Some upheld, recommendations

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.

Summary

Ms C complained about matters related to the care and treatment of her son (Mr  A), who had been an in-patient at the Royal Edinburgh Hospital. Mr A had a diagnosis of schizophrenia (a long term mental health condition that causes a range of different psychological symptoms) and had been subject to a Compulsory Treatment Order (an order that allows professionals to treat a person's mental illness). During the in-patient admission, the local authority's social work staff were working towards finding a suitable supported accommodation vacancy for Mr A, with input from clinicians. Ms C firstly raised concerns that board staff had contributed to delays in progressing Mr A towards discharge. We received independent advice from a consultant psychiatrist. We found that the clinical team reasonably fulfilled their responsibilities to identify a suitable accommodation placement for Mr A. We did not uphold this complaint.

On a particular occasion during the admission, Mr A did not return to the hospital following an agreed one hour period of leave. The hospital notified the police the next morning and informed Ms C later that day. Ms C raised concerns that the board failed to apply the correct risk level to Mr A's absence. We did not find evidence that the board had acted in accordance with the procedure for missing persons that was in use at the time. We upheld this complaint, however, we noted that the board had since revised and improved this procedure.

We also noted that the board's complaint investigation referred to the relevant procedure but did not identify that staff had not complied with this. We were critical of the complaint investigation and made a recommendation in relation to this.

Ms C was also unhappy with the level of communication with her during the time Mr A was absent from the hospital. In response to her complaint, the board acknowledged that there had been a delay in contacting Ms C to notify her. We found limited documentation of communication with Ms C and we concluded that communication was not in line with the procedure in place at the time. We upheld this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms C and Mr A for the failure to follow their Standard Operating Procedure for Missing Persons. 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 be familiar with the procedures to follow when a patient goes missing, and confident in applying these correctly.
• When a detained patient is missing, factual details such as dates/times of significant events and information discussed with next of kin and police should be recorded.

In relation to complaints handling, we recommended:

• A complaint investigation should identify any applicable policies or procedures and assess whether these have been followed (and if not, why).

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

Summary

Ms C complained about a number of aspects of the mental health care and treatment provided to her by the board over a number of years. In particular, Ms  C felt that the board failed to provide her with appropriate crisis support and appropriate psychiatric treatment. Ms C also complained that their communication around these matters was unreasonable and that their handling of her complaint was poor.

We took independent advice from a mental health nurse and a psychiatrist. We found that some of the crisis care provided to Ms C was reasonable, however, there were a number of areas where care could have been improved. We were not satisfied that the board had taken appropriate action, following an upheld complaint about staff attitude, to ensure that this issue did not impact on Ms C's access to the service in future. The mental health adviser noted that an out-of-hours care plan was not reviewed within the appropriate scheduled timescale and that the board held conflicting information in relation to Ms C's ability to access other services. Therefore, we upheld this aspect of Ms C's complaint.

In relation to Ms C's psychiatric treatment, we found that the care provided by a psychiatrist and a psychologist was reasonable. The psychiatric adviser noted that both the psychological treatment that Ms C received, and the administration of medication, was appropriate. Therefore, we did not uphold this aspect of Ms  C's complaint.

Additionally, Ms C felt that the board's communication around these matters had been poor as she had been unreasonably excluded from meetings where her care was being discussed. The psychiatric adviser considered that the board followed their usual and appropriate practice in relation to meetings held about a patient. We did not find evidence to suggest that Ms C had been unreasonably excluded from these meetings and that the boards communication with her was unreasonable. Therefore, we did not uphold this aspect of Ms C's complaint.

Finally, we found that the board had not consistently handled Ms C's complaints in line with their complaint handling guidance in place at the time. Therefore, we upheld this aspect of Ms C's complaint. However, we noted that since Ms C first made a complaint, a new complaints handling procedure has been introduced by the board and therefore, we made no recommendations for improvement on this point.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms C for failing to review her out-of-hours care plan as had been scheduled, failing to communicate with her consistently and accurately about her ability to access a crisis support service and failing to handle her complaints appropriately. The apology should meet the standards set out in the SPSO guidelines on apology available at https://www.spso.org.uk/leaflets-and-guidance.

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

• Staff should treat patients with courtesy and respect at all times. Staff should have access to appropriate focused clinical support and supervision.
• Care plans should be reviewed within the scheduled timescale. Where this is not possible, a reason for this should be documented. Care plans should accurately reflect a patient's ability or inability to access other support services, and communication about this matter should be consistent.

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

Summary

Mrs C complained about the care and treatment she and her baby received during and after the birth at the Royal Alexandra Hospital (RAH) and the Royal Hospital for Children (RHC). Mrs C was concerned that the baby was not admitted to the RHC when they attended A&E with concerns about the baby's eyes. Mrs C also had concerns about her care as she had to be readmitted to RAH for a procedure and later again for treatment of sepsis (blood infection).

We took independent advice from a midwife and consultant obstetrician (a doctor who specialises in pregnancy and childbirth). We found that the in-patient care and treatment Mrs C and the baby received from both midwifery and medical staff was of a reasonable and appropriate standard. We did not uphold the complaint about the baby's care and treatment.

However, we upheld the complaint about Mrs C's care and treatment on the basis that there was a failure in communication with Mrs C about her discharge medication and the record-keeping associated with this. We found that there was no evidence in the medical records to confirm that Mrs C was given information about the safety and dose instructions of the painkillers (paracetamol and ibuprofen) she was prescribed. We considered that this was not appropriate and could have resulted in serious harm in the event of an inadvertent overdose.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C for the failing in communication about discharge medication and record-keeping. 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 recommended/maximum daily dose and frequency of both paracetamol and ibuprofen should be documented in the medication section of the discharge letter. Staff discharging patients should document that the recommended/maximum daily dose and frequency of medication has been clearly explained to the patient.

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 surgery he received at Glasgow Dental Hospital and School, which involved placing Bio-Oss (bovine bone material) around his jaw in order that he would have enough bone to support dental implants. He complained that some of the surgery had been carried out by a trainee without him giving consent for this.

We took independent advice from a consultant oral and maxillofacial surgeon (a  specialist in the diagnosis and treatment of diseases affecting the mouth, jaws, face and neck). We found that it had been reasonable for the trainee to carry out the procedure, however, there was not sufficient evidence that Mr C had been informed of this. Therefore, we upheld this aspect of his complaint.

Mr C also complained that the board had not adequately informed him of the risks of the operation. We found that the information given to Mr C had been reasonable and we did not uphold this aspect of his complaint.

Mr C was also concerned that the board had delayed in investigating the complications that he had after the operation and that they had not provided an adequate explanation of what had gone wrong. We found that Mr C had received treatment after the operation without unreasonable delay and that the explanation he had received was reasonable. We did not uphold these aspects of Mr C's complaint.

Finally, Mr C complained that the board had delayed in amending the policy and procedures in the hospital to prevent the problems he experienced from happening again. We found that the action taken by the board to learn from the case had been reasonable and 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 the lack of clarity in the consent form about the involvement of a specialist trainee in his 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:

• The consent form should clearly and correctly reflect the situation if specialist trainees are to be involved in carrying out a 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.

Summary

Ms C complained to us about the care and treatment that her late partner (Mr A) received at Aberdeen Royal Infirmary when he attended on two separate occasions with severe chest pain. Mr A died during his second attendance at the hospital.

On Mr A's first attendance at the hospital he was seen in the Acute Medical Initial Assessment Unit and the Ambulatory Emergency Care Unit. Ms C complained about the assessment and examination that Mr A received and that he was diagnosed with musculoskeletal chest pain. We took independent advice from consultant in acute medicine. We found that assessments and examinations were reasonable and in accordance with the relevant guidance for chest pain. In particular, Mr A's chest pain was viewed as cardiac until it was positively excluded by the results of a troponin blood test and an electrocardiogram (ECG - a test which measures the electrical activity of the heart to show whether or not it is working normally). We did not uphold this aspect of Ms C's complaint.

Around two months later, Mr A attended the emergency department at the hospital. Ms C complained that Mr A's condition was too serious for him to be asked to sit and wait for an initial assessment. Mr A collapsed in the emergency department waiting area. He then went into cardiac arrest (where the heart suddenly and unexpectedly stops beating) and died. We took advice from a consultant in emergency medicine. We found that it was unreasonable that Mr A was asked to sit and wait for an initial assessment when he presented to the emergency department with chest pain and shortness of breath. 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 assess Mr A promptly when he presented to the emergency department with chest pain, clammy skin and shortness of breath. The apology should meet the standard 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 in a similar situation and/or with certain conditions and symptoms should be brought to the attention of nursing staff immediately, so that self-presenting patients can be fast-tracked for clinical assessment.

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.