Some upheld, recommendations

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.

Summary

Mrs C complained on behalf of her client (Ms B) about the care and treatment provided to Ms B's late father (Mr A). Mr A suffered from heart problems and had a history of diabetes (a disease in which the body's ability to produce or respond to the hormone insulin is impaired) and a previous stroke. Over a period of about 18 months he had several hospital admissions and underwent two cardiac catheterisation procedures (where a tube is inserted into a blood vessel near the heart, to look at the condition of the blood vessels and/or insert a stent to widen them), but no stent was inserted. Doctors then referred Mr A for consideration of coronary bypass surgery (surgery to bypass a section of existing blood vessel that is narrowed with a graft). However, while he was waiting for review, Mr A suffered a further stroke and heart attack, and he died in hospital a few weeks after this. Mr A's family felt he should have been offered surgery earlier. They also raised concerns about the medical and nursing care during his admissions, and the board's response to their complaint.

The board considered the medical care and communication was reasonable. However, they agreed there were some failings in the nursing care for Mr A's pressure ulcers and they apologised for this and took action to prevent a recurrence.

We took independent medical, cardiology and nursing advice. We found that the overall management of Mr A's heart problems was reasonable, and it was appropriate that surgery was not offered earlier as this would have been a very high risk for Mr A (in view of his pre-existing conditions). We did not uphold this aspect of Mrs C's complaint. However, we found that there was no evidence Mr  A or his family were told about Mr A's heart attack for several days, and we made a recommendation in light of this finding.

We upheld the complaint about nursing care, as we found failings in relation to fluid monitoring, pressure ulcers, falls monitoring and communication with the family about Mr A's palliative care.

We also upheld the complaint about complaints handling, as there were errors in the board's complaint response, which appeared to be due to the medical records being misread.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr A's family for the delay in informing them about the heart attack, the failings in nursing care and communication, and the errors in the 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:

• Patients and/or family should be promptly updated about significant events, such as a heart attack, and a record made of the communication.
• Good palliative care should ensure a comfortable and peaceful time for the patients, with support for relevant others and person-centred communication.
• There should be clear handover communication between staff, to ensure all staff are aware of a patient's needs.
• Fluid balance charts should be completed for patients requiring fluid restriction.

In relation to complaints handling, we recommended:

• Complaint investigations should involve a careful and thorough review of the medical records, having particular regard to the points of complaint raised.

Summary

Mr C, who is an MSP, complained on behalf of his constituent (Mr A). He said that the board had failed to provide Mr A with reasonable care and treatment in Monklands Hospital. We took independent advice from a general medical adviser, a nursing adviser and from a consultant orthopaedic and trauma surgeon.

Firstly, Mr C complained that the board had unreasonably discharged Mr A with a bacterial infection and that he then had to be readmitted to hospital. We found that Mr A's discharge had been reasonable, as his symptoms appeared to be acceptably controlled at that time on oral medication; he had been appropriately reviewed; and no concerns about his discharge were raised. The blood tests results showing the infection did not become available until after he was discharged. We did not uphold this complaint.

Mr C also complained that staff failed to prevent Mr A falling on two occasions when he was readmitted to hospital. We found that there had been a failure to complete and document a falls risk assessment when Mr A was admitted in line with standards of care for older people in hospital. There was also a failure to document communication with the family. We upheld this complaint.

Mr A also complained that staff delayed in obtaining an X-ray after Mr A's falls. We found that an X-ray had not been clinically indicated after the first fall. An X- ray was then obtained after the second fall. On balance, we did not uphold this complaint.

Mr C also complained that staff had given Mr A too much morphine (a medication for pain relief). We found that the approach to this and the doses prescribed had been reasonable. We did not uphold this complaint.

Mr C also complained that staff failed to follow-up Mr A's care after his discharge from hospital. We found that, although an interim discharge letter was issued, a follow-up discharge summary was not issued. There was also insufficient information about how Mr A's hypertension (abnormally high blood pressure) was to be followed up. We upheld this complaint.

Finally, Mr C complained that the board had unreasonably prescribed an antiepileptic drug to Mr A beyond the maximum of ten years. There is no guidance that states it should not be prescribed for more than ten years and there was no clear evidence that this had caused Mr A's health problems. We did not uphold this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr A for the failure to complete an appropriate risk assessment to prevent falls when he was admitted to hospital and to appropriately document communication with Mr A's family. 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:

• Risk assessment and care planning in relation to falls prevention should be carried out in line with guidance and policy, when the patient is admitted to hospital.
• Nursing staff should involve patients and families in care planning where appropriate and should keep clear records of conversations with families/carers using the relevant documents.

Summary

Ms C complained about the treatment which she received at Peterhead Hospital and Aberdeen Royal Infirmary. Ms C had been treated for heart issues although she had not been reviewed by a cardiologist (a doctor who specialises in disorders of the heart). Ms C was subsequently admitted to hospital on two occasions where the medication for her heart issues was continued. Ms C sought a private opinion which found that she did not have a heart problem and her medication was withdrawn. As a result of the medication withdrawal, Ms C's health improved. Ms C complained that she was unreasonably prescribed heart medication and that this medication was not kept under regular review.

We took independent advice from a consultant cardiologist. We found that it was appropriate for Ms C to have been treated for suspected angina (chest pains) in view of her presenting symptoms. We considered the prescription of heart medication to be appropriate and did not uphold this aspect of Ms C's complaint.

However, there was a failure to keep Ms C under review pending the outcome of further out-patient cardiology investigations which may have identified that she was suffering from potential side effects of the medication. There was an incident on discharge from hospital that Ms C had been prescribed two calcium channel blockers (medication to relax and widen the blood vessels) which was inappropriate, although it was unlikely that harm was caused due to the low dosages involved. We also found that there were failings in record-keeping regarding discussions with cardiology staff and that it would have been advisable that Ms C should have been physically examined by a consultant cardiologist. We considered that the board failed to keep Ms C's medication under review and upheld this aspect of her complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms C for the failure to keep her under review pending the outcome of further out-patient cardiology investigations. The apology should meet the standards set out in the SPSO guidelines on apology available at https://www.spso.org.uk/leaflets-and-guidance.
• Apologise to Ms C for the failure to recognise that she had been discharged from hospital while on two types of calcium channel blocking medication. 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 be aware to keep patients under review pending the outcome of further out-patient cardiology investigations.
• Pharmacy and ward staff should be aware that when patients are discharged from hospital that their medication is appropriate.

Summary

Mr C complained on behalf of his late grandmother (Mrs A) about the care and treatment she received at Aberdeen Royal Infirmary (ARI) and Kincardine Community Hospital (KCH).

Mrs A suffered from severe pain in her back and a suspected chest infection. She was referred by her GP to ARI, discharged on day five and then re-admitted to KCH ten days later. Mrs A was transferred back to ARI over a month later, and then back to KCH, where she later died.

Mr C complained that the board failed to provide a reasonable standard of medical care and treatment, failed to provide a reasonable standard of nursing care and failed to handle his complaint appropriately.

Regarding medical care, Mr C complained about Mrs A's pain management and a lack of communication around her treatment. We took independent advice from a consultant geriatrician (a doctor who specialises in medicine of the elderly). We found that Mrs A did not receive sufficient attention for her pain relief requirements. We found that this was an issue that could have been easily avoided, and one that caused Mrs A pain and the need for readmission. We also found that there was a lack of consideration for Mrs A's decision-making capacity regarding an operation that she underwent, and that there was a failure to discuss her care with Mr C and the family at this time. We upheld this aspect of the complaint.

With regards to nursing care, we took independent advice from a nursing adviser. We found that, while the communication did not meet Mr C's family's needs for specific periods of time, there was no evidence in the nursing records to indicate that the overall level of nursing care Mrs A received was unreasonable. We did not uphold this part of the complaint.

Lastly, regarding the board's handling of Mr C's complaint, we found that the board had apologised to Mr C for a delay in handling his complaint. However, we were concerned that, having given Mr C a revised timescale for providing a response, this was not then met and the board were not proactive about keeping him advised about the subsequent process of his complaint. We were also concerned that the complaint response appeared to be incomplete and did not address all of the questions Mr C raised. We upheld this aspect of Mr C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C and his family for the failure to provide Mrs A with sufficient attention for her pain relief and for the failure to adequately communicate with Mr C and his family about Mrs A's pain and its management. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/leaflets-and-guidance.

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

• Patients' pain relief needs should be fully assessed at the time of discharge from hospital. The management of a patient's pain after discharge should be fully discussed with patients and their families.
• Where a patient lacks decision-making capacity, their mental health should be respected and their care discussed with their family.

In relation to complaints handling, we recommended:

• Communication about revised complaint response timescales should be accurate and further contact should be made if it emerges that the revised timescale is not achievable. Responses to complaints should be accurate and address all the issues raised.

Summary

Mrs C complained about the care and treatment provided to her late husband (Mr  A) by the urology service (the service which deals with the male and female urinary-tract system and the male reproductive organs) at Victoria Hospital. Mr  A had a diagnosis of metastatic prostate cancer (prostate cancer that had spread to his bones) and had been reviewed roughly every three months by prostate cancer nurse specialists. Mr A received hormone therapy injections and his PSA (prostate specific antigen - a protein produced by normal cells in the prostate and also by prostate cancer cells) levels were measured to monitor his disease.

Over two years following his diagnosis, Mr A experienced back pain and he had a number of consultations with his GP. After Mr A's condition did not improve, the GP made a referral to the urology service to request urgent investigation. The urology service received the referral one day later and then made a referral to the radiology department to request a scan. A week passed following the initial GP referral, and by this time Mr A was struggling to move. Mr A was then admitted to hospital and a scan was performed. This indicated that he had a spinal fracture and cord compression from metastatic cancer. As a result of his condition, Mr A became paralysed below the waist.

Mrs C complained that the urology service did not carry out scans following Mr  A's diagnosis, even though it was known that the cancer had already spread to his bones. We took independent advice from a consultant radiologist (a doctor who specialises in diagnosing and treating disease and injury through the use of medical imaging techniques such as x-rays and other scans) and a consultant oncologist (a doctor who specialises in cancer). We found that it was reasonable for the board to monitor Mr A's prostate cancer using PSA testing and not with routine scans. We did not uphold this complaint. However, we noted that the board had failed to respond to this part of Mrs C's complaint and had not handled a request for a meeting about this appropriately.

Mrs C also complained that there was an unreasonable delay in arranging a scan when Mr A's condition began to deteriorate. The board acknowledged that there were issues with how the urology service made the referral for a scan and also how it was handled by the radiology department. The board provided us with details of a process improvement that aimed to help avoid delays in future. However, we found that the referral from the urology service was made using the incorrect pathway. We concluded that the Malignant Spinal Cord Compression Pathway should have been used, which would have resulted in a scan within 24 hours of the referral. We concluded that if this had happened, Mr A would have had an improved chance of receiving treatment to maintain mobility. We informed the board of this finding and asked them to consider what action would effectively reduce the chance of the issue reoccurring. We upheld this complaint and made a recommendation. We also asked for evidence of the actions the board had already said they were taking or planned to take.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C for the delay in arranging a scan when Mr A's condition deteriorated; not fully responding to all the points Mrs C raised in her complaint; and not responding to Mrs C's request for a meeting appropriately.The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/leaflets-and-guidance.