Some upheld, recommendations

Summary

Mr C, a patient adviser, complained on behalf of his client (Ms B) regarding the care and treatment provided to her father (Mr A) at Western Infirmary.

Mr A was an in-patient receiving dialysis (a form of treatment that replicates many of the kidney's functions) at the hospital for 12 weeks before he died. Ms B was concerned that Mr A did not receive appropriate dialysis treatment during the admission. We took independent advice from a consultant nephrologist (a  specialist in kidney care and treating diseases of the kidneys). They noted that the delivery of dialysis was difficult in this case because Mr A was frequently confused and unable to co-operate with the dialysis treatment. We considered that the records showed that Mr A received a reasonable number of dialysis sessions during the admission, and that the dialysis treatment prevented the toxins in his blood from reaching excessive levels. We found no evidence of failings in dialysis treatment, and we did not uphold this aspect of Mr C's complaint.

Ms B was also concerned that the board failed to take appropriate steps to ensure Mr A was comfortable and safe when receiving dialysis treatment. We took independent advice from a consultant in old age psychiatry and from a registered nurse. We considered that medical staff appropriately managed Mr A's delirium with the input from the hospital's old age psychiatry team. We found that the board had taken reasonable steps to help to ensure Mr A was comfortable when receiving dialysis and we noted that a number of fall risk assessments were carried out throughout the admission. The records showed that Mr A sustained a number of falls during the admission, and we were unable to conclude that the board followed their referral criteria for the hospital falls prevention co-ordinator. Although we were unable to conclude that earlier involvement from the hospital falls prevention co-ordinator would have prevented Mr A's third fall, we upheld this aspect of Mr C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms B for the delay in referring Mr A to the hospital falls prevention co-ordinator. 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 at risk of sustaining a fall in hospital should be referred to the hospital falls prevention co-ordinator if they meet the board's referral criteria.

Summary

Ms C was admitted to Aberdeen Maternity Hospital as she had symptoms of preeclampsia (a pregnancy-related condition involving a combination of raised blood pressure and protein in the urine). Ms C complained about decision making in terms of induction of labour, and the care and treatment provided during her labour, including administration of opiate pain relief and the decision that it was appropriate to proceed with a vaginal delivery, rather than a caesarean section. Ms C's baby experienced breathing difficulties following birth, believed to be associated with the opiate pain relief Ms C received, and was cared for by the neonatal team for around five days before they were both discharged home. Ms  C also complained that the board's view that her baby's physical and mental development will not be affected by this was unreasonable.

We took independent advice from a consultant obstetrician and gynaecologist (a  doctor who specialises in pregnancy and childbirth as well as the female reproductive system). We found that it was reasonable to induce Ms C's labour in the circumstances of her case. The records indicated that appropriate discussions had taken place with Ms C and that she had taken the decision to proceed with induction. Therefore, we did not uphold this aspect of Ms C's complaint.

In relation to Ms C's concerns about care and treatment during her labour, we found that it was reasonable to provide opiate pain relief. We found that the guidance indicates that whilst morphine administration may have significant side effects for mother and baby, these side effects are considered to be short-term. We found that the board had already offered an apology to Ms C in relation to delays in obtaining blood test results and that they had taken steps to improve service in this area. We noted that the blood should have been sent urgently for testing but that the delays were unlikely to have had any bearing on the care and treatment that Ms C received. We also found that it was reasonable to proceed with vaginal delivery in the circumstances, particularly as Ms C's labour had progressed very quickly. However, Ms C's notes indicated that there was a plan made that day for her to have a caesarean section and that the board's local policy on preterm labour and birth indicated that steroids should have been administered as a result. We considered that, in line with the local policy, Ms C should have received steroids. Therefore, we upheld Ms C's complaint about the care and treatment during labour and made further recommendations in this connection.

We took independent advice from a consultant neonatologist (a doctor who specialises in the medical care of newborn infants, especially ill or premature newborns) in relation to the board's view that Ms C's baby would have no long- term effects from the breathing difficulties following birth. We found that the board's view was reasonable as there was no indication of any issues. 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 failing to administer steroids in line with their local policy and that blood tests were not sent as urgent. 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 local policy should be followed regarding the administration of steroids. If policy is not followed, the reasons for this should be documented in the records. Patients awaiting blood tests for an emergency caesarean section or with severe preeclampsia in labour ward should have bloods sent as urgent.

Summary

Ms C complained that her prescribed medications had been mismanaged by the practice. She said that her medications were rarely available to collect from her local pharmacy after she had ordered them through the practice. Ms C said that she had been without key medication due to these access problems.

We took independent advice from a GP. We found that the practice prescribed Ms C's blood pressure medication regularly, however, we could not say whether this was provided within a reasonable time of Ms C's requests because there was insufficient evidence available. We also found that the practice was not unreasonable in failing to prescribe an updated contraception medication because they were not notified of the change prior to the medication being issued. Therefore, we did not uphold this aspect of Ms C's complaint.

Ms C also complained that the practice refused to take complaints by phone and did not respond to complaints made in writing. Ms C submitted two complaints. We found that the tone used by the practice in their response was confrontational, did not recognise the inconvenience Ms C had experienced, and did not reflect on whether there was learning to be taken from the complaint. We also found that Ms C was given no information about the complaints process and was not told whether she could escalate her complaint, either to stage two of the complaints process or to our office. In responding to the second complaint, there was no acknowledgement that Ms C had not received the previous response, despite it being clearly mentioned to them. We considered that the practice's responses to Ms C's complaints were unreasonable. 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 the failure to provide reasonable responses to her complaint and for the inappropriate tone and content of their letters responding to her complaints. The apologyshould meet the standards set out in the SPSO guidelines on apology availableat www.spso.org.uk/leaflets-and-guidance.

In relation to complaints handling, we recommended:

• The practice must have a complaints procedure in place which meets the requirements of the NHS model complaints handling procedure and the Patient Rights (Scotland) Act 2011.
• The practice must ensure that staff respond to complaints fully, in a timely manner and any responses should remain respectful at all times.

Summary

Mrs C complained that the board failed to carry out her total knee replacement appropriately in Dumfries and Galloway Royal Infirmary. Mrs C suffered pain and stiffness after the operation and eventually had to have a revised total knee replacement at another hospital.

We took independent advice from a consultant orthopaedic surgeon (a specialist in the treatment of diseases and injuries of the musculoskeletal system). Although there was evidence of malalignment (incorrect or imperfect alignment) of the knee on the x-rays and CT scan carried out some time after the operation, a few degrees of variation would not be unusual. This was unlikely to have contributed to the stiffness Mrs C experienced. We found that that without the benefit of hindsight, there was no evidence that the operation had not been reasonably carried out. Therefore, we did not uphold this aspect of Mrs C's complaint.

Mrs C also complained that the care and treatment provided to her after the operation was unreasonable. We found that, in general, the care and treatment provided to Mrs C after the operation was reasonable. However, we found that a letter the board issued to the hospital where she had the revised total knee replacement contained a number of inaccuracies. For this reason, we upheld this aspect of Mrs C's complaint.

Finally Mrs C complained that the board refused to lend her a continuous passive motion (CPM) machine. We found that it would not be routine for a patient to be given a CPM machine. We found that the board's actions in relation to this matter were reasonable. We did not uphold this aspect of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C that their referral letter to another hospital contained inaccuracies. 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:

• Referral letters should be accurate.

Summary

Ms C and Ms C raised their concerns about the care and treatment their late mother (Mrs A) received when she was admitted to University Hospital Crosshouse, in particular, about the clinical and nursing care and treatment Mrs A received. They also complained about the communication with their family and that the board had failed to handle their complaint in a reasonable way.

We took independent advice from a consultant geriatrician (a doctor who specialises in medicine of the elderly) and a nursing adviser. We found that there had been a failure to identify how unwell Mrs A was and a delay in initiating a higher level of care. We considered that the clinical care Mrs A received was unreasonable and upheld this complaint. However, we noted that it was possible that Mrs A would have died even with appropriate care, given the severity of her illness.

In relation to the nursing care given to Mrs A, the board acknowledged that Mrs A would have found it difficult to use the call system. As a result of a fall that Mrs A had suffered, the board staff had been advised that all patients with any degree of cognitive impairment should not be left unassisted within the ward where they could not been directly seen by nursing staff. We were satisfied with the action taken by the board. We also found no failings on the part of nursing staff regarding Mrs A's dehydration and dietary intake, medicine administration and Mrs A's personal care. Therefore, we did not uphold this aspect of the complaint.

In relation to communication, while we found there was evidence of some good communication, we found that overall the communication was poor, particulary after it was clear to medical staff that Mrs A's condition had deteriorated. We also found failings in relation to the communication surrounding the Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) decision. Therefore, we upheld this aspect of the complaint.

Finally, in relation to complaint handling, we found that the board had failed to comply with their complaints handling procedure and we upheld this aspect of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to the family for the failings in clinical care, communication and complaints handling. 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:

• Staff should recognise signs of deterioration in patients and actively manage this.

In relation to complaints handling, we recommended:

• Written responses should normally be sent within 20 working days of receipt of the complaint, or a revised timescale agreed with the complainant.

Summary

Mr C complained that the Scottish Prison Service (SPS) stopped his Special Escorted Leave (SEL). He also complained about the handling of his complaint.

We found that the prison did not stop Mr C's access to SELs but, within their authority under the relevant legislation, they questioned Mr C's need for visits to a specific place, given a change in circumstances. The SPS can limit access to SELs if they consider a proposed visit no longer serves the intended purpose. Mr  C still had access to SELs to visit other places. Therefore, we did not uphold this part of Mr C's complaint.

In dealing with Mr C's complaint, the SPS said that they would review the subject of Mr C's complaint. However, they did not share the outcome of the review with Mr C. Providing an explanation to him would have been appropriate and good practice. 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 failing to respond reasonably to his complaint. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/leaflets-and-guidance.
• Provide a full response to the issues raised in the complaint, and communicate the findings of the review.

In relation to complaints handling, we recommended:

• Staff should respond to points of concern raised within prisoners' complaints, and ensure that the main aspects of the complaint are addressed.

Summary

Mr C complained that the council failed to investigate the issue of strong odours which were affecting him at his place of work. These were coming from a nearby restaurant and separate smells from a sewer pipe at a neighbouring hotel. Mr C said that it was the council's responsibility to ensure that both the restaurant and hotel were complying with health and safety regulations.

The council responded by advising that they had investigated the matter and attended the restaurant who agreed to take action to reduce the smell. The council felt that this resolved this particular issue. They also contacted the hotel owner who confirmed that they were aware of the issue and were working with the water provider to resolve this. The council held the view that the matter was in hand, and as they did not have authority over the sewerage pipes, they would not take any further action. Following continued complaints, the council visited Mr C's place of work but did not identify any smells that would be classed as a Statutory Nuisance and therefore could not issue an Abatement Order. They also liaised with the water provider to encourage the necessary work to be completed. Mr C remained unhappy and brought his complaint to us.

We found that the council had responded to the issues appropriately and promptly. The council remained largely involved in trying to resolve the issues by assisting the relevant parties involved despite having limited authority. Therefore, we did not uphold this aspect of Mr C's complaint.

Mr C also complained that the council failed to provide a reasonable response to his complaint. We found that some of the language used in their response to Mr  C was inappropriate and they failed to advise him on how to escalate his complaint. Therefore, we upheld this aspect of Mr C's complaint. The council acknowledged these failings and have already taken action to prevent issues occurring again in the future.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for the upset caused by the confrontational language in their response and the failure to advise him correctly of the next stage of the complaints process and for failing to identify these errors in their stage two complaint response. 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 that his late mother (Miss A), who stayed in a council owned care home, was not provided with appropriate care in relation to monitoring her prior to and after a fall in which she broke her arm. He also complained that the council failed to appropriately communicate with him regarding Miss A's condition.

In response to Mr C's complaints, the council identified that there had been some failings in recording. They provided us with an action plan for improvements to be made, and a new policy in relation to falls. On reviewing the council's policies and guidance alongside Miss A's notes, we found that when she fell and complained of pain in her arm, there was a failure to immediately seek urgent medical opinion as per the council's policy. We also found that the falls risk assessment had not been reviewed as often as was specified by guidance. We upheld this aspect of Mr C's complaint, however, considered that the council's new falls guidance would, if followed, prevent a recurrence of these events.

In relation to communication with Mr C about Miss A's condition, we found that Mr C was not Miss A's recorded next of kin and that there was no policy that required Mr C to be contacted by the council. We did not uphold 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 follow their policies on care after a fall and falls risk assessment. 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 council should follow their policies on care after a fall and falls risk assessment.

Summary

Mr C complained that the social work department unreasonably failed to act when he made reports of risk to his children, and that their arrangements for him to have access to his children were unreasonable.

We took independent advice from a social work adviser. We found that in relation to the council's response to Mr C's reports of risk to his children, whilst they had been responsive to these reports and had taken reasonable action in the majority of instances, on one instance they had changed their plans for following up a report without recording the reasons why. We further found that on one occasion a discussion between staff in which decisions were made regarding action to be taken hadn't been recorded; and that there were some delays in signing off on a child protection case conference record and implementing one of the actions agreed at the case conference. Therefore, we upheld this aspect of Mr C's complaint.

In relation to the council's arrangements for Mr C to have access to his children, we found that the council had reasonably assessed Mr C and his children, encouraged Mr C to suggest activities, and ensured they had enough notice from all parties for contact to go ahead. We found that the council's handling of this matter was reasonable and, therefore, we did not uphold 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 record why the plan for following up one instance of his report of risk to his children was changed, failing to document a discussion between the social worker and child protection coordinator and the delay in implementing one of the actions agreed at the child protection case conference. 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:

• When plans for follow-up are changed, the reasons for this should be recorded.
• Discussions regarding cases between staff members in which decisions are made should be documented.
• Deadlines as stipulated in the Child Protection Procedures and Guidance should be adhered to.
• Actions agreed at child protection case conferences should be taken forwards in a timely manner.

Summary

Mr C complained on behalf of his son (Mr A) about a number of matters in relation to social work involvement with their family. We took independent advice from a child and family social work adviser.

In relation to a social work assessment, Mr C was unhappy with the level of assessment of Mr A and his partner that was carried out. We found that the council had a good reason not to complete a full assessment of Mr A and his partner and we did not uphold this complaint.

Mr C was also unhappy about a delay in completing the assessment. We noted that the council had upheld Mr C's complaint about the delay in completing the assessments. We found that the council had issued a briefing note to staff regarding this issue. We upheld the complaint and gave the council feedback about further good practice for learning from complaints.

Mr C also raised concern about a social worker communicating sensitive information by phone rather than at a meeting. The council upheld the complaint and issued a briefing to staff about communication. Subsequently, the issue reoccurred and the council agreed to amend guidance to staff. We upheld the complaint.

Mr C complained about the way the council handled his request for a change in a member of staff involved in his family's case. We found that there was a lengthy delay in the council responding to Mr C. We noted that the response did not come from the officer who made the decision and no explanation for the decision was provided. We upheld the complaint.

Mr C further raised concerns about a number of aspects of complaint handling. We found that the council had failed to apologise to Mr C for the use of inappropriate language (an aspect of the complaint they had upheld) and had failed to fully investigate part of Mr C's complaint. We upheld the complaint.

Mr C also complained that the council failed to share with the family a concern about the wellbeing of the children that was identified by their school. We found that it would have been good practice to have shared this information. However, we were unable to conclude that the council acted unreasonably and we did not uphold this complaint.

Finally, Mr C complained about a delay in the school sharing assessments of the children with Mr A, when it had been agreed this would happen. The council acknowledged that there was no good reason for the delay. We upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr A and Mr C for the delay in the completion of the assessments and the communication in relation to this, not arranging a meeting to share sensitive information, the way they handled Mr C's request for another member of staff, the way Mr C's concern about the member of staff was handled, the use of inappropriate language, not investigating part of Mr C's complaint fully and unreasonably delaying sharing assessments. 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:

• Where a service user or their representative requests a change in the staff involved in their case, this should be considered and appropriately responded to by the officer making the decision within a reasonable timescale with reasons given for their decision.
• Action points from a meeting should be completed within an agreed period of time.

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 customer a full, objective and proportionate response that represents the final position.