Some upheld, recommendations

Summary

Ms C complained about the nursing care that her partner (Ms A) received at Queen Elizabeth University Hospital while she was recovering from brain surgery. We took independent advice from a nursing adviser. We found that the nursing care provided to Ms A was reasonable and did not uphold this aspect of Ms C's complaint.

Ms C also complained about the medical care and treatment that Ms A received. We took independent advice from a consultant in acute medicine and from a consultant neurosurgeon (specialist in surgery on the nervous system, especially the brain and spinal cord). We found that there was a lack of documented medical assessments regarding Ms A's orientation/confused status, and when confusion was identified, this was not appropriately investigated and documented. We also found that there was no consultant medical review prior to Ms A's transfer from Queen Elizabeth University Hospital to another hospital. Therefore, we upheld this aspect of Ms C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms C and Ms A for the lack of documented medical assessments regarding Ms A's orientation/confusion status and the failure to carry out a consultant medical review prior to Ms A's transfer between hospitals. 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 recovering from neurosurgery should have documented medical assessments of their orientation and where confusion is identified this should be investigated and appropriately documented.
• Where possible, in-patients should receive daily senior clinical review and these reviews 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.

Summary

Mrs C complained on behalf of her late son (Mr A) about the care and treatment he received from his GP practice. Mr A phoned the practice as he was coughing and felt unwell. Mr A was considered to have symptoms of a cold and he was prescribed a cough suppressant. Around a week later, Mr A died from pneumonia (an infection of the lungs).

Mrs C complained that the practice unreasonably diagnosed Mr A over the phone, even though he had asthma and learning difficulties. We took independent advice from a GP. We found that as Mr A was noted to have symptoms of a cold, it was reasonable that he was diagnosed over the phone, even though he was a vulnerable adult. We did not uphold this aspect of the complaint.

Mrs C also complained that when she was admitted to hospital shortly afterwards, the practice did not contact her son to check on his condition. We found that the practice had not been informed of Mrs C's hospital admission or advised of any concerns about Mr A. Therefore, we found that the practice had no cause to check on Mr A's condition. We did not uphold this aspect of the complaint.

Lastly, Mrs C complained about the practice's handling of her complaint. We found that there were failings in their complaints handling, which the practice had already acknowledged and apologised for. We noted that Mrs C's complaint was not acknowledged within the relevant timescale and her request for a phone call was not followed up. Therefore, we upheld this aspect of the complaint.

Recommendations

In relation to complaints handling, we recommended:

• Complaints should be handled in line with the NHS Scotland Model Complaints Handling Procedure. The model complaints handling procedure and guidance can be found here: www.valuingcomplaints.org.uk/handling-complaints/complaints-procedures/nhs

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 psychiatric treatment she received for anxiety. She complained that there were unnecessary delays and a lack of communication regarding her treatment which added to her anxiety. Ms C complained that her psychiatrist did not assess her properly and proceeded with options for therapy without first carrying out an appropriate assessment.

We took independent advice from a consultant psychiatrist. We found that Ms C's assessment had been appropriate and reasonable, and that medical staff tried to work constructively with Ms C and to tailor treatment to her specific needs and wishes for treatment. We considered that the board had taken Ms C's social anxiety into consideration when arranging appointments. Therefore, we did not uphold this aspect of the complaint.

Ms C also complained about the board's complaints handling. We considered that the board could have clarified aspects of the complaint at the outset, with a view to agreeing a reduced number of complaints. This may have provided for a more manageable complaint from the point of view of investigation. We noted there had been significant delay in providing complaint responses, which had added to Ms C's stress. We considered that the delays were unreasonable and we therefore upheld this aspect of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms C for the delay in providing a response to her complaints. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/leaflets-and-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

Mr C complained about the care and treatment he received at Ayr Hospital. Mr C attended the orthopaedic department (specialising in the treatment of disease and injury of the musculoskeletal system) in relation to knee pain. He had surgery but despite that he continued to experience pain. Mr C was unhappy because he was discharged by the consultant without his pain being fully investigated.

We took independent advice from an orthopaedic consultant. We found that the standard of care that Mr C received for his knee was reasonable and that post-operative follow-up was appropriate. Therefore, we did not uphold this aspect of the complaint.

In addition, Mr C became aware of comments written in his clinical record by the consultant which Mr C described as slanderous. We found that the language used was unreasonable, inappropriate and unfair. However, we noted that the consultant had apologised to Mr C and had reflected on the fact that the language used was open to misinterpretation. We upheld this aspect of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for the inappropriate comment written by the consultant in the clinical letter. The apology should meet the standards set out inthe 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 complained about the care and treatment provided to her by Crosshouse Hospital both during and after her pregnancy. She felt that she was not monitored appropriately during pregnancy and that her concerns had not been taken seriously. She also raised concern that she had requested a caesarean section but this had been denied, and that planning for delivery had not been reasonable.

We took independent advice from a midwife and an obstetrician (a doctor specialising in pregnancy and childbirth). We noted that there was an inappropriate remark recorded in Ms C's records by a midwife and we made a recommendation to the board about this. We found that, whilst many aspects of the care and treatment provided to Ms C were reasonable, there was a failure to take appropriate and timely action when Ms C presented with polyhydramnios (increased fluid) and accelerated foetal growth. Therefore, we upheld this aspect of Ms C's complaint.

In relation to Ms C's concerns about post-pregnancy care, we found that this was appropriate and in line with standard practice. Therefore, we did not uphold this aspect of Ms C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms C for the inappropriate description in her medical records, and the failure to investigate the cause of polyhydramnios and accelerated fetal growth in a timely 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:

• Notes made in medical records should be appropriate and in line with relevant nursing and midwifery standards.
• Polyhydramnios and accelerated fetal growth should be investigated in a timely manner.

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 Scottish Water (SW) delayed in reinstating a permanent water supply to his property and that their communication in relation to this matter was unreasonable.

Mr C requested a mains supply lead replacement. After completing works, the new pipes were attached to the water supply system. Shortly afterwards, his neighbours reported that they had no water. It was established that during the works at Mr C's property, the joint supply to his neighbours had been cut. Mr C was unhappy because he said that he had been misled by SW into believing that the water supply at this property was not a joint one. SW considered that a public health issue had arisen as the neighbours' water supply had been disrupted and they took action to install a temporary overland water supply. They also apologised for the incorrect information they had given. At the same time, they detailed the works they would carry out to renew the existing pipework to the rear of Mr C's property and to the boundary of each of his neighbours (SW are only responsible for the water main in the street and communication pipe up to and including the stop-cock. The water supply to individual premises inside a property boundary is the responsibility of the property owner).

It was SW's view that, notwithstanding any incorrect information they may have given Mr C, it was in fact his responsibility to establish the actual situation with regard to the supply pipes; they did not hold records about these nor were they part of the public supply network. Their role in this was only to remove the lead pipe belonging to them and lay a new pipe from the public water main to the boundary of Mr C's property where it connected to the private pipework. The temporary mains pipe was laid and it was not until a year later that it was removed.

We found that despite any incorrect information SW may have given, it was Mr C's responsibility to determine whether or not his water supply was shared. Delays were caused by this, but they were not of SW's making. Therefore, we did not uphold this aspect of the complaint.

In relation to communication, we found that there was a great deal of confusion by SW in the way they dealt with the correspondence and there were omissions and delays in sending replies. Therefore, we upheld this aspect of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for the failure to communicate in a reasonable way. 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:

• Correspondence, including complaints correspondence, should be acknowledged and responded to in accordance with stated policies.

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 council failed unreasonably to respond to her complaint about flooding at her home and, that they failed to provide a reasonable emergency out-of-hours service.

We found there to have been confusion with the councils complaints handlers on whether Mrs C's original contact was a request for service, and not a service complaint. Mrs C then asked for her complaint to be escalated to Stage 2, where she experienced several months delay awaiting a response. Only after this office's involvement did Mrs C receive an appropriate final letter. Therefore, we upheld this aspect of the complaint.

However, we found the council to have responded reasonably to Mrs C's request for an out-of-hours service, and they did so in line with the system they had in place at that time. There is no statutory requirement for the council to maintain a comprehensive out-of-hours service for customers with issues on the local roads network, and in the event of someone calling their out-of-hours number, they would be given other appropriate advice. Therefore, we did not uphold this aspect of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C for the failure to deal reasonably with her complaint. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

In relation to complaints handling, we recommended:

• Staff should be aware of and follow the council's 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

Mrs C complained about the actions of her child's (Child A) school following reports of bullying. She explained that her child had been bullied most of their school life and that the bullying had mostly been carried out by one other child. Mrs C acknowledged that the school had taken some actions and the situation had started to improve. However, incidents later continued, leaving her child increasingly upset and anxious. In light of this, Mrs C felt the school had not done enough to prevent the bullying incidents and provide support to her child. Mrs C also complained about whether the incidents of bullying had been recorded appropriately by the school. Finally, Mrs C complained about how the council had communicated with her during and after the complaints process.

In respect of the first complaint, we concluded that the school had taken reasonable and appropriate steps to address incidents of bullying experienced by Child A. We noted that the school had appeared to have taken a number of steps to prevent interactions between Child A and the other child, provide support to Child A and put in place measures to address the other child's behaviours. The approach taken by the school appeared to be tailored to the individual circumstances of Child A and the type of bullying they were experiencing. We acknowledged that there were times where the other child had interacted with Child A in an upsetting way despite these measures being in place. However, we recognised that it can be very difficult to prevent such incidents from happening completely. Overall, we concluded that the school took the reports of bullying seriously and made reasonable efforts to assist Child A and prevent further incidents from happening. Therefore, we did not uphold this aspect of the complaint.

The second complaint related to how the school recorded incidents of bullying. Mrs C had submitted a freedom of information (FOI) request to determine what incidents involving Child A had been recorded on the SEEMiS system used by schools in the council area. The FOI revealed that one incident had been recorded on the SEEMiS system. Mrs C understood this to mean that only one incident of bullying had been recorded by the school. The council explained that, at the time of their complaint response, bullying incidents were recorded by the school in SEEMiS. However, previous incidents had been recorded in paper format.

The council's anti-bullying policy stated that schools should ensure that bullying incidents are recorded and monitored using SEEMiS. From the information we reviewed, it is apparent that the school was not using the SEEMiS system for a significant period of time while this policy was in place. The council advised us that the Scottish Government Supplementary Guidance did not place a statutory duty on councils to record incidents using SEEMiS. They also highlighted that there would be a period of transition towards using SEEMiS in schools and this would take time. We recognised the council's perspective but measured the school's actions against the specific council policy in place at the time. This policy appeared to be clear that SEEMiS should be used by schools at that point in time, not that there was an intention to move towards its use. Therefore, we upheld this aspect of the complaint.

Mrs C also complained about how her complaint to the council and subsequent correspondence was handled. We concluded that the council's handling of the actual complaint itself was reasonable. However, we noted that Mrs C had contacted the council to query some of the contents of their Stage 2 (investigation stage) response. The council did not respond to this for 27 days, during which time Mrs C had approached the executive director of education and children's services. As a result of this delayed response, the school term had ended and the head teacher could not be reached due to being on annual leave. This led to a delay in Mrs C receiving clarification on the issues she had raised. We considered that the council's communication after their Stage 2 response was issued to be unreasonable. 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 record bullying incidents on the SEEMiS system, in line with the relevant council policy and for not acting on or responding to post-complaint correspondence within a reasonable timeframe. 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:

• Correspondence received after a Stage 2 response has been issued should be acted on and responded to within a reasonable timeframe.

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 time taken for the board to refer him to specialist care for pain in his hip following a hip replacement.

We found that for several years the board's actions were reasonable. However, at one point, the board recognised the possibility of infection but chose not to aspirate (drain fluid from) Mr C's hip. We considered this to be unreasonable and that Mr C should have been refererred for specialist care. We upheld this aspect of the complaint.

Mr C also complained about the boards handling of his complaint. We found that the board complaint handling was reasonable and, therefore, we did not uphold this aspect of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for failing to provide reasonable treatment in relation to pain in his hip. The apology should meet thestandards 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 develop a written policy for the investigation of painful hip replacements that takes into consideration the content of the European Consensus Document on Periprosthetic Infection (https://www.efort.org/wp-content/uploads/2013/10/philadelphia_consensus.pdf).

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 actions of the prison health care service. Following a medication spot check, Mr C was found to be short of antidepressant tablets, and as a result his medications were stopped with immediate effect. Mr C explained that his medication count was short as his medication safe was broken into recently and everything was taken. In response to his complaint, the board explained they would not reinstate Mr C's medication. They also stated they had made enquiries with the Scottish Prison Service (SPS) and were informed that Mr C had not reported his safe being broken into.

Mr C complained to us about his medication being stopped and about the enquiries the board made into whether or not he had reported his safe being broken into.

In respect of the complaint about Mr C's medication being stopped, we took independent advice from an GP adviser. We noted that, ideally, a GP would not withdraw anti-depressant medication suddenly. However, we found that this may not be the case if there is poor compliance with the requirements of the medication. We also highlighted guidance about prescribing medication in a prison setting and noted that Mr C had signed a medical agreement treatment form that acknowledged his medication may be stopped if not appropriately managed. After reviewing Mr C's medical records, we noted that an early entry had suggested potential drug misuse. Based on the review of the information available, we concluded that healthcare staff's decision to stop Mr C's medication was appropriate and their actions reasonable. Therefore, we did not uphold this complaint.

In respect of the second complaint, the board acknowledged that they had not appropriately described their enquiries in their responses to Mr C. The board had spoken with SPS staff and stated that SPS had confirmed Mr C had not reported his safe being broken into. However, Mr C had, in fact, reported his safe as being broken into to SPS staff. The board accepted this error had caused Mr C further concern and apologised for this. We considered this likely to be a case of miscommunication rather than any attempt by the board or SPS staff to mislead. However, although we considered the enquiries made by the board to be in good faith, we concluded that they could have been clearer and taken into account the content of Mr C's complaint more closely. Furthermore, the outcome of the enquiries could have been relayed to Mr C more accurately. On this basis, 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 failing to make reasonable enquiries to the SPS about what happened to his medication and whether his safe had been broken into. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/leaflets-and-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.