Some upheld, recommendations

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.

Summary

Ms C complained to us about the care and treatment she received from the board when she was diagnosed with lung cancer. Ms C was told that the tumour in her lung had been visible in a CT scan she had several years earlier, which was taken to plan her radiotherapy treatment (a treatment using high-energy radiation) for breast cancer. Ms C complained that the lung tumour was not identified at that time or if it was, she was not offered any treatment. We took independent medical advice from an oncologist (cancer specialist). We found that CT scans for planning radiotherapy are not taken with enough detail to be used for diagnostic purposes. We also found Ms C's lung tumour was small and it could have easily been missed by a clinician who was not reviewing her CT scan for diagnostic purposes. We found it was reasonable that Ms C's lung lesion was not identified at that time and we did not uphold this aspect of her complaint.

Ms C also complained about the communication with her about her condition and treatment, leading up to her diagnosis of lung cancer. In particular, that Ms C was sent an appointment letter for a chest CT scan without being told the reason why she was being referred for a CT scan. We took independent medical advice from an acute medical consultant. We found that Ms C and her GP were not appropriately informed about the outcomes of investigations that had been carried out; and why there was a need to carry out further investigations into her condition. We upheld this aspect of Ms C's complaint.

Ms C also complained about the board's complaints handling. We found that the board did not keep Ms C appropriately updated during their investigation. We found that the board had failed to identify and respond to all aspects of Ms C's complaint; it was unclear what the conclusions of their complaints investigation had been; and they did not apologise to Ms C for failings they had identified. 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 the failings in their communication with her; and for failing to handle her complaint in a reasonable manner. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets .

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

• Patients and their GPs should be appropriately informed about the outcomes of investigations and the need to carry out any further investigations.

In relation to complaints handling, we recommended:

• In line with the NHS complaints handling procedure, complaint responses should address all the issues raised and demonstrate that each element has been fully and fairly investigated; include the conclusions of the investigation; and include an apology where things have gone wrong. 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

Mr C complained about the care and treatment he received from Aberdeen Royal Infirmary. Mr C had a nerve sheath tumour (a type of tumour of the nervous system) in his neck in an area known as the brachial plexus (a group of nerves that come from the spinal cord in the neck and travel down the arm. These nerves control the muscles of the shoulder, elbow, wrist and hand, as well as provide feeling in the arm). Mr C had surgery to remove the tumour. During the operation three nerves were found to be running through the tumour. All three nerves were stimulated electrically. One nerve made the deltoid muscle twitch and this nerve was preserved. The other two nerves produced no apparent muscle movement and were cut and removed with the tumour. This resulted in Mr C losing the use of large muscles in his arm.

We took advice from an otolaryngology (the study of diseases of the ear and throat) and head and neck surgeon and from a consultant neurosurgeon (a surgeon specialising in surgery of the brain and nervous system). We found that:

advice should have been sought from the Scottish Brachial Plexus Team prior to Mr C's operation

intraoperative neurophysiological nerve monitoring (IONM – where fine needles are placed in the target muscles and spontaneous muscle fibre electrical activity is continuously displayed on a screen as waves) should have been used during Mr C's operation

Mr C's nerves should not have been cut during the operation

Mr C was not referred to the Scottish Brachial Plexus Team within a reasonable amount of time following his surgery

the board failed to consider at an earlier stage whether an Adverse Event Review should have been carried out.

We upheld Mr C's complaint that the board did not provide him with reasonable care and treatment.

Mr C also complained that the board did not inform him of the risks of the surgery. We found that the board did communicate reasonably with Mr C about the risks of the surgery and therefore we did not uphold this aspect of Mr C's complaint.

Finally, Mr C complained that the board failed to handle his complaint reasonably. We found that:

the board's own complaint investigation did not identify the serious failings in the care provided to Mr C

there was a delay in responding to Mr C's complaint and he was not kept updated on the progress of his complaint or provided with a revised timescale for the response

the board's complaint response said that Mr C's reparative surgery took place on an incorrect date.

Therefore, we upheld this aspect of Mr C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for the failure to seek advice from the Scottish Brachial Plexus Team prior to his operation; the failure to use IONM; cutting his nerves during the operation; the length of time taken to refer him to the Scottish Brachial Plexus Team after the operation; the delay in responding to his complaint and that he was not kept updated and; that the complaint response did not accurately state the date his reparative surgery took place. 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:

• The board should consider carrying out an Adverse Event Review where an event has occurred that could have resulted in harm (a near miss) or did result in harm to a patient.

In relation to complaints handling, we recommended:

• Complaint responses should contain accurate information.
• Complaints should be handled in line with the model complaints handling procedure. The model complaints handling procedure and guidance can be found here www.spso.org.uk/the-model-complaints-handling-procedures .
• The board's complaints handling system should ensure that failings (and good practice) are identified, and that it is using the learning from complaints to inform service development and improvement (where appropriate).

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, an advocacy worker, complained on behalf of Ms B that the board failed to provide her late mother (Mrs A) with reasonable care and treatment at Aberdeen Royal Infirmary and that staff at the hospital failed to communicate adequately with Mrs A's family about her care and treatment.

Mrs A had been admitted to the hospital's intensive care unit with respiratory failure where she died. Mrs A had suffered from a number of chronic illnesses. We took independent advice from a consultant in emergency medicine. We found that the care Mrs A received was reasonable and in line with current guidelines and good clinical practice. The evidence available showed that, ultimately, Mrs A's failure to respond to the treatment was because of the seriousness of her condition, and not the treatment itself. We did not uphold this aspect of the complaint.

In relation to communication with Mrs A's family, we found that it was clearly recorded in the clinical notes that on Mrs A's admission there had been a discussion with her family. It had been explained that there was a very real risk that Mrs A would not survive the admission and why performing cardiopulmonary resuscitation (CPR, where the heart and/or breathing is restarted if it stops) would not be in her best interest. However, other than this initial conversation, in general, communication with Mrs A's family was very poor. In particular, the decision to extubate Mrs A (to remove a breathing tube) should have been discussed with her family prior to this taking place. Therefore, we upheld this aspect of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms B and her family for the communication failures 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:

• Patients and their families should be involved in the decision-making process where appropriate and should receive regular updates. This should be recorded in the clinical records.

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 the board failed to communicate reasonably with him and his wife (Mrs C) about his child's (Child A) care and treatment. Mr C raised concerns about the timeliness and accuracy of medical advice; the failure to engage with Mr and Mrs C in a meaningful way; and a failure to obtain proper consent on a number of occasions.

We took independent advice from a paediatrician, and a paediatric surgeon with an interest in gastroenterology (the branch of medicine that deals with disorders of the stomach and intestines). We found that many aspects of communication had been reasonable, however, there was a lack of documentation regarding information given to Mrs C both prior to and following a endoscopy procedure (a medical procedure where a tube-like instrument is put into the body to look inside) carried out on Child A. The documentation was not in line with General Medical Council guidance on consent and protecting children and young people. We therefore upheld this aspect of Mr C's complaint.

Mr C also complained about the care and treatment provided to Child A. We found that the care and treatment provided was reasonable and did not uphold this aspect of the complaint.

Finally, Mr C complained about the board's handling of his complaints. Whilst we acknowledged that there was a significant volume of correspondence for the board to consider and respond to, we considered it clear that there were multiple occasions on which Mr and Mrs C's complaints were not handled in line with the appropriate complaint handling procedures. We considered that the volume of complaints made by Mr and Mrs C was partially as a result of complaints not being managed and responded to in an effective and timely manner; and that the board's failure to address correspondence correctly contributed to the breakdown in the complaints procedure. We also noted that the board had agreed at one point to issue a formal written apology about Child A being removed from the hospital without consent, but this apology had never been sent. We upheld this aspect of Mr C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr and Mrs C for the lack of documentation regarding information given to Mrs C both prior to and following the endoscopy procedure; the failure to handle the complaints in a reasonable and timely manner; Child A being removed from the hospital without consent; and the failure to issue an apology for this at the 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:

• Discussions with family members should be documented.

In relation to complaints handling, we recommended:

• Complaints should be handled in a reasonable and timely manner, and in line with the complaint 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

Mrs C complained that the association unreasonably communicated with her regarding her rent and rent arrears. We considered that, while the association was clear in the amount and frequency of payments, an element of their communication had been unreasonable and we upheld this aspect of Mrs C's complaint.

Mrs C also complained that her request for joint tenancy was unreasonably refused. We note that legislation states that a landlord must consent to the alteration of the tenancy unless they have reasonable grounds for not doing so. The association explained that they had refused the joint tenancy request as they had served a notice which warned that they may seek eviction and explained that the rent account was currently in arrears. The notice referred to was valid at the time and the association offered a reasonable explanation to explain their grounds for refusal. Therefore, we did not uphold 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 reasonably communicate with her in relation to her rent and rent arrears. 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.

Amendment

When originally published (20/11/2019), this summary included the line: "We considered that, while the association was clear in the amount and frequency of payments, elements of the communication had been unreasonable and we upheld this aspect of Mrs C's complaint."

This has since been changed to: "We considered that, while the association was clear in the amount and frequency of payments, an element of their communication had been unreasonable and we upheld this aspect of Mrs C's complaint."  We apologise for this error.