Some upheld, recommendations

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.

Summary

Mrs C complained that the board failed to prevent her baby (Baby A) developing hypothermia (the condition of having an abnormally and typically dangerously low body temperature) in the hours after their birth at the Royal Infirmary of Edinburgh.

We took independent advice from a midwife. We found that Mrs C and hospital staff had different recollections of what was said about the reason why Baby A developed hypothermia. The medical records noted the likely reasons, such as possible infection or due to medication given to Mrs C during labour, but did not reach a definitive conclusion. We noted that staff gave Baby A antibiotics in line with relevant clinical guidance to ensure they recovered. We did not find evidence that the board acted unreasonably. Therefore, we did not uphold this aspect of Mrs C's complaint.

Mrs C also complained that the board's response to her complaint was unreasonable. Mrs C was particularly concerned that Baby A's hypothermia could have developed because the birthing centre was too cold. We found that the board failed to investigate this specific part of Mrs C's complaint, and did not respond to her about it, despite having noted it in their acknowledgement letter. Therefore, we upheld 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 investigate and respond to her specific complaint about the birthing centre temperature. 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 address the points raised, or explain why information cannot be provided.

Summary

Mr C complained about the care and treatment he received at Monklands Hospital. Following an accident, Mr C presented to the emergency department on three occasions over a two day period. He raised concern that doctors did not listen to his concerns about his injury and that an x-ray was not performed until his third presentation. At the first presentation, Mr C was examined for a head injury and was discharged without an x-ray being performed. Mr C returned to the department the next day and was assessed by a different doctor who also discharged Mr C. A short time later, the doctor revised their decision to discharge Mr C and he returned to the department a short time later. An x-ray identified that he had suffered a spinal fracture.

In response to Mr C's complaint, the board acknowledged that a scan should have been performed at the first presentation and an apology was offered to Mr  C. The board detailed a number of steps that would be taken to learn from the issues identified. We took independent advice from an emergency medicine consultant. We found that the board had appropriately identified all the failings in relation to this matter. We upheld this aspect of Mr C's complaint and asked the board to provide evidence of actions taken to prevent these failings reoccurring.

Following the diagnosis of a spinal fracture, Mr C experienced an episode of urinary retention (inability to empty the bladder completely) during the admission. A number of attempts at urethral catheterisation (insertion of a thin tube into the urethra to drain and collect urine from the bladder) were made, yet these were unsuccessful. Urology doctors (a doctor who specialises in the male and female urinary tract, and the male reproductive organs) offered to perform suprapubic catheterisation (surgical insertion of a thin tube through the skin to drain and collect urine from the bladder), yet Mr C did not consent to this procedure. Mr C felt that doctors did not listen to him when attempting catheterisation and was unhappy that a camera was not used to assist catheterisation. We took independent advice from a consultant urologist. We found that the attempts at catheterisation were not sufficiently documented and that the documentation regarding consent was inadequate. Therefore, we upheld this aspect of Mr C's complaint.

Finally, Mr C was unhappy that, during a previous admission to hospital a number of years before, he was not informed that he had experienced complications related to urological treatment. We did not find evidence that Mr C had experienced complications related to earlier treatment and so we were unable to conclude that there had been a failure to inform Mr C. Therefore, we did not uphold this aspect of his complaint. However, we gave feedback to the board regarding communication as it seemed that a communication breakdown had contributed to Mr C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for the inadequate documentation of the urethral catheterisation attempts and the inadequate documentation of the consenting process for catheterisation. 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 catheterisation has been attempted, this should be documented along with any complications (such as bleeding). Where the attempt fails, the size of the catheter used, the level of obstruction within the urethra and number of attempts should be clearly documented.
• The risks and benefits of catheterisation should be explained to the patient and this should be documented. If a patient has objections or queries about catheterisation, these should be listened to, documented and resolved before proceeding with catheterisation.

Summary

Mrs C had surgery to remove her gallbladder at Queen Elizabeth University Hospital. Mrs C was experiencing severe pain following her surgery and it was subsequently discovered that bile was leaking into her abdomen. Mrs C underwent further procedures to resolve the bile leak. Mrs C complained about the medical treatment she received both during and after her surgery.

We took independent advice from a general surgical adviser. We found that the medical care Mrs C received during her surgery was reasonable and did not uphold this aspect of her complaint. However, we did find that there was an unreasonable delay in recognising that Mrs C's symptoms may have been caused by a bile leak. Therefore, we upheld Mrs C's complaint that the board failed to provide reasonable medical treatment after her surgery.

Mrs C also complained about the nursing care she received after her surgery. We took independent advice from a nursing adviser. We found that there was no pain assessment and care plan completed following her surgery. Therefore, we upheld this aspect of Mrs C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C for the delay in recognising her symptoms may have been caused by a bile leak and that there was no nursing pain assessment and care plan completed following her surgeries. 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 possibility of a bile leak should be considered by medical staff in patients who do not recover as expected from laparoscopic cholecystectomy (gallbladder removal).
• Post-operative patients should have their pain assessed, recorded and treated by nursing staff in accordance with relevant guidance.

Summary

Mrs C complained about the palliative care and treatment that her father (Mr A) received at Queen Elizabeth University Hospital. Mr A was later transferred to a hospice where he died. Mrs C was concerned about the types and doses of medication prescribed to Mr A and the board's communication with the family about Mr A's condition and the medication he was receiving.

We took independent advice from a consultant in palliative medicine. We found that the majority of the palliative care and treatment that Mr A received was reasonable. However, we found that the handover between the hospital and the hospice could have been better. In particular, the hospice referral letter did not detail all the drugs that Mr A was receiving and it did not explain the reasons for the unusual combinations he was prescribed. Therefore, we upheld Mrs C's complaint about the palliative care and treatment that Mr A received.

In relation to communication from the board with the family, we did not find evidence that this was unreasonable. Therefore, we did not uphold this aspect of Mrs C's complaint.

Mrs C also complained about the nursing care that Mr A received. We took independent advice from a nursing adviser. We found that the majority of the nursing care was reasonable. However, we also found that the Nutrition Profile and Malnutrition Universal Screening Tool were not completed within 24 hours of Mr A's admission to hospital. On balance, we upheld Mrs C's complaint about nursing care.

Finally, Mrs C complained about the way the board handled her complaint. We found that:

• there was a delay in responding to Mrs A's complaint.

• the board did not agree a timescale with Mrs A about when she could expect to receive the minutes of a meeting about her complaint.

• the board's complaint response used generic terms and did not clearly explain what medication Mr A received, why the medication was changed, what the possible side-effects were and how these were monitored.

Therefore, we upheld Mrs C's complaint that the board failed to handle her complaint reasonably.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C for the failure to clearly document the handover of Mr  A's drug regimen to the hospice, the failure to complete the Nutrition Profile and Malnutrition Universal Screening Tool within 24 hours of Mr A's admission, the delay in responding to Mrs C's complaint, that no timescale was agreed with her about when she could expect to receive the meeting minutes and that the complaint response did not clearly explain what medication Mr A received. 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 handover of patient drug regimens to other care providers should be clearly documented.
• Patients should receive adequate nutritional assessment and care planning in accordance with the relevant standards.

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 here: www.valuingcomplaints.org.uk/handling-complaints/complaints-procedures/nhs.
• There should be an appropriate level of detail in complaint responses that can be clearly understood.

Summary

Mrs C complained about the care and treatment she received from the board following spinal surgery. We took independent advice from a consultant neurosurgeon (a doctor who specialises in conditions of the nervous system, including the brain, the spine, the spinal cord and nerves) and from a nurse.

Firstly, Mrs C complained that the board failed to reasonably prevent and treat her infection following the surgery. We found no evidence that the board had failed to prevent the infection. However, we found that Mrs C was not assessed and treated as soon as the results showing the infection were reported. There had also been a delay in carrying out a wound washout which was unreasonable. We, therefore, upheld this complaint.

Mrs C also complained that the board failed to provide her with appropriate pain relief immediately after surgery. We noted that the board had acknowledged their failing in relation to providing post-operative pain relief and had apologised for this. We upheld this aspect of Mrs C's complaint.

Mrs C also complained that the board failed to provide a reasonable standard of nursing care following her operation. We found that overall the nursing care was reasonable and did not uphold this aspect of Mrs C's complaint.

Finally, Mrs C complained that the board unreasonably delayed in responding to her complaint. We found inaccuracies in the board's response, and that there were delays in acknowledging and responding to the complaint. Further to that, the board did not keep Mrs C updated about the delay. We also noted that the board did not appear to have kept a full record of their internal investigation. We upheld this aspect of Mrs C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C for the delays in treating her wound infection and the inaccuracy in their 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.

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

• Lab results showing infection following spinal surgery should result in prompt assessment and treatment.
• Emergency wound washouts should be carried out promptly.

In relation to complaints handling, we recommended:

• Complaint responses should be accurate and supported by relevant evidence in the medical records. Any failings should be openly acknowledged and used to improve services and prevent a recurrence of the issues found.
• Stage 2 complaints should be acknowledged within three working days and responded to within 20 working days where possible.
• Where complaints cannot be responded to within 20 working days, the board should give a revised timeframe and keep the complainant updated regularly (for example, every four weeks).
• Complaint files should include records of all the information gathered during an investigation (and copies of internal correspondence about this).