Some upheld, recommendations

Summary

Ms C complained about the primary school her child (Child A) attended. She complained that she was not updated about Child A's academic progress; that Child A was unreasonably given access to scissors; that there was an unreasonable failure to record incidents with other pupils; and that there was a failure to communicate reasonably with her regarding her concerns.

In relation to Child A's academic progress, we found that there were appropriate pupil progress reports and that these had been discussed with Ms C at parents' evenings. We considered that this was reasonable and that although there was no record of other discussions about Child A's academic progress, this was appropriate as it was not something which appeared to have been raised. We did not uphold this aspect of Ms C's complaint.

With regard to Child A having access to scissors, we were not able to establish that this had occurred and we did not uphold this aspect of Ms C's complaint. However, we noted that there appeared to have been some inconsistencies in the way an incident was recorded, and we suggested that the council may wish to reflect upon this.

We found that the council's recording of incidents with other pupils was reasonable and in line with policy, and therefore we did not uphold this aspect of Ms C's complaint.

Finally, in relation to communication, we found that on one occasion, there was a failure to pass a letter that Ms C had handed in to the school to the appropriate person. We considered that this was likely to be a one-off failure, however, we upheld the complaint about communication on this basis.

Recommendations

What we asked the organisation to do in this case:

• Apologise for the failure to pass on Ms C's letter to the class teacher. 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

Mrs C complained about the care and treatment provided to her father (Mr A) during two admissions to Ninewells Hospital. Mrs C complained about nursing care, medical treatment, surgical treatment, communication, and complaint handling.

During our investigation we took advice from a nurse, a consultant in acute medicine, a dermatologist (a specialist in diseases of the skin, hair and nails), a plastic surgeon, and a vascular surgeon (a clinician who treats disorders of the circulatory system).

In relation to nursing care, we found that there had been failings in relation to wound assessment and management; pressure ulcer prevention and management; mouth care; medication administration; adhering to fluid balance; and involving palliative care specialists. We were also concerned that the board's own investigation had not identified these failings. We upheld Mrs C's complaint about nursing care.

In relation to medical treatment, we found that many aspects of this were reasonable and that dermatology care was of a very good standard. However, we identified that there was a delay of around 12 hours in Mr A receiving antibiotics at one point and on this basis, we upheld this aspect of Mrs C's complaint.

We found that the surgical treatment provided to Mr A by both plastic and vascular surgery was reasonable and did not uphold this aspect of Mrs C's complaint.

With regard to communication, we found that the communication between the different teams and clinicians had been of a good standard. We also found that in general, there was good communication with Mr A and his family. However, at a point when Mr A's condition was deteriorating and it was unclear how much information he could understand and retain, there was a gap in communication with his family and we considered this to be unreasonable. We therefore upheld this aspect of Mrs C's complaint.

We considered the board's handling of Mrs C's complaint. We found that there were significant and unacceptable delays throughout the complaints process, and that communication from the board was reactive rather than proactive. We also found that there were a number of failures or delays in answering Mrs C and her family's questions. We considered the handling of Mrs C's complaints to have been unreasonable and we upheld this aspect of her complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C for failing to provide reasonable nursing care to Mr A; failing to provide reasonable medical treatment to Mr A; failing to reasonably communicate in relation to Mr A's care and treatment; and failing to handle Mrs C's complaint in a reasonable and timely manner. 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:

• Wounds should be assessed and managed appropriately and timeously, and in line with relevant guidance.
• Pressure ulcer prevention and management should meet the Healthcare Improvement Standards for Pressure Ulcer Prevention 2016.
• Mouth care should be carried out frequently, especially in patients who are not eating or drinking well, and if problems develop they should be addressed in a timely manner.
• Medication should be administered in accordance with the Nursing and Midwifery Code and the board's own local policy on prescribing and administration of medication. Where medications are not administered reasons for this should be documented.
• Accurate fluid balance and adherence to fluid restriction should be a priority in patients who have renal failure.
• Patients such as Mr A should be reviewed by palliative care staff in a timely manner, and efforts should be made to make patients comfortable during the end of life period.
• Action should be taken in a timely manner when a patient develops a new fever, and antibiotics should be commenced promptly.
• It should be documented if a patient is able to understand and retain information, and if not, communication with relevant family members should take place and be documented.

In relation to complaints handling, we recommended:

• Complaints should be handled in a reasonable and timely manner, and in line with complaint handling guidance.
• The board's complaints handling system should ensure that failings (and good practice) are identified, and enable learning from complaints to inform service development and improvement.

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 that her late mother-in-law (Mrs A) received when she attended the emergency department at University Hospital Monklands on two separate occasions. Mrs A was also under the care of a consultant surgeon at the time.

We took independent advice from a consultant in emergency medicine and a general surgeon. We found that the majority of the care and treatment provided in the emergency department was reasonable. However, we also found that the on-call surgical doctors did not make Mrs A's consultant surgeon aware of her attendances to the emergency department. Therefore, we upheld this aspect of Mrs C's complaint. The board said that they had already taken action to address this issue so we asked them to provide evidence of this.

Mrs C also complained that the board failed to handle her complaint reasonably and in particular that the board did not respond to all the points of her complaint. We found that the board provided a response to the majority of the concerns Mrs C raised and, 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 make Mrs A's consultant surgeon aware of her attendances to the emergency department. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

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

Summary

Ms C complained about the care and treatment her late sister (Ms A) received in Dr Gray's Hospital before her death. Ms A attended the emergency department in the hospital after striking her head. She had suffered a laceration (cut in the skin), which was glued shut, and she was then discharged. On the following day, she was admitted to the hospital with a high heart rate and shortness of breath. It was subsequently noted that Ms A was suffering from acute chronic kidney injury and chronic atrial fibrillation (a heart condition that causes an irregular and often abnormally fast heart rate). She became unresponsive and was taken for a CT scan to check if her head injury was contributing to her loss of consciousness. Ms A died in the radiology department.

We took independent advice from an emergency medicine adviser and a consultant in acute medicine. We found that the standard of documentation for Ms A's presentation to the emergency department was poor. It was also unreasonable that she was not scanned in the emergency department before she was discharged, given her reduced level of consciousness and confusion; her headache; and the fact that she was on anticoagulant medication (medication to prevent blood clots). Further tests should have been carried out and her discharge from the emergency department was contrary to guidance. In addition, the advice given to her when she was discharged from the emergency department would have been challenging for Ms A to understand and retain. It was also surprising that, when she was admitted to hospital, Ms A was given increasing doses of beta-blockers given that she had an allergy to. Therefore, we upheld this aspect of the complaint. The board said that they have taken action to address these failings and we have asked them to provide evidence of this.

Ms C also complained that the board had failed to provide an accurate account of Ms A's death. We found that the board's response on this matter had been accurate. We did not uphold this aspect of the complaint.

Ms C complained that the board failed to communicate appropriately with her family. We found that it had been unreasonable for the board not to contact the next of kin when Ms A deteriorated. We upheld this aspect of the complaint. However, we noted that the board had acknowledged and apologised for this failure and we made no further recommendations in relation to this.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms C for the failure to provide reasonable care and treatment to Ms A in the hospital's emergency department. 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 and Mrs C complained about the treatment Mrs C received both during and after her pregnancy. Mrs C felt unwell throughout her pregnancy with nausea, heartburn and abdominal pain. Mr and Mrs C reported her symptoms during phone calls to the midwife unit. Mrs C was advised to take pain relief and get back in touch if the pain worsened. When Mr and Mrs C attended the Victoria Hospital for their 20 week scan they were told there was no foetal heartbeat.

After delivery of the baby Mrs C had bloods taken, and tests from the placenta, but waited more than ten weeks to see a doctor to discuss the test results. After chasing up the results Mr and Mrs C were told that bloods had been lost, requiring Mrs C to return to the ante-natal clinic for further testing. She was subsequently told she tested positive for lupus (an autoimmune condition that affects the body's defences against illnesses and infections) and required further blood testing. Errors in the testing meant that Mrs C had to return to the clinic again. Each time she had to wait with pregnant couples and found this distressing. Mr and Mrs C felt the miscarriage could have been avoided if Mrs C had received better treatment. They complained that Mrs C's lupus should have been diagnosed sooner, and that the loss of their baby might have been avoided.

We took independent advice from a midwife and a consultant obstetrician (a doctor who specialises in pregnancy and childbirth). We found that the advice given to Mrs C each time she contacted midwives regarding her symptoms was reasonable. We did note, however, that Mr and Mrs C's account of the reported symptoms was not reflected in the records and we were unable to reconcile the two. We found that testing for lupus during pregnancy is unreliable because results may be falsely positive and that there were no clinical indicators for Mrs C to be screened prior to her miscarriage. We considered that the treatment Mrs C received during her pregnancy was reasonable and did not uphold this aspect of the complaint.

In relation to treatment after the miscarriage, we found that errors in the blood sampling were unreasonable. We noted that Mrs C had experienced a traumatic loss and that having to return to the ante-natal clinic several times to have bloods taken added significant stress to her situation. Therefore, 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 these failings in their care, with an acknowledgement of the impact this had on them. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

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

• The board should consider whether alternative arrangements could be offered for future patients who have experienced stillbirth or miscarriage, particularly if the procedure could be carried out elsewhere.

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 during two admissions to Galloway Community Hospital. Mrs C was admitted with abdominal pain and she was suspected to have sepsis (blood infection). We took independent advice from a consultant in acute medicine. We found that during Mrs C's first admission, there was a delay in administering her antibiotics and that she should have been given intravenous fluids (fluid through a drip). We also found that during both admissions there was an unreasonable delay in investigating and establishing the source of her underlying infection. We upheld this aspect of Mrs C's complaint.

Mrs C also complained about the follow-up care she received from the board in response to her ongoing abdominal pain. We took independent advice from a consultant colorectal surgeon (a specialist in conditions of the colon, rectum or anus). We found that reasonable steps were taken to investigate Mrs C's condition and she was given appropriate advice that surgery would not be appropriate treatment for her. We did not uphold this aspect of Mrs C's complaint. However, we gave feedback to the board about the potential benefit of offering out-patient follow-up for patients with complex and unresolved conditions like Mrs C.

Finally, Mrs C complained about the board's handling of her complaint. We found that there was a failure to update Mrs C during the board's investigation, which the board had acknowledged and apologised for. We also found that the board failed to investigate and respond to all aspects of Mrs C's complaint. Therefore, we upheld this aspect of Mrs C's complaint and we made further recommendations in relation to this.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C for the unreasonable failings in her care and treatment and for the failings in the board's complaints handling. 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:

• When a patient is suspected to have sepsis, they should receive appropriate treatment, including the prompt administration of antibiotics.
• If a patient's diagnosis is unclear, there should be a system in place so medical staff can seek advice or a prompt review from a consultant.

In relation to complaints handling, we recommended:

• Complaints should be handled in line with the model complaints handling procedure. The model complaints handling procedure and guidance can be found at 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

Mr C complained that he was unreasonably billed by Clear Business Water (CBW), despite having paid his water bills regularly. He also complained about the way CBW had pursued payment of the disputed amount.

We found that Mr C's accounts had previously been inaccurately recorded by another water provider. However, we found that CBW had explained the reason for the outstanding sum and that Mr C had used the water that payment was being requested for. We did not uphold this aspect of the complaint.

In relation to CBW's debt collection process, we found that it was confusing and unreasonable and therefore upheld this aspect of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for the failings identified in this case. The apology should meet the standards set out in the SPSO guidelines on apologyavailable at www.spso.org.uk/leaflets-and-guidance.
• Review a good will gesture, showing consideration has been given to all the service failures identified in our decision.

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

• CBW need to ensure correspondence sent out by Universal Debt Collection accurately identifies the relationship between the two organisations and sets out clearly and accurately what the debt recovery process is.
• CBW need a written debt recovery procedure, which sets out clearly the timescales and actions they will take when pursuing payment. This should include a clear explanation of when an account will be passed to external agencies for recovery.

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 his withdrawal from his course. The issues we investigated related to an unreasonable failure to advise Mr C of why he was withdrawn from the course in the letter issued by the Progression and Awards Board; an unreasonable failure to advise Mr C that his appeal against the decision of the Progression and Awards Board should have been made on the grounds set out under the university's regulations on appeals; an unreasonable delay in providing Mr C with feedback following a transfer event; and also an unreasonable failure to contact Mr C when he did not attend monthly progression meetings with his director of studies, when the director of studies had supported his application for an interruption of studies.

We upheld the first complaint on the basis that the university failed to document and advise Mr C of why he had been withdrawn from the course. We considered that Mr C should have been made aware of the reasons so that he could base his appeal on this decision.

We also upheld the second complaint. This was on the basis that Mr C appealed against the decision of the school panel on the grounds that they had not applied their policy on student non-engagement properly. However, the decision to withdraw Mr C had been made by a different body, the Progression and Awards Board, and that body had the authority to make decisions regarding progress. Appeals to the Progression and Awards Board require to be raised on different grounds according to the university's regulations. We did not uphold this complaint on the basis that information about the second transfer event had been given to Mr C within a reasonable period of time. We also did not uphold the fourth complaint. Whilst there was a lack of evidence to demonstrate what communication the director of studies had with Mr C, on balance it was concluded that as a holder of a Tier 4 visa, the onus was on Mr C to meet the terms of Tier 4 visa requirements regarding university engagement.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for failing to advise why he was withdrawn from the course; failing to advise Mr C that his appeal against the decision of the progression and awards board should have been made on the progression and awards board appeal form on the grounds set out under the University Senate Regulations 13 Student Appeals s13.3.2, and; rejecting Mr C's appeal due to non-engagement when the progression and awards board had no authority to remove him from the course on the basis of non-engagement. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/leaflets-and-guidance.
• The Progression and Awards Board should clearly explain why Mr C was withdrawn from the course. Mr C should then be entitled to issue an appeal against this decision, should he choose to do so, in accordance with the university's regulations.

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 water damage to her property due to works carried out by the council as part of a Flood Prevention Scheme (FPS). Ms C said that the council failed to investigate the effect of the water damage and remedy these issues. Ms C also complained about vibrations from a nearby road, the quality of the council's communication with her about these issues and their response to her complaint.

We found that the council did conduct a suitable investigation into the effect of water damage to Ms C's property. They investigated concerns about sediment in a burn and took action to remedy this. They continued to monitor both the water flow and level and conducted annual inspection of the burn. No further problems had been identified since the gabion mattresses (a cage or box filled with rocks or other material for use in landscaping, road building etc) were installed and we considered that the council's investigation and remedial action had been reasonable. Therefore, we did not uphold these aspects of Ms C's complaints.

In relation to the vibrations from the nearby road, we noted that the council repaired the road, but when Ms C raised continued concerns, no further inspection was conducted. We considered that the council should have attended the road and/or met with Ms C to establish any outstanding issues. Therefore, we upheld this aspect of Ms C's complaint.

In relation to complaints handling, we found that the council's response to Ms C's complaint was appropriate and responded to the issues raised within the timescales set out in their complaint handling procedure. We did not uphold this aspect of Ms C's complaint.

Finally, we found that the council did not respond to two letters Ms C sent raising her concerns. 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 for failing to respond to her letters. The apology should meet the standards set out inthe SPSO guidelines on apology available at www.spso.org.uk/leaflets-and-guidance.
• Contact Ms C to establish if the road issue remains a problem to her. If it does, they should then conduct an investigation and advise Ms C of their findings.

Summary

Mr C complained that the council failed to follow a number of social work procedures. Mr C and his wife (Mrs C) had been foster carers; however, following a child protection investigation (CPI) regarding one of the children they cared for, an investigation was carried out and Mr and Mrs C were deregistered as foster carers. Mr C complained that the council failed to follow procedures in relation to the CPI and the deregistration.

We took independent advice from a social worker. We found that, in relation to the CPI procedures, it was unclear as to whether one or two social workers should conduct interviews with children. We also found that the National Guidance for Child Protection in Scotland was not followed as Mr and Mrs C were not provided with information about the concern at the earliest possibility. There was also not a clear record regarding the risks and benefits of moving the children from the placement. We further found that the CPI took too long to conclude, and that the council did not ensure that Mr and Mrs C were aware of their ability to access independent support and advice throughout the investigation. We upheld this aspect of Mr C's complaint.

In relation to the deregistration, we found that the council had reasonably followed procedures and we did not uphold this aspect of Mr C's complaint. However, we noted that the foster carer agreement documents had not been reviewed or updated throughout Mr and Mrs C's time as foster carers, and we made a recommendation to the council on this matter.

Finally, Mr C complained about the council's handling of his complaint. We found that the council had failed to deal with his complaint in a reasonable manner as timescales were not met, and at various points Mr C was given incorrect information about the complaints process. We upheld this aspect of Mr C's complaint. Given that the council had stated that they were updating the foster carer agreements with a section on complaints, we asked for evidence of this being approved and implemented, but did not make any further recommendations on complaints handling.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for failing to reasonably follow procedures in relation to the child protection investigation; and for failing to reasonably follow procedures in relation to complaints handling. The apology should comply with the SPSO guidelines on making an apology, available at: www.spso.org.uk/leaflets-and-guidance.

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

• It should be clear whether one or two social workers will conduct Child Protection Investigation interviews.
• Actions taken with regards to allegations made in placements should be in line with the National Guidance for Child Protection in Scotland.
• A clear record should be maintained clarifying both the risks and benefits of ending a placement following an allegation, before a decision is taken.
• CPI's should be completed within a reasonable timeframe.
• The council should ensure that foster carers are made aware of their ability to have access to independent support and advice following an allegation.
• The contents of fostering agreements should be reviewed at intervals by the authorities and any proposed changes or additions explained and discussed with carers.