Some upheld, recommendations

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.

Summary

Mrs C, an advocacy and support worker, complained on behalf of her client (Mr  A) who is in the process of gender transition. Mr A heard that a consultant in the Gender Identity Clinic (GIC) was going on extended leave, with no cover being provided, and therefore requested an out of area referral. He had been advised by his psychiatrist to seek the extra-contractual referral for medical reasons. Mrs C complained that the board failed to address Mr A's request in their response to his complaint and failed to provide an adequate service.

After Mrs C brought the complaint to us, the board wrote to Mr A and apologised for not having addressed his query about extra-contractual referral when they originally responded to the complaint. They explained that they would not support a referral to another board because they were continuing to offer the same level of service as previously. Given that the board had not addressed this referral request at the time it was made, we upheld this aspect of Mrs C's complaint.

In relation to the complaint about service provision, we took independent advice from a psychiatric adviser (a medical practitioner who specialises in the diagnosis and treatment of mental illness). We found that the level of service at the GIC had not changed and that there were plans in place and enacted to cover the period of leave taken by the existing consultant. We also noted that given there were no additional risk factors identified such as major mental or physical illness, there would be no indication to go outwith the normal process followed by the board. We considered that the board had gone to significant effort to ensure their service was not adversely affected by the period of leave and provided Mr A with a reasonable service. We did not uphold this aspect of Mrs C's complaint.

Recommendations

In relation to complaints handling, we recommended:

• When responding to complaints, staff should be confident that they have addressed all relevant matters.

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 the care and treatment he received from the board's mental health services. In particular, he raised concerns about the board only offering appointments outwith his home when he had difficulty leaving his home and that they did not discuss his care plan with him. Mr C also complained about the board's handling of his complaint.

We took independent advice from a mental health nurse. We found that there was evidence that a thorough assessment had been carried out in which Mr C was meaningfully involved. We acknowledged that it was clear that leaving the house was anxiety-provoking for Mr C. However, it appeared that Mr C was resorting to managing his anxiety by displaying avoidant behaviour which generally serves to increase anxiety in the long term. We considered that the types of support offered to Mr C, including group and one-to-one sessions aimed at confidence building, were reasonable under the circumstances. We also found evidence that confirmed Mr C's participation in discussions about his care plan. Therefore, we did not uphold this aspect of Mr C's complaint.

In relation to complaints handling, the board accepted that there had been unacceptable delays caused by confusion around who was investigating the complaint. We found that the board had unreasonably classified Mr C's original complaint as a 'concern', when it should have been treated as a complaint. Even after it was classified correctly, the board took almost three months to respond to the complaint. We were also critical of the board's failure to send Mr C an application to access his medical records, despite him twice providing the information they had requested. Therefore, we upheld this aspect of Mr C's complaint.

Recommendations

In relation to complaints handling, we recommended:

• The board should have a system for keeping track of commitments made during a complaint investigation.
• An expression of dissatisfaction with the standard of service provided should be treated as a complaint.

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 advocacy and support agency, complained on behalf of her clients (Mr and Mrs A) who were kinship carers for their grandchild (Child B). Ms C complained that the partnership failed to conduct a kinship care assessment in line with their obligations and failed to provide a reasonable response to her complaint. Mr and Mrs A reported significant delays in a kinship care assessment being concluded and when their case was being prepared for approval, they were informed there was no legal basis for the placement of Child B and their case would not be passed to the kinship panel as they did not meet the criteria.

The partnership responded to the complaint and stated that they had acted appropriately as the placement of Child B with Mr and Mrs A had been a private arrangement. They said that Child B was not deemed to be a looked after child (a child in the care of a local authority) and, therefore, it was correct that Mr and Mrs A's case was not put before the kinship panel. Mr and Mrs A were unhappy with this response and Ms C brought their complaint to us.

We took independent advice from a social worker. We found that Child B was placed with Mr and Mrs A by the police, and social work later asked if they would continue to care for Child B. We found that Child B should have been assessed as being a looked after child. We also noted that the partnership took Mr and Mrs  A through a lengthy kinship care assessment process lasting 12 months, only to inform them that they did not meet the criteria based on information known from the beginning of the placement. Therefore, we upheld this aspect of Ms C's complaint.

In relation to complaint handling, we found that the quality of the partnerships response to Ms C's complaint was reasonable. We did not uphold this aspect of Ms C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr and Mrs A for failing to undertake a consistent and correct process regarding a kinship care assessment. The apology should meet the standards set out in theSPSO guidelines on apology available at https://www.spso.org.uk/leaflets-and-guidance.

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

• The partnership should ensure that staff reflect on and learn from the findings of this investigation. In particular, there should be training for staff to ensure they are clear on the process and legal obligations when working with kinship carers.

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 that the ambulance service delayed in sending an ambulance to her daughter (Miss A) when Miss A dislocated her knee. The ambulance took almost an hour to arrive, which the ambulance service acknowledged was much longer than they would have expected. They apologised for the delay and explained it was due to a lack of resource, and the need to prioritise life threatening situations.

We took independent advice from a paramedic. We found that the request was assessed and prioritised appropriately. We were satisfied that the ambulance service responded reasonably to the request, and could not have done anything differently with the resources available to them at the time. We did not uphold this complaint.

Mrs C also complained about the time taken to respond to her complaint; the lack of interim update which led to her having to chase for a response; and also the adequacy of the response in addressing her concerns. We were content that the response was a reasonable and proportionate response to Mrs C's complaint. However, we were critical that the ambulance service failed to adhere to the NHS Scotland Model Complaints Handling Procedure in that they did not issue their response within 20 working days, and did not proactively contact Mrs C in the interim to explain the delay and agree a revised response timescale. We upheld this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C for failing to adhere to the terms of the NHS Scotland Model Complaints Handling Procedure when dealing with her complaint. 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:

• SAS should adhere to the terms of the NHS Scotland Model Complaints Handling Procedure when dealing with complaints – complaints handling staff should be reminded of these terms and the findings of this investigation should be brought to their attention.

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 the board delayed in providing his late wife (Mrs A) with a diagnosis of pancreatic cancer. He said that, had Mrs A been diagnosed sooner, her care and treatment may have been different and she could have had a better quality of life. In their response to Mr C's complaint, the board acknowledged a delay in diagnosis and apologised, but they said that Mrs A's illness had been difficult to detect and that her symptoms had been vague. They said that their delay had not affected Mrs C's outcome.

We took independent advice from consultants in radiology (a doctor who uses medical imaging such as x-rays, ultrasounds and scans) and oncology (a specialist in the study and treatment of tumours). We found that, while Mrs A had three scans, it was not until after the third scan that her diagnosis was made. However, we confirmed that her symptoms had been subtle and that there could be up to a 20 percent failure rate in detection. We did not uphold the complaint. However, we made a recommendation as the delay had not been without consequences. Had Mrs A's illness been picked up earlier, then she would have had earlier access to palliative care (end of life care) which may have made her final months easier to bear. We considered that there had been an insufficient recognition of this.

Mr C also complained that the board delayed unreasonably in responding to his complaint. We found that the board had taken too long to respond to Mr C's complaint, and so we upheld this aspect of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for failing to recognise the consequences of the delay in Mrs A's diagnosis. The apology should meet the standards set out in SPSO guidelines on apology available at www.spso.org.uk/leaflets-and-guidance.
• Apologise to Mr C for failing to reply to the complaint in a timely manner. The apology should meet the standards set out in 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 board should follow their stated complaints procedures.