions. Mr C complained that the Scottish Prison Service (SPS) unreasonably failed to ensure adherence to the previously agreed peer tutoring arrangements. He also complained about a subsequent review of peer tutoring arrangements. In particular, Mr C said the handling of the review was unreasonable.

The SPS' position was that the timetable referred to by Mr C was just a suggested protocol with proposed times of when peer tutoring may take place. We accepted that there would be occasions when access to certain activities, including peer tutoring, may be curtailed due to operational requirements arising within the prison. On the occasions when Mr C had not been unlocked from his cell for peer tutoring, this was because of operational requirements. We concluded that there was no official agreement in place with regards to peer tutoring times but a suggested protocol had been drawn up instead in an effort to support the function as much as possible.

We also looked at the prison's handling of the review. Mr C was concerned that the findings of the review were not communicated to him before the new process was implemented and that further layers of uncertainty were introduced. Mr C also felt the review failed to address issues which arose in relation to participation in the scheme or the times during which peer tutoring could take place. The SPS explained the review sought to examine how the role of peer tutoring was carried out and to address some concerns that had been raised. We agreed that the SPS had discretion to carry out reviews like this and they were responsible for deciding what areas to focus on during the review. We did not uphold either of Mr C's complaints.

Finally, we also looked at Mr C's concerns about the prison's handling of his complaints. He was concerned that despite raising his complaints there appeared to be an ongoing lack of awareness amongst staff regarding peer tutoring arrangements. Mr C also felt the prison failed to clarify issues raised surrounding the handling of the review of arrangements. We found that in responding to the complaints raised by Mr C, staff failed to take effective steps to ensure clarity surrounding the arrangements. We also felt it had not been made clear that the timetable Mr C understood was in place was only a suggested protocol and responses issued to Mr C were inconsistent. Therefore, we upheld this aspect of complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for failing to take effective steps to provide definitive clarity surrounding peer tutoring arrangements. The apology should meet the standards set out in the SPSO guidelines on apology available at https://www.spso.org.uk/information-leaflets .

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

• The prison should be clear on their standard approach to peer tutoring and should clearly communicate the position to staff and prisoners involves in those arrangements.

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 that the council failed to ensure that there was adequate support in place for her child (Child A) at school. The council had accepted that there were occasions when information about Child A was not taken into account and there were occasions when it was not fully shared. There was also insufficient up-to-date information for new staff at the school and there should have been more proactive partnership working with mental health services. In view of these failings, we upheld the complaint.

Ms C also complained that Child A's teacher had unreasonably failed to support them in class. We did not find any clear evidence of failings in relation to this and we did not uphold the complaint.

Ms C complained that the head teacher at the school unreasonably failed to fulfil their role as named person and lead professional under the Highland Practice Model. We found that the child's plan in place at the start of the school year had been out-of-date and there were then delays in updating this. We upheld this complaint.

Finally, Ms C complained that the council had failed to carry out a reasonable investigation into her complaints. We found that the council had carried out a thorough investigation, but that the response did not provide adequate information about the action the council would take to put things right or to ensure that the failings were not repeated. It also failed to adequately apologise for the failings identified. For these reasons, we upheld this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms C for the failings identified. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/leaflets-and-guidance .

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

• Ensure that there is clear guidance in place for staff in relation to the relationship between a child's plan and co-ordinated support plan.
• Where appropriate under the Highland Practice Model, there should be an up-to-date child's plan 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

Ms C complained to the council on behalf of her son (Mr A) about a council property he moved into.

Ms C complained that the council failed to carry out repairs to Mr A's property in line with their obligations and relevant policies and procedures. We agreed with the council that there may be snagging issues when someone moves into a new property. Therefore, we did not consider the fact there were repair issues after Mr A moved into the property to be unreasonable. However, we found some of the timescales and communication around repairs to be unreasonable. Furthermore, we did not consider the council always gave sufficient consideration to Mr A's personal circumstances, particularly when scheduling repairs and providing notification of visits. Therefore, we upheld this aspect of the complaint.

Ms C also complained that the council failed to carry out reasonable adaptations to Mr A's garden in line with their obligations and previous assurances provided to him. We noted the council's policies and guidance, which indicated that only basic work will generally be carried out in respect of garden areas before a new tenant moves in. Furthermore, we did not consider there to be evidence to suggest the council failed to carry out specific work or adaptations previously committed to. We agreed with Ms C that evidence she provided shows the garden was in a poor condition and not clear of rubbish when Mr A initially moved in, although this was addressed by the council later. We provided feedback to the council about this. However, we did not consider this to mean that the council failed to carry out reasonable adaptations to the garden. Therefore, we did not uphold this aspect of the complaint.

Finally, Ms C complained that the council let the property to Mr A when it was not in a safe or reasonably suitable condition for him to move in. Ms C highlighted the number of repairs that were carried out after Mr A moved into the property and the fact that the windows in the property were replaced shortly after he moved in to bring them up to Scottish Housing Quality Standard. We considered the council's position, that the fact Mr A's windows were replaced as part of a scheduled programme of works, did not mean they were unsafe to be reasonable. In respect of the repairs required, we did not consider that the council failed to carry out appropriate pre-tenancy checks. We had some concerns about the accuracy of the information contained in the council's pre-tenancy paperwork. However, overall, we did not consider the evidence to indicate that the council let the property to Mr A when it was not in a safe or reasonably suitable condition for him to move in. Therefore, on balance, we did not uphold this aspect of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr A for failing to carry out repairs to his property in line with their obligations and relevant policies and procedures. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets .
• Make contact with Mr A or his representative and offer to discuss the best way to arrange repairs or visits in the future.

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

• The council should carry out and co-ordinate repairs within a reasonable timescale and give appropriate consideration to a tenant's health issues when doing so.

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.