Some upheld, recommendations

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.

Summary

Mr C complained to the council, on behalf of his sister (Ms A), about the company that the council contracted to provide her care. Mr C said that they inappropriately charged her for Personal Protective Equipment (PPE) for staff, that they had failed to evidence that Ms A received a warm home discount each year and had unreasonably failed to calculate and refund costs associated with the use of Ms A's phone by staff. Mr C also complained that the council failed to provide a reasonable response to his enquiries. The council confirmed that a refund was being looked into regarding the PPE and that a refund had been issued for one year of phone bills, with five years in total to be assessed. This remained unresolved and Mr C brought his complaint to us.

The council advised a different care provider was contracted for the first two years of care. They did not have evidence of the phone bills or PPE for that period as the company in question has since ceased to exist. The council have since provided Ms A with a refund for three years for the PPE. They provided three years of phone bills but did not offer to issue a further refund in this regard. We considered that the council unreasonably failed to calculate and refund costs for the PPE and use of Ms A's phone by staff. We upheld these aspects of Mr C's complaint and asked the council to examine the full five years in question.

In relation to the warm home discount, the council were able to evidence that Ms A had correctly received this. We did not uphold this aspect of Mr C's complaint.

Finally, we considered that the council had failed to provide a reasonable response to Mr C's enquiries. We noted that the company providing care to Ms A delayed in their response to the council but considered that the delay in responding to his enquiries was unacceptable. 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 process the appropriate refunds for PPE and phone bills to Ms A; for failing to provide him with information in relation to this; and for the unacceptable delay in responding to his enquiries and complaints. The apology should meet the standards set out in the SPSO guidelines on apology available at https://www.spso.org.uk/leaflets-and-guidance.
• The organisation should calculate the PPE and phone bill refunds for five years, evidence this, and refund Ms A accordingly. If information is not available, the council should explain how any estimate has been determined.

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

• Evidence that there is a clear process in place when the council is seeking evidence from a contracted company to prevent future delays of this nature.

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

Miss C suffered ongoing complex urological problems (problems relating to the urinary tract, bladder or kidneys), and underwent a dilation and cystoscopy procedure (a procedure to look inside the bladder and stretch the urinary opening) at Ninewells Hospital. During the procedure biopsies (samples of tissue) were taken. Miss C complained about the medical and nursing care during this procedure, which she found very painful and distressing. Miss C also complained about her medical care following the procedure, and that it took several months for the board to refer on to a urological specialist in another board area after she requested this.

Medical and nursing staff met with Miss C to discuss her concerns. The board apologised for some aspects of the nursing care, and said the day-of-surgery admission pathway had not been suitable for Miss C, as it could not provide much of the support she required. Miss C was not satisfied with this response, and she brought her complaint to us.

We took independent advice from a consultant urologist and a nurse. We found that most of the medical care Miss C received was reasonable. However, the operation note was not sufficiently detailed to show why it was necessary to take biopsies, which caused Miss C post-operative pain. We upheld this aspect of Miss C's complaint.

In relation to the nursing care, we noted that the board had acknowledged certain aspects of care were staff could have acted differently and had taken action to discuss Miss C's concerns with staff. We considered these actions to be reasonable and found that the nursing care Miss C received was appropriate. We did not uphold this aspect of Miss C's complaint.

Finally, we found that there was a delay in referring Miss C to a specialist. We noted that some of the delay was due to her requiring urgent hospital admission in this period; however, part of the delay was due to a lack of cover arrangements during an unexpected staff absence. We upheld this aspect of Miss C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Miss C for the delay in referring her to a specialist and for the failure to document why the biopsies were necessary. 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:

• Operation notes should include sufficient detail to explain the clinical decisions taken during the operation.

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 is a patient adviser, complained on behalf of her client (Mr B), who was unhappy about the care and treatment provided to his mother (Mrs A) at Hairmyres Hospital. Mrs A experienced a stroke and was assessed in the emergency department before being transferred to a medical ward. A week following her admission to the ward, Mrs A was admitted to a specialist stroke ward. Soon after the transfer, she experienced a further stroke and died a number of days later.

Mr B complained that there had been a delay in assessing and treating Mrs A in the accident and emergency department. We took independent advice from a consultant geriatrician (a doctor who specialises in medicine of the elderly) with experience in stroke care. We found that the records showed that Mrs A was assessed almost immediately following admission and that a scan was arranged promptly. We did not find evidence that there was an unreasonable delay in assessing and treating Mrs A, and we did not uphold this part of Ms C's complaint.

Mr B was also concerned about the care provided on the medical ward. We found that the board had apologised to Mr B for the delay in transferring Mrs A to a stroke ward. We considered that it was unreasonable that Mrs A was not transferred to a stroke ward sooner. While we considered that the general medical care provided was reasonable, we were critical that Mrs A did not receive the benefit of specialist stroke unit care sooner. We upheld this aspect of the complaint.

Finally, Mr B was unhappy with the level of communication with the family. We found limited evidence of staff communicating with the family in the period following Mrs A's admission and prior to her deterioration. We, therefore, upheld this aspect of Ms C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr B and his family for the lack of communication in the period following Mrs A's admission and prior to her deterioration. 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:

• Stroke patients requiring admission to hospital should be admitted promptly to a stroke unit staffed by a co-ordinated multi-disciplinary team with a special interest in stroke care, in accordance with Scottish Clinical Guidelines.
• Medical staff should be mindful of the needs of family members/ significant others of the patient, as described in Scottish Clinical Guidelines, and ensure that there is adequate communication.

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 at Wishaw General Hospital (WGH) when he attended the emergency department after falling at home and injuring his lower back. Mr C was concerned that he was discharged home without having had an x-ray. He was also dissatisfied about the in-patient hospital care he received after being admitted to hospital two days later at which time an x-ray confirmed a spinal fracture. Mr C was unhappy about delays in transferring him to a different hospital spinal unit and being informed that he had a second spinal fracture.

We took independent advice from a consultant in emergency medicine and a consultant orthopaedic surgeon (a specialist concerned with the musculoskeletal system). In relation to the care Mr C received in the emergency department, we considered that the decision not to do an x-ray and the delay in diagnosis were reasonable given that a number of factors made this type of injury unlikely in Mr C's case. Therefore, we did not uphold this aspect of Mr C's complaint.

In relation to the orthopaedic care received, the board acknowledged that it would have been appropriate to have discussed Mr C's case again with the spinal unit of another hospital. We found that there was a lack of communication with Mr C in relation to his second fracture and that a more senior discussion with the spinal unit may have led to more timely transfer. Therefore, we upheld this aspect of Mr C's complaint. However, we noted that these issues were unlikely to have influenced his subsequent treatment.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for the failings in communication regarding his second fracture. 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 should be informed of relevant test results and this should be fully 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

Mrs C complained to us on behalf of her late sister (Ms A). Ms A had cancer and was receiving radiotherapy treatment (a treatment using high-energy radiation) in hospital. Mrs C complained that there was an unreasonable delay in providing Ms A with radiotherapy treatment and Mrs C felt that Ms A should have been prioritised due to her pain levels. Mrs C also complained that the board did not investigate her complaint reasonably.

We took independent advice from a consultant oncologist (a doctor who specialises in cancer treatment). We did not find that there was an unreasonable delay in providing Mrs A with treatment. The adviser commented that it is not routine practice to prioritise patients' scans or treatment slots based on symptoms. We also considered that the board took reasonable steps to manage Ms A's pain whilst in the hospital, as she had been provided with pain relief medication during her admission. We did not uphold this aspect of the complaint.

Regarding complaints handling, we were unable to definitively assess how accurate or inaccurate the board's response to Mrs C's complaint was as they could not provide us with evidence on Ms A's admission timings. The board, therefore, failed to demonstrate that their response to Mrs C's complaint was evidence-based and we upheld this aspect of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C for not investigating her complaint reasonably. The apology should meet the standards set out in the SPSO guidelines on apology available at https://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.