Some upheld, recommendations

Summary

Mrs C complained on behalf of her child (Child A) about the care and treatment they received at the Royal Edinburgh Hospital. Child A was admitted to hospital and diagnosed with a severe depressive episode and suicidal thoughts. Child A remained in hospital some months, and mental health staff consulted with social work about alternative accommodation (as it was not appropriate for Child A to return to the family home at that time). However, Child A's behaviour became increasingly violent, and Child A was discharged with a few days' notice to social work staff, who arranged accommodation at a young people's centre. Child A ran away from the centre threatening to harm themselves on several occasions, and had to be detained by the police. Child A was then transferred to secure accommodation, where they remained for several months.

Mrs C complained that the board inappropriately discharged Child A without ensuring adequate arrangements were in place for their safety and welfare. We took independent advice from a psychiatrist and found Child A's discharge to be unreasonable. We found that the discharge decision was made at short notice, without adequate planning for Child A's future accomodation and follow up care. We were also critical that a psychiatrist at the hospital instructed other staff not to detain Child A under the Mental Health Act if they returned to hospital. The adviser noted that detention under this Act is an important option to protect people who are a risk to themselves or others, and it was unreasonable for staff to try and remove the availability of this protection. Therefore, we upheld this aspect of Mrs C's complaint.

Mrs C also complained that the board used different diagnostic labels at different times to influence the management of Child A's care. We found that a mixture of diagnostic labels were used during Child A's admission, and it was not clear that a structured approach was used to formulate a diagnosis. However, we did not find that staff used these labels for the purpose of influencing the management of Child A's care. We did not uphold this aspect of Mrs C's complaint. However, we made recommendations to the board in relation to the use of different diagnostic labels.

Mrs C also felt that communication with her in relation to Child A's different diagnoses was poor. We found that the board had failed to respond to specific questions raised by Mrs C in a letter and could not explain why these had not been answered. We upheld this aspect of Mrs C's complaint.

Finally, Mrs C complained that the board failed to keep clear and accurate medical records. We found that the board's record-keeping was reasonable and that Child A's discharge letter contained sufficient information. We did not uphold this aspect of Mrs C's complaint. However, the adviser noted that some records were unclear and that several emails had not been recorded. While we did not uphold this complaint, we made recommendations to the board in relation to improvements in record-keeping.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Child A and their family for unreasonably discharging Child A (with inappropriate instructions not to re-detain them under the Mental  Health Act), for the lack of clarity in diagnostic terms used, and for failing to respond to the questions Mrs C raised in her letter. 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:

• Child and Adolescent Mental Health Service (CAMHS) patients should not be discharged without safe accommodation and adequate support in place, with specific follow-up plans in place and explained to the patient and their family in advance.
• A diagnosis should be clearly formulated based on symptoms reported and observed. Diagnoses (including provisional and differential diagnoses) should use an accepted diagnostic system (usually International Classification of Diseases (ICD-10)).
• Detention under the Mental Health Act should be available as an option to protect people when they are a risk to themselves or others. Staff should not try to remove the availability of this protection for a patient.
• Medical records should include all records relevant to the admission (including emails) and entries should clearly identify the author and their role.

In relation to complaints handling, we recommended:

• Responses to complaints should address the points raised (or explain why information cannot be provided).

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

The Scottish Environment Protection Agency (SEPA) stopped Mr C's shipping container for inspection. Mr C complained about the amount of time it took SEPA to release the hold on the container and the amount of time it took SEPA to arrange a further inspection. Mr C also complained that SEPA did not communicate reasonably.

We found that, during the period that the hold was on the container, SEPA were undertaking investigations to establish if the container could be returned to Mr  C's load site, and to establish if it was safe for their staff to carry out a further inspection there. We found that the hold on the container was released 12 days before it was returned to Mr C's load site for inspection. We found that the container was not moved as soon as the hold was released because of a disagreement between Mr C and his shipping agent. We, therefore, did not uphold Mr C's complaint that SEPA took an unreasonable amount of time to release the hold on the container.

We also found that SEPA were in a position to carry out a further inspection of the container five days after the hold on the container was released. However, we found that they were not able to carry out this inspection because the container remained in port due to the disagreement between Mr C and the shipping agent. We did not uphold Mr C's complaint that SEPA took an unreasonable amount of time to arrange a further inspection of his container.

Regarding communication, we found that SEPA should have communicated to Mr C, or to his shipping agent, why there was a delay in releasing the hold on the container. 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 explain what investigations were taking place regarding the load site before the hold on the container could be released. 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:

• Any reasons for a delay in releasing a hold on a shipping container should be communicated to the shipping agent or to the shipper.

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 about various matters related to the sale of public land to private individuals.

We found that the council's actions had been reasonable in relation to most of the complaints Mr C raised. However, we did uphold a complaint that the council had unreasonably failed to address the impact of proposed development on land designated as greenspace in a delegated report, but did not consider that this had any significant impact on the ultimate decision to grant the application.

We also upheld a complaint that the council had not responded reasonably to complaints raised in a particular email. We found that they did not address two specific points and did not discuss the need for an extended timescale with Mr C or provide him with a revised timescale for response.

Recommendations

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

• All planning applications should be assessed against all relevant policies.

In relation to complaints handling, we recommended:

• Complaints responses should respond to all relevant concerns raised and, where an extension to complaint response timescales is necessary, discuss this with the complainant and provide them with a new timescale within which they can expect a response.

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 the redevelopment of a park which backs on to her property. Ms C also complained about how the council responded to her complaints.

Ms C complained that the layout of the redevelopment of the park had changed and that she had not been consulted on this matter. The council explained that the original plans were concept designs only, and that it was normal for the specifics of the design to evolve as the project progressed. Non-material variation permissions were sought for the movement of some park equipment. We took independent advice from a planning adviser. The adviser said that the council's response and explanation were reasonable and was satisfied that the correct permissions had been sought. We did not uphold this complaint.

In relation to Ms C's complaint about the way that the council had handled her complaint, we found that the council had not treated correspondence from either Ms C or her representative as complaints when they should have been. Therefore, we upheld this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms C for not reasonably responding to her correspondence. 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:

• The council should be clear about what process to put correspondence into. They should check this with the sender, if they are unsure. Correspondence should be replied to promptly, or the sender should be told why there will be a delay, or why no response will be issued.

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 the care and treatment provided to her late sister (Miss  A). Miss A had attended a routine appointment with a practice nurse for her asthma, and had reported symptoms of a urinary tract infection. The nurse had taken a urine sample and had the on-call GP prescribe antibiotics. Several days later Miss A's condition deteriorated and she was admitted to hospital with sepsis (a blood infection), where she then died. Ms C complained that the practice nurse should have realised how unwell Miss A was and carried out further checks such as heart rate, temperature and blood pressure. Ms C felt that if these had been carried out Miss A would have had appropriate treatment sooner.

We took independent advice from a practice nurse and a GP. We found that there was nothing in the medical record to note what symptoms Miss A presented with or any assessment undertaken, and we considered this to be unreasonable. We found that based on the symptoms described by the practice nurse in her complaint investigation statements, the practice nurse should have undertaken a thorough history of Miss A's symptoms, checked her temperature, pulse and blood pressure, and checked for signs of pain. We upheld this aspect of Ms C's complaint.

Ms C also raised concerns that Miss A's blood test results were not acted upon in the weeks leading up to her death. We found that the blood tests that were being monitored were part of the practice's routine screening for chronic disease, and that any abnormal results were followed up appropriately and were not related to Miss A's later diagnosis of sepsis. We did not uphold this aspect of Ms  C's complaint.

Finally, Ms C complained about the practice's handling of her complaint. We found that the practice failed to handle Ms C's complaint reasonably and that it did not meet the complaints handling guidance in place at the time. 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 failing to appropriately assess Miss A and for failing to handle her complaint reasonably. 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 should receive full and appropriate assessments, from the appropriate person, based on their reported symptoms. These should be documented in accordance with recognised standards such as the NMC Code of Conduct.

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). Mr A was admitted to hospital as an emergency with abdominal pain, and investigations were carried out over the next few days. Following a request by the family for medical review, Mr A was reviewed by a surgeon and a scan was carried out, which showed a bowel obstruction. Mr A had surgery the next day. Following this, Mr A was transferred to the high dependency unit (HDU) where he contracted a chest infection. He was then transferred to a ward, but his condition deteriorated and he developed sepsis. Mr A was transferred back to the HDU four days later, and then into intensive care. His condition deteriorated further, palliative care (end of life care) was started and Mr A later died.

Mrs C complained to the board about the care and treatment provided to Mr A. The board met with Mrs C about her complaints and carried out a significant clinical incident review. Mrs C was not satisfied with the outcome, or the way the board handled her complaint, and so she brought her complaints to us. She complained that the board did not provide reasonable medical treatment to Mr A, did not provide reasonable nursing care to Mr A, did not communicate reasonably with the family during Mr A's admission, and did not respond reasonably to her complaints.

We took independent advice from a consultant in general medicine, a nurse and a consultant radiologist (a doctor who uses medical imaging such as x-rays, ultrasounds and scans to diagnose and sometimes treat ilnesses). We found that there were delays in investigating and diagnosing Mr A's condition, and in identifying, responding to, and recording the deterioration following the surgery. We also found that there was no documentation of the reasons for transferring Mr C from the HDU, and poor documentation of a decision to commence using a ventilator. We found that, while aspects of the communication with the family were reasonable, on the whole the standard of communication fell below a reasonable standard, especially in light of the fact that the family held power of attorney. We upheld Mrs C's complaints about medical care and treatment, and about communication.

We did not find failings in the nursing care provided to Mr A, and so we did not uphold this aspect of the complaint.

We found that the board had failed to respond to many of the issues Mrs C had raised in her complaints, despite taking a significant amount of time to investigate. The board was also poorly prepared for the meeting they had with Mrs C about her complaints. We upheld Mrs C's complaint about the board's handling of her complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C for the failings in medical care and communication, and for failing to respond to the points raised in 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.

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

• Patients should be reviewed regularly, with prompt consideration of the results of any investigations to inform diagnosis and treatment.
• Medical staff should clearly record the reasons for key decisions.
• Deterioration in patients should be identified and escalated to senior staff, with timely transfer to high-dependency care where appropriate.
• Welfare attorneys should be involved in decisions about care, and discussions should be clearly documented.

In relation to complaints handling, we recommended:

• The board should adequately prepare for complaint meetings by ensuring staff attending are aware of the specific complaint issues and are able to respond to the specific issues and discuss the timeframes covered by the complaint. They should also agree an agenda or format prior to the meeting, to ensure shared expectations.

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 his daughter (Mrs A) received at Royal Cornhill Hospital. In particular, he complained that the board had failed to carry out appropriate risk assessments for Mrs A.

We took independent advice from a consultant psychiatrist. We found that Mrs  A had been been provided with reasonable care and treatment and that regular risk assessments were carried out. We also noted that Mrs A had been appropriately assessed on her return to the ward after absconding from the hospital. However, we were concerned that, when Mrs A first went missing from the hospital, the board did not follow their missing persons policy. We found that there was a delay in the board contacting the police and that their missing persons policy did not specify a time period within which to initiate the actions to be followed when an in-patient goes missing from care. We were also concerned that the nursing records did not state when the first ward check was carried out after Mrs A went missing, and that there was no record of the actions taken by the board between the first check and a later check at 21:30. Therefore, we upheld this complaint.

Mr C also complained that Mrs A had not been provided with appropriate medication. We found that the board's approach to medication treatment was appropriate and reasonable and in line with relevant guidelines. Therefore, we did not uphold this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C and Mrs A for failing to follow the missing persons policy. 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 times of ward checks should be documented.
• When an in-patient goes missing from care, the missing persons policy should be followed in relation to police contact.
• There should be clear guidance in place in relation to the timescales for taking action when an in-patient goes missing from care.

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 mother (Miss A) during two admissions to the mental health unit at Forth Valley Royal Hospital. In relation to Miss A's first admission, Mr C had concerns about the monitoring and treatment of blood pressure and the treatment provided to Miss A by a psychiatrist. In relation to her second admission, Mr C had concerns about medical care, nursing care and issues around communication. Mr C also complained about the gap in community psychiatric care in the period between the two admissions.

We took independent advice from a nurse and a consultant psychiatrist. We found that there were failings by nursing staff in the monitoring of Miss A's blood pressure and upheld this aspect of Mr C's complaint. However, we noted that the board had acknowledged this failing and had introduced a new system for recording observations. Overall, we found that the medical treatment provided to Miss A during her admission was reasonable and did not uphold these complaints. However, we noted that one letter sent to Mr C contained unhelpful language and we made a recommendation in light of this.

In relation to the gap in community psychiatric care in the period between the two admissions, we found that the board had not followed the clinical management plan in place once Miss A's psychiatrist left the community mental health team. Therefore, we upheld this aspect of Mr C's complaint. We did note, however, that the board had apologised for this failing and had put a new appointment system in place to address this issue.

In relation to Miss A's second admission, neither adviser identified any failings in medical care, nursing care or communication. Therefore, we did not uphold these aspects of Mr C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Miss A and Mr C for the failure to appropriately monitor Miss  A's blood pressure and the content and tone of the letter sent to Mr C. 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:

• Blood pressure monitoring should be carried out in line with the instructions by the medical team.

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 works for an independent advocacy service, complained that there was unreasonable delay in providing the required care and treatment to her client  (Miss A) when Miss A was admitted to Crosshouse Hospital after her Percutaneous Endoscopic Jejunostomy tube (PEJ tube - a feeding tube that is put inside an outer tube which goes into the stomach. The inside tube goes into the small intestine) became blocked. Mrs C also complained that the board's handling of her complaint was unreasonable.

We took independent advice from a gastroenterologist (a doctor who specialises in the digestive system). We found that the board's staff referred Miss A for an initial review, specialist review, arranged investigations and arranged for a replacement PEJ tube in a reasonable time. In view of this, we did not uphold Mrs C's complaint regarding the time taken to treat Miss A. However, we identified that there was no nutrition team involvement in Miss A's care, and that a nutrition assessment was not carried out. We were critical of this and made a recommendation to the board to address this matter.

Regarding complaints handling, we found that there was a lack of clarity as to how the board were investigating the issues raised by Mrs C. In addition, we found that the board did not adhere to the timescale required, nor did they appropriately update Mrs C on their progress. We, therefore, upheld this aspect of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C for the failure to clarify how the complaint would be handled and for not keeping her reasonably informed about the progress of the complaint. 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 involvement of a nutrition team should be considered where stopping of nutrition due to a blocked feeding tube is the reason for admission, and the patient cannot be easily assessed with regards to nutrition status. Nutritional assessment of such patients should be documented.

In relation to complaints handling, we recommended:

• Complaints should be dealt with in accordance with the complaints 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

Mrs C complained about the care and treatment provided to her late father (Mr  A) at University Hospital Ayr. Mr A was elderly and had a visual impairment. Mrs C complained that nursing staff failed to take into account her father's visual impairment when communicating with him and that they failed to recognise he needed extra assistance when reaching for food and drinks. Mrs C also complained about the handling of the discharge process. She felt that the nursing staff did not give accurate information to the social work department about Mr A's mobility, which resulted in difficulties in managing his care at home. Mrs C also raised concerns about the board's handling of her complaint.

The board acknowledged their communication with Mrs C could have been better and that they should have consulted with her more regarding her father's discharge planning. The board also acknowledged that nursing staff communication with Mr A was not acceptable. Mrs C remained unhappy and brought her complaints to us.

We took independent nursing advice. We found that the nursing care provided to Mr A was below an acceptable standard and that the discharge planning could have been improved by holding a case conference. We upheld these two aspects of Mrs C's complaint. However, we found that the board did take adequate steps to ensure that Mr A received appropriate post-discharge care at home. We did not uphold this aspect of the complaint.

Regarding complaints handling, we found that the board did not handle Mrs C's complaint in line with their complaints handling procedure. We upheld this part of the complaint.

Recommendations

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

• Staff should be more aware of how to take into account and accommodate the individual needs of visually impaired patients and should ensure these needs are recorded appropriately in the records.
• The board should recognise the importance of personalised discharge planning, particularly when patients are elderly and frail and are already receiving complex care at home.

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.