Some upheld, recommendations

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.

Summary

Mr and Mrs C complained about the partnership's management of their adult son's care (Mr A). Mr A's care was managed by the partnership for a number of years. The partnership moved Mr A's care away from his family base when they came to the view that the level of support he required could not be provided at that location. Mr and Mrs C complained that this was unreasonable and appropriate actions were not taken to allow Mr A's care to be provided closer to his family's home.

We took independent advice from a social worker. We found that the partnership attempted to provide the support Mr A required close to home, and when this was not possible, appropriate steps were taken to ensure that he received the care he required elsewhere. The partnership reasonably communicated with Mr and Mrs C about the decisions that were being made and listened to their views. The partnership took reasonable steps to ensure Mr A was appropriately placed and received appropriate support. We did not uphold this aspect of the complaint.

Mr and Mrs C also complained about the response to their complaint. The complaint was formed as a series of questions. The partnership's complaints handling procedure states that, where appropriate, the partnership should discuss the complaint with the complainant to understand why they are dissatisfied and what outcome they are looking for. As the partnership failed to clarify Mr and Mrs C's complaint, discuss the outcomes they were seeking by pursuing the complaint, and failed to clearly explain their findings, we upheld this aspect of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr and Mrs C for failing to provide a reasonable response to 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:

• The partnership should contact complainants to clarify complaints and outcomes where necessary before investigating a complaint.
• The partnership should ensure complaints investigated result in findings which are clearly communicated to complainants.

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, an MSP, complained on behalf of his constituents Ms B and Ms A (Ms B's daughter) about the service provided by a community mental health team (CMHT). Ms A was a young adult with Asperger's Syndrome (a form of autism, in which people may find difficulty in social relationships and in communicating) and she received treatment for obsessive compulsive disorder (OCD, a common mental health condition where a person has obsessive thoughts and compulsive behaviours) and depression.

During our investigation of Mr C's complaint, we considered the evidence provided by Mr C and the board. We also received independent advice from a consultant psychiatrist.

Mr C raised concern that the CMHT did not provide Ms A with reasonable mental health care and treatment. We considered that the doctors involved in Ms A's care appropriately took into account her Asperger's Syndrome and we found that the treatment provided for Ms A's OCD and depression was reasonable. We did not uphold this complaint.

Mr C complained that the CMHT failed to provide Ms B with reasonable advice and information to support her as a carer for Ms A. We found that Ms B and Ms A were given details of support organisations and Ms B was offered a carer's assessment. However, we did not find sufficient evidence that general information about management of conditions was provided to Ms B. On balance, we upheld this complaint.

Finally, we considered whether the board provided a reasonable response to Mr C's complaint. We found that the board had accurately identified and responded to many of the complaints raised. However, we noted that the board did not address all the points that Ms B raised separately. We were unable to conclude that the board provided a full response to the points Ms B raised in line with the requirements of the NHS Scotland Complaints Handling Procedure. On balance, we upheld this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms B for failing to provide general information about management of conditions and treatments, and not responding to a number of points raised in 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:

• Family members supporting the care of a patient should receive general information about management of conditions and treatments, whilst maintaining a patient's right to confidentiality.

In relation to complaints handling, we recommended:

• Under the NHS Scotland Complaints Handling Procedure an investigation should establish all the facts relevant to the points made in the complaint and to give the person making the complaint a full, objective and proportionate response that represents the final position.

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 she received following elective abdominal surgery. When Miss C awoke following the surgery, she had considerable pain in her leg. She was given pain medication but her leg became significantly worse the next day. Compartment syndrome (when pressure rises in a compartment bordered by a facial covering because of a reduction in the blood flow to the muscle) was suspected and later diagnosed. Miss C underwent surgery but suffered outer muscle loss on her left leg. Miss C complained that there had been a delay in diagnosing compartment syndrome in light of her symptoms. She also complained that the board failed to provide proper treatment because of this delay. Finally, Miss C complained about how the board handled her complaint.

We took independent advice from a surgeon. We found that there had been an unreasonable delay in diagnosing compartment syndrome. Specifically, the signs and symptoms Miss C experienced should have led to an earlier orthopaedic consultant (specialist in the treatment of diseases and injuries of the musculoskeletal system) review and diagnosis of compartment syndrome. In light of this, we upheld this aspect of the complaint.

In respect of Miss C's second complaint, we considered that her symptoms were well-monitored and recorded. We considered the failing to be in the interpretation of the clinical observations. Outside of this failure, we considered Miss C's management to be good and as expected following significant surgery. Once compartment syndrome was diagnosed, we found the care and treatment to be reasonable. We concluded that the failing had been the unreasonable delay in diagnosing compartment syndrome and not in the treatment provided. Therefore, we did not uphold this aspect of the complaint.

Finally, we concluded that it took an unreasonable length of time for the board to carry out their stage 2 complaint investigation and that Miss C was not appropriately updated about this delay. Furthermore, we did not consider the board's response to clearly reflect the findings of an Adverse Event Review that was carried out. Finally, the board's internal records indicated that Miss C's complaint was upheld but this was not apparent in their stage 2 response. As a result of this, we upheld this aspect of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Miss C for failing to diagnose compartment syndrome promptly and for failing to keep her adequately informed about delays in the investigation of her complaint and the progress and outcome of the Adverse Event Review. 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

Mrs C complained on behalf of Mr B about the care and treatment provided to Mr B's late wife (Mrs A). Mrs A had an underlying heart condition and her medication had to be carefully balanced to avoid kidney damage. Mrs A saw her GP about problems with bowel function and her deteriorating general condition. The GP referred her to the colorectal (relating to or affecting the colon and rectum) clinic. Blood tests taken around the same time showed her kidneys were deteriorating and she was referred for an urgent renal (relating to the kidneys) appointment.

During her colorectal consultation, Mrs A was offered various investigations but a CT scan (a scan that uses x-rays and a computer to create detailed images of the inside of the body) and colonoscopy (examination of the bowel with a camera on a flexible tube) both involved some kidney risk, so she wished to wait for her renal appointment before making a decision. She received a renal appointment four months after her GP appointment and was admitted the following day for further tests including a CT scan performed without contrast (contract material is a dye used to help highlight areas of the body being examined) as this was safer for her kidneys. Around a month after admission for tests, stage 4 cancer was found in bowel, stomach and lungs, which Mrs A was advised had been present for months. A decision had been taken to downgrade Mrs A's renal referral without seeing her, and without informing her GP. Mrs C complained that this decision was unreasonable.

The board confirmed that Mrs A's urgent renal referral was downgraded without her being seen, based on the likelihood that her renal dysfunction was a composite of her heart disease and medication. As her blood test results were relatively stable the board had considered there was no need for an urgent referral. The board apologised that the GP had not been informed. We took independent advice from a nephrology (the branch of medicine that deals with the physiology and diseased of the kidney) adviser. We found the downgrading of the referral to be reasonable under the circumstances. Therefore, we did not uphold this aspect of Mrs C's complaint.

Mrs C also complained that the board unreasonably failed to offer Mrs A a CT scan without contrast at an earlier stage. We took independent advice from a colorectal adviser. We found that although this could have been offered, the consultant responsible reasonably balanced consideration of establishing a diagnosis and of investigating only should her symptoms recur, given the severity of her underlying disease. Therefore, we did not uphold this aspect of Mrs C's complaint.

Finally, Mrs C complained that the communication between specialisms involved in Mrs A's care and treatment was unreasonable. We found that the decision to downgrade the renal referral was not conveyed to Mrs A's GP or her cardiac consultant and that Mrs A's cardiac consultant had delayed in informing her about the availability of the advanced heart failure specialist nurse. We also found that communication between medical staff had not been copied to the Mrs A, noting that if this had done, the perceived lack of communication could have been avoided. Overall, we found that the board's systems were reasonable, in that all Mrs A's records were available to those involved in her care. However, we upheld this aspect of Mrs C's complaint on the basis that the board had accepted errors and delays.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr B for the failings in communication, with a recognition of the cumulative impact of these failings on Mrs A's treatment experience. The apology should acknowledge the impact of these failings on Mrs A and her family. 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

Mrs C complained about the care and treatment she received at University Hospital Monklands where she had surgery to remove her gallbladder. Mrs C said that she developed a number of unpleasant symptoms following the surgery and, despite seeking treatment for these from the board, including attendance at the hospital's emergency department, they remained unresolved.

We took independent medical advice on the complaint from a consultant general surgeon and a consultant in emergency medicine. In her complaint, Mrs C said that the consent process followed by the board did not include reasonable information about the consequences of gallbladder removal. We found that the symptoms Mrs C experienced were not recognised as complications directly related to her gallbladder surgery and were, therefore, not discussed with her prior to her surgery. We found that efforts were made to ensure that reasonable explanations were given to Mrs C on the risks and benefits of her surgery and her consent form listed the risks of the surgery. We did not uphold this aspect of the complaint.

Mrs C said that the care and treatment provided to her in the emergency department was unreasonable. We found that the treatment Mrs C received was reasonable and there was no reason to admit her to hospital at that time. While we note that the time that Mrs C waited to be seen was slightly outwith the triage timescales, we did not identify this as a failing or evidence of unreasonable care. Therefore, we did not uphold this aspect of the complaint.

Mrs C also complained that the follow-up surgical care and treatment was unreasonable. We found that once Mrs C made the board aware that she was experiencing significant symptoms following her surgery, and given her anxiety issues, they should have offered her an early out-patient appointment within a few weeks. It would also have been reasonable to have arranged to see her in clinic to discuss her endoscopy and biopsy results and options open to her at that time. Therefore, we upheld this aspect of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C for failing to offer her an early out-patient appointment after she reported she was experiencing significant symptoms following her surgery; and failing to arrange to see her in clinic to discuss her endoscopy and biopsy results and options open to her at that time. 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:

• In cases such as this, the board should arrange to see patients in clinic to discuss their test results.
• In cases such as this, the board should offer patients out-patient appointments within a reasonable time.

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.