Some upheld, recommendations

Summary

Mr C complained about the physiotherapy treatment (the treatment of disease, injury or deformity using physical methods such as massage, heat treatment, and exercise) given to his wife (Mrs A) after her hip operation at University Hospital Hairmyres. Mr C also complained that the board had failed to communicate reasonably with himself and Mrs A about Mrs A's rehabilitation potential.

We took independent advice from a senior physiotherapist. We found that Mrs A had been provided with reasonable physiotherapy. The advice we received from the senior physiotherapist was that there were two treating physiotherapists which was excellent practice. We also found that the decision not to provide physiotherapy following discharge had been reasonable and that the communication about Mrs A's rehabilitation potential had been reasonable. Therefore, we did not uphold these aspects of Mr C's complaint.

Mr C also complained about the pressure area care given to Mrs A. We took independent advice from a nursing adviser. We found that the pressure area care given to Mrs A was unreasonable. In particular, that there was a lack of risk prevention strategies implemented when Mrs A was admitted to reduce her risk of developing pressure damage; when the first damage to Mrs A's skin was identified no care plan was put in place to reduce further risk of damage; and when Mrs A's ulcer developed into a grade three pressure ulcer (grade four is the highest form of damage) the relevant guidance was not followed. We also found that the nursing communication with Mr C had been unreasonable and that there was no evidence of a care plan being initiated to address Mrs A's weight loss. We also noted that that the nursing records were unreasonable 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 and Mrs A for the failings identified in pressure area care. The apology should meet the standards set out in the SPSO guidelines on apologyavailable at www.spso.org.uk/leaflets-and-guidance.

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

• Nursing staff should ensure risk assessments for pressure ulcer prevention are accurate. SSKIN care bundles should be followed appropriately to reduce the risk of a patient developing a pressure ulcer.
• Patients with pressure ulcers should have an individualised care plan implemented to further reduce risk of deterioration to the skin.
• Nursing staff should ensure the Healthcare Improvement Scotland standard for prevention and management of pressure ulcers is followed.
• Ensure that there is appropriate communication with patients and/or their families during a patient's stay in hospital.
• Patients with a pressure ulcer should have appropriate nutritional assessments undertaken and receive effective nutritional care, which is in line with relevant guidance.
• Accurate records should be maintained in line with Nursing and Midwifery Council code of record-keeping.

Summary

Ms C raised concern about a number of issues in relation to the Child and Adolescent Mental Health Service (the service) provided to her child (Child A) by the board. We took independent advice from a consultant child and adolescent psychiatrist (medical practitioner who specialises in the diagnosis and treatment of mental illness) and a registered mental nurse in a child and adolescent mental health service.

Ms C complained about the assessment and care provided to Child A and the way staff behaved to them both. We did not find evidence that staff within the service behaved inappropriately towards Ms C or Child A. We concluded that the assessment and intervention provided to Child A by the service was reasonable. We did not uphold this complaint.

Ms C also complained that the service failed to manage the sharing of confidential information appropriately. The board apologised to Ms C for failings in taking and recording consent for information sharing with the local authority and agreed to take action for learning and improvement. We identified a further instance where information was shared with the local authority without consent. We upheld this complaint and made recommendations in light of our findings.

Ms C was unhappy with the way that the board investigated her complaints and she raised concern that the investigating officer was not sufficiently independent. We did not find evidence that might indicate bias or partiality on the part of the investigating officer. However, we noted that the board reported inconsistent findings between two complaint responses. We felt that the board's failure to 'get it right first time' prolonged the complaints process. We upheld this complaint

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms C and Child A for sharing information with the Social Work Service without appropriate consent; and reporting inconsistent findings between the complaint responses. 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:

• Patient confidentiality should be maintained in line with Data Protection legislation. Where information is shared, this should be documented.

In relation to complaints handling, we recommended:

• 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 your final position. The investigation should 'get it right first time'.

Summary

Miss C complained about the care and treatment she received at the Royal Alexandra Hospital. Miss C complained that staff failed to recognise that her waters had broken, that she was not allowed an epidural (anaesthetic introduced into the space around the spinal cord to produce loss of sensation below the waist) and that she was advised that she was not allowed gas and air as it was not available.

We took independent medical advice from a consultant obstetrician and gynaecologist (a doctor who specialises in pregnancy, childbirth and the female reproductive system) and a midwife. We found no evidence in the records of Miss C's water breaking. However, we considered that the management of Miss C's analgesia (pain relief) as she awaited transfer to the obstetric unit for epidural was unreasonable as she should have been offered pain relief such as gas and air, further oral analgesia or injections of opiate analgesia. Therefore, we upheld this aspect of Miss C's complaint.

Miss C also complained that her baby (Baby A) was not fed or put in a nappy after delivery, did not go to special care and nobody checked on them when she was still in theatre. We found that appropriate steps were taken by the board to ensure that Baby A was cared for. Due to an emergency situation with Miss C, and as findings of Baby A's examination were normal, we found that it was reasonable for Baby A to be left with a family member. We also found that the delay in transferring Baby A to special care was not unreasonable, given that Miss C's care was the priority post-delivery. Therefore, we did not uphold this aspect of Miss C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Miss C for the failing in the provision of pain relief. 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:

• Appropriate pain relief should be provided to patients awaiting transfer to the obstetric unit for epidural.

Summary

Ms C complained about the care and treatment her late brother (Mr A) received at Glasgow Royal Infirmary. Mr A had previously suffered a brain injury and required to be managed under the Adults with Incapacity Act 2000. Mr A had difficulty swallowing and was considered unsafe for all food by mouth. Although Mr A required to undergo a number of investigative procedures, these could not be carried out due to his reluctance. Mr A also fell twice and after Ms C raised concerns with staff, he was later found to have broken his hip for which he required surgery. Before this could be carried out, Mr A suffered a heart attack and died a few days afterwards. Ms C complained that the gastroenterology (digestive system), nursing, orthopaedic (musculoskeletal system) and cardiology (heart and circulatory system) care and treatment Mr A received was unreasonable.

We took independent advice from consultants in acute care, orthopaedics and cardiology and from a registered nurse. We found that the team looking after Mr A struggled to balance the need to perform interventions with a desire not to treat him forcibly or against his will. We considered that the gastroenterology care Mr A received was reasonable. Mr A's cardiology treatment was also found to be reasonable. Therefore, we did not uphold these aspects of Ms C's complaint.

In relation to Mr A's nursing care, we found that he was not properly supervised and a number of nursing procedures were not correctly followed or recorded. In particular, despite being unsteady on his feet, he was sent for x-ray unsupervised and he fell. This incident was not recorded or followed-up as it should have been. After this fall, we found that the orthopaedic care was poor and there was a delay in planning the surgery required which was contrary to national guidelines. We considered the nursing care and orthopaedic care to be unreasonable and, therefore, we upheld these aspects of Ms C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms C for failing to properly follow procedures, to keep full records and notes and for the delay in proposed surgery. The apology should meet the standards set out inthe SPSO guidelines on apology available at www.spso.org.uk/leaflets-and-guidance.

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

• All nursing records should be completed as appropriate in accordance with the requirements of the Nursing and Midwifery Council.
• Patients should undergo surgical intervention within 48 hours in line with national guidelines.

Summary

Mrs C, an advocacy and support worker, complained on behalf of her client (Ms  B) about the care and treatment her elderly mother (Mrs A) received at Wishaw General Hospital and Kello Hospital. Mrs A had been in hospital after being diagnosed with lung cancer. Due to her frail condition, Mrs A was unsuitable for further care and could only be made comfortable. She was discharged home. Mrs A's condition deteriorated further and she was admitted to hospital for pain relief and palliative care. Mrs C complained that Mrs A was not fit for discharge and there was insufficient discussion with the family about this or about the medication Mrs A required to take at home. Mrs C also complained that the support provided by a nurse was unreasonable and on admission to Kello Hospital, staff failed to communicate reasonably with Mrs A family and delayed in providing appropriate pain relief.

We took independent advice from a doctor and from a specialist registered nurse. We found that discharge planning for someone with a terminal illness was complicated and difficult. While it was acknowledged that Mrs A wanted to go home, the arrangements made for her discharge had been hasty with insufficient discussion with the family who were unprepared for the demands of looking after her; they had no clear understanding of the medication prescribed and needed by her. Therefore, we upheld these aspects of Mrs C's complaints.

In relation to the nursing care, we found the support to be reasonable. We also considered the communication from staff at Kello Hospital to be appropriate and found no concerns with the pain relief given to Mrs A. Therefore, we did not uphold these aspects of Mrs C's complaints.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms B for failing to fully discuss with her the advanced nature of Mrs A's illness and discharge medication. 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:

• Patients and their family/carers should receive appropriate information on discharge arrangements and, where appropriate, have an adequate understanding of the nature and seriousness of the condition. Conversations about this should be recorded.
• Patients should receive the medication prescribed and this should be documented.

Summary

Mr C complained about a cafe premises near his property. The complaint included issues relating to the operation of a kitchen in the basement of the cafe and the placing of seating and tables outside the front of the cafe.

In relation to the operation of a basement kitchen, Mr C stated that the council failed to enforce building standards within a reasonable period of time after becoming aware of the fact that the cafe was operating a kitchen in the basement. We found that the council had made efforts over a period of time to get the cafe owner to comply and remove the basement kitchen, however, the cafe owner did not comply. Given the period of time that had passed it was clear that negotiations were not successful. We noted that the council have discretion regarding whether or not they will take enforcement action. However, we considered that the council should have taken a proactive approach and confirmed if the current situation was acceptable to them and why, or take suitable enforcement action within a reasonable period of time. Therefore, we upheld this aspect of Mr C's complaint.

Mr C also complained about a failure on the part of the council to address health and safety breaches in relation to the café's kitchen. We considered that the council are required to make their decision regarding the existence of the basement kitchen clear before it could be determined if the council required to seek further compliance with the health and safety matters raised. Therefore, we did not uphold this aspect of Mr C's complaint.

In relation to the seating and tables, Mr C complained that the cafe had not applied for planning permission for outdoor seating and the council had failed to address this within a reasonable period of time. We found that the cafe owner had signed The Street Cafe Annual Agreement that stated that planning permission must be obtained. We noted that the council were aware of the fact that this had not been obtained. We considered that the council should have confirmed that they were content to accept the current position and explain why they did not consider planning permission was required or what steps would be taken to ensure compliance. Therefore, we upheld this aspect of Mr C's complaint.

Mr C also considered that the cafe had breached the Street Cafe Annual Agreement in relation to several other areas. The council stated that the breaches were minor and they accepted them. We found that it was not reasonable for the council to make a determination on these matters until they had decided whether or not they accepted the seating outside the cafe without planning permission being obtained. 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 clarify whether or not they intend to take enforcement action or exercise discretion in relation to a breach of the Street Café Annual Agreement and in relation to the creation and operation of a basement kitchen. The council should also apologise for taking a view on breaches of the Street Café Annual Agreement when it was not reasonable to do so until they had clarified their position on another breach relating to a lack of planning permission. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/leaflets-and-guidance.
• The council should clarify whether or not (i) they intend to take enforcement action in relation to a breach of clause eighth of the Street Café Annual Agreement or (ii) exercise discretion and accept the current position without planning permission, and provide reasons for doing so. The council should clarify (i) whether or not they intend to take enforcement action in relation to the creation and operation of a basement kitchen or (ii) exercise their discretion and accept the current position without building regulation requirements and explain their reason for doing so.

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

• Where the council have been unsuccessful in asking a customer to comply with planning or building regulation requirements they should establish on a case by case basis a timescale in which they should reach a decision on whether or not they intend to take enforcement action or exercise their discretion in accepting the current position and provide reasons for doing so.
• Ensure there is a reporting mechanism within Development and Regeneration Services so that information can be shared about complaints received and breaches identified that impact on the decisions made by other departments.

Summary

Mrs C's child (Child A) was injured by another child while at school. Mrs C said that she was not contacted until around two hours after the incident and complained that the school failed to act in an appropriate and reasonable manner. Mrs C was also unhappy that the school had recorded Child A as being a participant in a fight rather than being assaulted and that the level of support provided to Child A after their return to school was unreasonable.

In their responses to Mrs C, the council indicated that the priority after the incident was to establish what had happened. Their responses were unclear, however, in terms of whether they understood Child A to have been displaying signs of a head injury after the incident. The council stated that the school followed NHS advice on head injuries and provided us with a copy of this. However, we noted that there was no direct reference to the NHS advice in staff statements, incident reports or the council's response to Mrs C. In their response to Mrs C, the council acknowledged that they should have handled things differently and did not contact her soon enough. They also stated that they had a new procedure in place in respect of head injuries at school. However, the evidence we reviewed showed a confused account of events and, as a result, we upheld this aspect of Mrs C's complaint.

In respect of the school recording the incident as a fight, we considered this reasonable. We found that the school accepted that Child A had been assaulted and made clear that the reference to a fight was in relation to what lead up to the assault. The account recorded by the school was based on multiple accounts of what happened. In addition to this, we saw nothing in the evidence provided to us that indicated that the school held the view that Child A was partially or wholly at fault for the way the incident escalated. Finally, the council indicated that they were happy for additional information Mrs C wanted to record to be appended, if appropriate. We concluded that the school and council provided a reasonable justification for why the incident was recorded this way and did not uphold this aspect of Mrs C's complaint.

In relation to the support Child A received after their return to school, we found that the school had made appropriate arrangements and that Child A did not take up everything that was offered. We acknowledged that a laptop had not been made immediately available for Child A but noted that this was addressed in a phone call with Mrs C and one was provided the next day. Finally, we considered that a risk assessment had been completed and reviewed appropriately. 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 not taking reasonable action following reports that Child A had sustained a head injury, clearly acknowledging where there has been fault. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/leafletsand-guidance.

Summary

Mr C complained that the partnership failed to handle his complaint properly and that they had not responded to his concerns about his child.

We found Mr C had made his complaint prior to 1 April 2017. This means that his complaint should have been progressed under the old social work complaints procedure with a Complaint Review Committee hearing as the final stage in the process. Although Mr C had evidence that he had requested that his complaint be escalated, this had not happened. We found that the partnership had incorrectly signposted Mr C to us (as per the new social work complaints procedure introduced from 1 April 2017). Therefore, we upheld this aspect of Mr  C's complaint.

We were unable to consider Mr C's second complaint as it had to have gone through the appropriate complaint process.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for failing to handle his complaint reasonably. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/leafletsand-guidance.

In relation to complaints handling, we recommended:

• The partnership should allow Mr C to progress his complaint through the process that was in place prior to 1 April 2017.

Summary

Mr C complained about the treatment he received from the board for pain in his thigh. Mr C said that he attended Perth Royal Infirmary and Ninewells Hospital over nearly a three year period for treatment for his condition and was seen by three different consultant vascular surgeons (a specialist in the treatment of diseases affecting the vascular system including diseases of the arteries, veins and lymphatic vessels). Mr C said he was not satisfied with the treatment suggested by the consultants and was subsequently seen and assessed by a surgeon at a private hospital, who carried out treatment which cured the pain in Mr C's thigh.

We took independent medical advice from a consultant vascular surgeon. We found that Mr C's treatment by the board was reasonable and found no failings in the treatment offered. Therefore, we did not uphold this part of Mr C's complaint.

Mr C also complained that the board failed to provide him with an adequate response to his complaint. We found that aspects of the board's response to Mr C's complaint did not appear to match with the evidence in the medical record and the response also failed to answer all Mr C's questions at the end of his letter of complaint. Therefore, we upheld this part of Mr C's complaint.

Recommendations

What we asked the organisation to do in this case:

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

In relation to complaints handling, we recommended:

• Responses to complaints should take into account the evidence in the medical records and address all the issues raised, in accordance with the NHS Scotland Complaints Handling Procedure.

Summary

Mr C complained that his wife (Mrs A) had undergone open heart surgery at Edinburgh Royal Infirmary when she had been due to undergo a less invasive procedure. Following surgery, Mrs A was transferred to another hospital where she died shortly afterwards. Mr C said that his wife suffered from dementia and could not have understood the decision to change the procedure or have provided informed consent. Mr C noted he had welfare power of attorney and accompanied his wife to all her appointments. Mr C said that he had not been informed about the change of procedure. Mr C also complained that Mrs A was unreasonably discharged to another hospital. Mr C felt that Mrs A would have survived if she had been treated differently.

We took independent medical advice from a consultant cardiothoracic surgeon (a specialist who operates on the heart, lungs and other chest organs). We found that Mrs A's procedure was changed after an appropriate assessment of the risks of both types of surgical procedure and that it was reasonable to proceed with open heart surgery. There was no evidence that Mrs A's chances of survival were compromised by this decision. We also found that an assessment had been carried out which found that Mrs A had a mild memory impairment, however, medical staff were satisfied that she had the capacity to understand and consent to the change in procedure. We considered that this was reasonable. Therefore, we did not uphold these aspects of Mr C's complaint.

In relation to the hospital transfer, we found that this was unreasonable given Mrs  A's condition. We upheld this aspect of Mr C's complaint. However, we could not determine that Mrs A would have survived if this had not taken place.

In relation to the board's communication with Mr C and his family, we found that Mrs A had been in hospital for over a week prior to the procedure due to a chest infection and that Mr C had been present every day. We considered that the board should have discussed Mrs A's care when Mr C was present. Therefore, we upheld this aspect of Mr C's complaint. We noted that the board had acknowledged and apologised for this failing.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for unreasonably deciding to transfer Mrs A to another hospital before she had sufficiently recovered from surgery. 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:

• Review their policies and procedures for patient transfer to ensure that distance travelled is taken into account as part of the decision.