Some upheld, recommendations

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).

Summary

Mr C complained about the care and treatment provided to his late mother (Miss  A) by the practice. He complained that the decision to initiate end of life care for Miss A was unreasonable and that she should have been moved to a more appropriate facility for active treatment.

We took independent advice from a GP. We found that the decision to commence Miss A on end of life care was reasonable as she was no longer responding to treatment. We further found that it would not have been appropraite to transfer Miss A to a different facility. We did not uphold this aspect of Mr C's complaint.

Mr C also raised concerns about the practice's handling of his complaint, as they had declined to release any information to him due to him not being Miss A's recorded next of kin and them having no information regarding his position to make a complaint. We found that whilst it was not unreasonable for the practice to take this position, it would have been helpful for them to acknowledge Mr C's complaint in a timely manner and seek further information from Mr C regarding Miss A's personal representative. We also found that the practice failed to respond to Mr C within 20 working days and did not signpost him to this office. 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 handle his complaint in a reasonable manner. 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:

• Complaints should be handled in line with the model Complaints Handling Procedure.

Summary

Mr C raised a number of concerns about the council's handling of a planning application. In particular, that the council had unreasonably failed to carry out an appropriate assessment of the impact of the new development on his property. He also complained that the council had failed to take enforcement action in relation to an alleged breach of planning control.

We took independent advice from a planning adviser. We considered that the assessment of the planning application in relation to the impact on Mr C's property, in terms of privacy and overlooking, was unreasonable and we upheld this aspect of his complaint. However, in making recommendations to the council in light of this finding we noted that they had, prior to our investigation, taken action to suggest to the applicant that additional screening be installed to address Mr C's concerns about overlooking.

In reference to enforcement action we were satisfied that the council had take action in line with their monitoring and enforcement charter and we found no failings. Therefore, we did not uphold the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for failing to carry out an appropriate assessment of the impact of the development on Mr C's property. 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:

• All representations made against a planning application should be taken into account in compiling the report.
• A thorough assessment of proposals against the development plan policies and supplementary guidance should be carried out.

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 social work's involvement with him, after his stepchild was referred to the social work department. Mr C complained that the partnership did not provide him with reasonable support as no parental course was offered to him and he was not shown the child plan for his stepchild. Mr C also complained that the partnership's complaints handling was unreasonable as his concerns were not fully addressed.

We took independent advice from a social worker. We found that there was evidence that that social worker attempted to arrange parental work with Mr C. We found that it was reasonable Mr C was not shown the child's plan, as he was no longer in the family home when it was prepared and he did not have parental rights and responsibilities for his stepchild. Therefore, we did not uphold this aspect of Mr C's complaint.

In relation to complaints handling, we found that the partnership did not accurately identify all of Mr C's concerns and provide a reasonable response to them. 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 for not accurately identifying and providing an appropriate response to all aspects of his complaint, and provide Mr C with a full response to the concerns raised. 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:

• Complaint responses should accurately identify and provide a reasonable response to all the issues of concern.

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 the council had failed to assess her temporary accommodation. Mrs C also complained that her Self Directed Support (SDS) assessment took too long to complete and that the council had failed to communicate with her appropriately.

We took independent social work advice. We found that the council was not obliged to assess Mrs C's temporary accommodation as she had chosen to move into a privately rented property. Therefore, we did not uphold this aspect of Mrs  C's complaint.

We found that Mrs C's SDS assessment did not take an unreasonable length of time, however, it had been signed electronically on her behalf, without any evidence of her consent. We considered that this was inappropriate and upheld this aspect of Mrs C's complaint. However, we noted that the council were taking action to prevent this reoccurring.

We also found that the council had not communicated reasonably with Mrs C about a decision to stop her direct payment. This was unreasonable as they were aware Mrs C had previously required assistance in managing this. 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 electronically signing a document on her behalf without her agreement and for failing to communicate with Mrs C reasonably. 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 have a process in place that informs service users when direct payments are going to be stopped and tells them who to contact if they are having difficulties in managing their payments.
• The council's procedures should ensure that the SDS team and Care Manager are informed of issues with direct payment budgets and should investigate when issues are noted.

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, who works for an advice and support agency, complained on behalf of her client (Mr A) about the care and treatment provided to him at Uist and Barra Hospital. Mr A was catheterised (a process that involves inserting a tube to the patient's urethra to allow urine to drain freely from the bladder for collection), and Ms C complained that this was done unnecessarily, and without his consent. She also complained that the record-keeping for this admission was not of an appropriate standard.

We took independent advice from a consultant physician and a nurse. We found that it had been necessary from a medical standpoint to catheterise Mr A. We also found that whilst Mr A's consent was not documented, there is no requirement for this and there was no evidence to suggest that Mr A did not consent to catheterisation. We considered that record-keeping was of a reasonable standard. We did not uphold these aspects of Ms C's complaint.

Ms C also complained that Mr A's initial verbal complaints were not handled appropriately. The board accepted that this was the case and we, therefore, upheld this aspect of Ms C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr A for failing to handle his initial verbal complaints appropriately. 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:

• Verbal complaints should be handled in line with the complaints handling procedure.

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