Some upheld, recommendations

Summary

Ms C attended an antenatal screening which tested for Down's syndrome before the birth of her child (Child A) and it was determined that she was at low risk to have a child with this condition. Following the birth, Child A was diagnosed with Down's syndrome. Ms C said that the board's communication with her about Down's syndrome, before and after the birth was unreasonable.

During the pregnancy, an ultrasound scan confirmed Child A had a hole in their heart. Child A died a few months after birth and Ms C complained that the board had unreasonably failed to diagnose, discuss and treat Child A's heart condition and breathing problems.

We took independent advice from a midwife and consultants in cardiology, emergency medicine and neonatology. We found that, before the birth of Child A, Ms C was given reasonable information about the Down's symdrome screening process but after their diagnosis there was little evidence of what had been said and discussed. There was no record of the conversation telling Ms C about Child A's diagnosis and the immediate plan for them. We upheld this aspect of Ms C's complaint.

In relation to Child A's heart condition and breathing problems, we confirmed that there are limitations in the antenatal screening process, with screening identifying only half the number of heart defects. We found that Child A's heart and breathing problems had been reasonably diagnosed and treated but that there were also lung problems which could have not been predicted. We did not uphold this aspect of Ms C's complaint.

Recommendations

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

• Full records require to be maintained and available for a clinical audit trail and scrutiny.

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 provided to his late mother (Mrs A) at Monklands Hospital. In particular, he complained that Mrs A had been inappropriately discharged. He also complained that the board's communication about Mrs A's positive Methicillin-resistant Staphylococcus aureus (MRSA, a strain of antibiotic-resistant bacteria) result was unreasonable.

We took independent advice from a consultant in acute medicine and a nurse. Regarding Mrs A's discharge, we found that she had been fit for discharge and that the discharge planning for her had been reasonable. We also found that Mrs A's nutritional care had been reasonable. Therefore, we did not uphold this aspect of Mr C's complaint.

In relation to the communication about the positive MRSA result, we found that the level of communication with Mr C and his family had been unreasonable and that the board had failed to follow their policy for the control and management of patients colonised or infected with MRSA. We also noted that the board had accepted and apologised for the breakdown in communication in relation to the MRSA result. We upheld this aspect of Mr C's complaint.

Recommendations

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

• The policy for the control and management of patients colonised or infected with MRSA should be adhered to. In particular, the patient/relative should be informed about a positive result, given a copy of a MRSA patient information leaflet and that this should be documented in the medical records.

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 provided to him at the Queen Elizabeth University Hospital. Mr C had suffered visual disturbance and had attended the Emergency Department (ED). He was assessed and discharged as there were no abnormal findings. The following day, Mr C attended the ED again as he again was suffering from visual disturbance, and also had some leg numbness. Clinical examination was again normal and he was discharged. Later that day, Mr C attended the ED again with new symptoms of facial muscle weakness. He was admitted for further investigation and was found to have suffered a stroke. Mr C complained that it took three attendances for him to be diagnosed and he felt that if he had been given treatment on his first attendance the visual loss which he subsequently suffered would have been prevented.

We took independent advice from a consultant in emergency medicine and from a consultant stroke physician. We found that, whilst the overall standard of Mr C's care and treatment was reasonable, on his second attendance the possibility of transient ischaemic attack (a ‘mini stroke’ caused by temporary disruption of blood supply to the brain) should have been considered. We, therefore, upheld this aspect of Mr C's complaint.

Mr C also complained that he had not received appropriate follow-up. We found that follow-up was of a reasonable standard and, therefore, did not uphold this aspect of Mr C's complaint.

Finally, Mr C complained that the board failed to respond to his complaint in a timely manner. We found that the board had taken well over 20 working days to respond to his complaint, and had failed to keep him updated about the delays. 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 the failure to consider the possibility that he had suffered a transient ischaemic attack. 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:

• In similar circumstances, a differential diagnosis of transient ischaemic attack should be considered.

In relation to complaints handling, we recommended:

• Where a complaint response takes more than 20 working days, the board should explain the reasons for the delay and agree a new timeframe.

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, an advocacy worker, complained on behalf of her client (Mrs B). Mrs B was concerned about the care and treatment her husband (Mr A) received during his admission to Queen Elizabeth Hospital. Mr A had suffered a broken neck in an accident and he was being treated with a neck brace. Ms C's main concern related to Mr A swallowing his dental plate and explained that this was not discovered for almost two weeks even though Mr A had a sore throat and difficulties swallowing. Ms C also complained about the nursing care and that there was inadequate communication with Mr A's family. In particular, when his condition deteriorated and he was thought to have sepsis (a blood infection). Finally, Ms C complained that the board's handling of the complaint was unreasonable and that no significant clinical incident review was carried out.

We took independent advice from a consultant orthopaedic trauma surgeon (a surgeon who diagnoses and treats a wide range of conditions of the musculoskeletal system) and a registered nurse. The board considered that swallowing a dental plate was a very unusual occurrence so it was reasonable this was not suspected by hospital staff. We found that the medical treatment initially received for Mr A's swallowing and eating difficulties was appropriate. However, we found there was an unreasonable delay in referring Mr A to ear, nose and throat and this delayed the discovery of his swallowed dental plate. We upheld this aspect of Ms C's complaint.

In relation to the nursing care received, we found that Mr A was given a reasonable level of personal care and his food input and fluid intake was appropriately monitored by staff. We noted that nursing staff recognised Mr A's difficulties swallowing and eating and made appropriate referrals. Therefore, we did not uphold this aspect of Ms C's complaint.

In relation to communication, we found that communication with Mr A's family was not to the appropriate standard. We upheld this aspect of Ms C's complaint. However, we noted that the board had acknowledged this failing and had apologised to Mrs B.

Finally, we found that the board failed to commmunicate clearly about meeting to discuss the complaint or about the significant clinical review and it's findings. We upheld this aspect of Ms C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs A for the delay in making the referral to ear, nose and throat; and for the failings in their communication about meeting with her and about the significant clinical incident review. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/leaflets-and-guidance.
• Provide Mr A's family with a copy of the significant clinical incident review.

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

• Ensure there is appropriate communication with patients and/or their families during, and at the conclusion of, significant clinical incident reviews.

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 on behalf of his wife (Mrs A) about the care and treatment she received at the Royal Alexandra Hospital. Mrs A experienced a traumatic birth when problems with the fetal heart occurred and an emergency caesarean section was required. Mr C complained that both the obstetrics (the field of medicine concerned with pregnancy, childbrith and the post-birth period) and midwifery care was unreasonable.

We took independent advice from a consultant obstetrician and from a midwife. We found that consideration could have been given by the obstetric staff to the possibility that the drug terbutaline (medication to stop uterine contractions) could have resulted in improvement in the fetal heart rate. We also noted that there was insufficient evidence to show that a thorough debrief of the birth took place with Mrs A. However, we found that the overall obstetric care during Mrs A's admission was appropriate and that the problems with the fetal heart rate were promptly recognised, with timely action being taken to deliver the baby in line with national guidance. We did not uphold this aspect of Mr C's complaint but made recommendations to the board in light of the failings identified.

In relation to the midwifery care Mrs A received, we found that there was a lack of evidence to show what action had been taken when it was recorded that she was in discomfort when being triaged around the time of admission to hospital. There were also insufficient records to show that Mrs A had been kept informed about the baby's progress while in the special care baby unit; however, we noted that the board had apologised for this failing. We also found that there was poor record-keeping to demonstrate what information had been shared with Mrs A when she was discharged from hospital, particularly in relation to advice regarding self-administration of blood thinning medication and advice regarding breastfeeding given she had experienced problems during her admission. We were also critical of the lack of evidence to show what information had been shared with the community midwifery team at the time of discharge. Finally, we considered that there was no evidence of assessment or support of Mrs A's psychological needs during her admission. Therefore, we upheld this aspect of Mr C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise for the failings in addressing Mrs A’s discomfort and psychological needs, the lack of information given to her, and the community midwives, on discharge and for the failings in record-keeping. 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:

• Where appropriate for patients in labour, consideration could be given to the administration of terbutaline, in accordance with national guidance.
• In a similar situation patients should be adequately debriefed and this should be properly recorded in the medical notes.
• Patients should be properly advised on any discharge medication and this should be properly documented in the medical notes.
• Midwifery patients should receive appropriate assessment of their needs, including any psychological needs, during admission which should be appropriately planned and documented.
• Midwifery patients should have their pain/discomfort suitably assessed and acted on when in triage.
• In a similar situation midwifery patients should receive detailed information in relation to the care and treatment of their baby and this should be properly recorded in the midwifery notes.
• Midwifery patients and community midwives (on handover) should receive adequate information on their care and treatment on discharge. This should include the discharge plan for women and babies leaving hospital, that each woman has received a copy of Ready Steady Baby, that there has been an effective handover between the hospital and community midwifery staff, and the guidance and support given to women having difficulties breastfeeding.

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 provided to her late husband (Mr A) at Victoria Hospital. Mr A attended the emergency department on two occasions as he was experiencing blood in his urine and was having difficulty passing urine. Following a urology (the area of medicine which specialises in the urinary tract and the male reproductive system) referral and investigation, Mr A was diagnosed with bladder cancer. Mrs C complained that that the care provided to Mr A in the emergency department was unreasonable, that there had been unreasonable delays in his subsequent care which meant his treatment options were limited and that the nursing care provided during later admission was unreasonable.

We took independent advice from an emergency medicine consultant, a consultant urologist and a nurse. We found that the care Mr A received in the emergency department was reasonable and we did not uphold this aspect of Mrs C's complaint. In relation to the delays, we found that there had been an unreasonable delay in providing Mr A with appropriate information about the plan for his out-patient care. We upheld this aspect of Mrs C complaint; however, we found that Mr A's prognosis was unaffected by this failure. Finally, we considered that there had been inadequate care planning for Mr A. The nursing adviser was unable to form a reasonable picture of Mr A's needs from the records provided which was unreasonable. We noted that the board had already acknowledged failings in connection with the nursing care. We upheld this aspect of Mrs C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr A for the delay in providing appropriate information on the plan for out-patient investigation of his symptoms. 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:

• Appropriate care should be provided and this should be clearly evidenced in the nursing notes.
• Staff caring for patients like Mr A should have access to detailed information needed to ensure care is individualised and tailored to their needs.

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, who is a transgender man, complained to us that a GP practice that he was about to register with had discussed his transgender status before he had even registered there. We took independent advice on the complaint from an equalities adviser. We found that, under the Gender Recognition (Disclosure of Information) (Scotland) Order 2005, the practice should have sought consent from Mr C before discussing his transgender status. We upheld this aspect of his complaint.

Mr C also complained that a GP from the practice withdrew the offer of a meeting prior to his registration at the practice. The practice confirmed to us that they did originally agree to a meeting, but this offer was withdrawn when Mr C’s previous GP said that this might take approximately 40 minutes. We considered that ideally the practice should have been able to meet Mr C before he joined the practice. However, we did not consider that their actions in cancelling this meeting were unreasonable. On balance, we did not uphold this aspect of Mr C’s complaint.

Mr C complained that the practice had logged his address incorrectly. We found that his address had been recorded incorrectly on the practice’s computer system and upheld the complaint. However, we considered that the explanation provided by the practice about this had been reasonable. In addition, they had apologised for the error.

Mr C also complained that the practice had failed to provide him with a reasonable standard of care, as they had told him that he was not able to have a flu vaccine, despite the fact he had ME (Myalgic Encephalopathy) / Chronic Fatigue Syndrome. We took independent advice on this complaint from a GP adviser. We found that the actions of the practice in relation to this matter 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 discussing his transgender status without his consent, prior to his registration at the practice. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/leaflets-and-guidance.

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

Summary

Mr C, who is a transgender man, complained to us that an NHS board had failed to remove his female Community Heath Index number (CHI - a ten digit number that identifies a patient in the NHS in Scotland) from their database. Mr C had previously been allocated a male CHI number. Overall responsibility for CHI numbers lies with NHS National Services Scotland. We did not consider that there had been any failings by the board in relation to this matter and we did not uphold this part of the complaint.

That said, we found that the board should not have used Mr C’s old female CHI number to record his screening results on a national screening database. We upheld his complaint about this. In order for Mr C’s results to be recorded on the screening database, and to prevent this happening again, NHS National Services Scotland allocated Mr C a new male CHI number that could be used on the national screening database. However, Mr C subsequently told them that he wanted to retain his original male CHI number. In view of this, we made a recommendation to the board about this matter.

Mr C also made complaints that a laboratory and a screening service from the board had disclosed his transgender status without his permission. We found that, under the Gender Recognition Act and the Gender Recognition (Disclosure of Information) (Scotland) Order 2005, Mr C’s transgender status should not have been disclosed without his permission. We upheld these aspects of his complaint, although we noted that the board had apologised for this.

Finally, Mr C complained that the board’s responses to his complaint had been unreasonable. We found that the letters issued by the board had been a reasonable response to the issues Mr C had raised. We did not uphold this aspect of his complaint.

Recommendations

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

• Given that Mr C has stated that he wishes to retain his old male CHI number and this was agreed with NHS National Services Scotland, the board should consider if a separate protocol (which includes guidance for staff on sharing information about transgender patients) is required for him to prevent these problems recurring.

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, who is an MSP, made a complaint about Business Stream on behalf of her constituent (Mr A). Mrs C complained that plans which Business Stream prepared for a new water and sewerage connection were not accurate. Mr A said that his contractor had to undertake additional work as a result of concrete surrounding the pipework and that this resulted in an increased bill for Mr A. Mrs C considered that Business Stream should be liable for these costs. Mrs C was also unhappy about the time taken by Business Stream to respond to the complaint.

Business Stream advised us that the purpose of the drawings was to allow Scottish Water to make an informed judgement as to whether a connection could be granted; it is stated on the drawings that they are created on approximate information and that no guarantee of accuracy can be given. Given this, Business Stream stated that any contractor providing a quote for prospective work should undertake an investigation prior to proposing the cost of work. Business Stream acknowledged that the layout of the pipework was different than expected but stated that, despite some additional difficulties, they understood that the contractor completed the work. They were unsure why the costs had increased but speculated that this was because the contractor opted to drill through the concrete rather than follow an approach that the inspector had suggested.

We noted that Business Stream provided documentation to Mr A prior to the creation of the plans which he was charged for. This documentation stated that plans were a "best estimate of work" and that the existing location of water and sewer mains were unknown and therefore all lengths "will be assumed at this stage"

Based on the above information, we considered the potential for the plans to be inaccurate was outlined to Mr A prior to the plans being drawn up and work commencing. No further charges were raised by Business Stream when it was identified that the pipework was different from the plans. The only additional cost to Mr A arose from the invoice from his contractor. We did not uphold this aspect of the complaint.

Regarding complaints handling, we found that Mrs C submitted the complaint to Business Stream but did not receive a final response for many months. There was no evidence to suggest that Business Stream had identified that it was going to take longer to respond to the complaint or that they had proposed an extended deadline. We also held concerns that, in addition to the excessive delays in responding to Mrs Cs's complaint, Business Stream continued to fail to meet deadlines to respond to enquiries from this office. We also noted that complaint responses did not include reference to SPSO as the next stage available in the process. Moreover, Business Stream seemed to be under the impression that as long as they continued to update Mrs C within a 20 working day timescale then it was acceptable to continue to delay providing a substantive response to the complaint. We upheld this aspect of Mrs C's complaint.

We noted that Business Stream had apologised for the delays, but we did not consider that this was commensurate with the excessive nature of the delays. We asked Business Stream to consider their position on this further and they agreed to credit a further £100.00 credit to Mr A's outstanding balance. We also made some recommendations.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C for the unacceptable delay in responding to her complaint. The apology should meet the standards set out in the SPSO guidelines on apology available at https://www.spso.org.uk/leaflets-and-guidance.

In relation to complaints handling, we recommended:

• Business Stream should ensure that all complaints handling staff are familiar with the complaints handling procedure, and identify and address any training needs. If a complaints response takes more than 20 working days, Business Stream should explain the reasons for the delay and agree a new timeframe. This should be the exception, not the norm.

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 is an adviser to Ms A. Ms A was a looked after child by the council in a foster care placement, which ended with short notice. At the time the council advised Ms A that she should present as homeless in order to secure accommodation.

Ms C complained that the council failed to provide the required support and aftercare to Ms A as a looked after child, and that they wrongly used homelessness legislation in order to secure accommodation for Ms A. Ms C also complained about the council's handling of the complaint. Ms C said that the council failed to provide a response to the complaint within the agreed extended timescale and she also questioned the impartiality of the investigating officer.

We took independent advice from a social worker. While the council acknowledged that they failed to provide consistent support to Ms A, we did not consider that the council adequately acknowledged their failings. We identified that the council missed a number of opportunities to plan proactively for Ms A leaving care, that they wrongly advised Ms A to present as homeless and that they failed to evidence the after-care support they provided. We upheld this aspect of the complaint.

With regards to the council's handling of Ms C's complaint, we found that the investigating officer appointed was suitably impartial, and that they took steps to ensure they took into account Ms A's views. However, we recognise they failed to respond within the agreed timescale. On balance, we did not uphold this aspect of the complaint.

Recommendations

What we asked the organisation to do in this case:

• The council should update the Pathway Plan and provide clear information on what Ms A's eligible needs are and details of how they will provide the advice and assistance they consider necessary to meet those eligible needs.
• The council should apologise for failing to involve Ms A in discussions about her future, for failing to provide the required support and aftercare and for failing to respond to Ms C's complaint within the agreed timescale. The apology should meet the sta

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

• The council should carry out an audit of young people under their care that are due to leave their care placement in the next 12 months. They should ensure that the appropriate assessments and plans are in place to support these young people when they lea
• The council should take the necessary steps to ensure that the principles of involving young people in discussions about their future arrangements are fully established and embedded within the practice of the social work department and consider whether fu
• Proper records should be kept of the advice and support their staff have provided to their clients.

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.