Some upheld, recommendations

Summary

Mr and Mrs C complained on behalf of their daughter (Ms A) about the orthodontic treatment (a speciality field of dentistry that deals with malpositioned teeth and the jaws) she received. Ms A underwent orthodontic treatment to treat mild crowding of her teeth (when there is not enough space for all teeth to fit normally within the jaws). Four of her teeth were removed, and braces were fitted. After the braces were removed Mr and Mrs C were concerned that the treatment had changed Ms A's facial profile and affected her lip support. They believed that there had been other methods of treatment available, which they felt that the orthodontist had failed to discuss with Ms A.

We took independent advice from a dental and orthodontic adviser. We found that Ms A's overcrowding was treated appropriately and that a good result was achieved. We did not uphold the complaint about the treatment provided.

Mr and Mrs C also complained that the orthodontist failed to obtain Ms A's informed consent before proceeding with the treatment. We found that there was no evidence of a proper discussion of the problem that Ms A presented with or the expectations she had of any treatment. We also did not see any evidence of any information being given to Ms A about what treatment options were availale. We upheld this aspect of the complaint.

Finally, Mr and Mrs C complained about their way that their complaint was handled by the orthodontist. We found that the complaint had been handled appropriately and in a timely manner. We did not uphold this aspect of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise for failing to obtain valid consent to the treatment plan, with recognition of the implications of failing to obtain full consent on the choices made. The apology should meet the standards on apology 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 quality of the orthodontist's clinical treatment notes should be improved. In particular, they should focus on improving the way they document orthodontic assessments, gather orthodontic records and use them to ensure that a comprehensive explanation

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 at Victoria Hospital. Ms C had several admissions for pain associated with gallstones. She complained that the nursing care during two of her admissions was not of a reasonable standard, and that she was not provided with pain relief in a timely manner. Ms C also complained about the treatment provided to her for a wound infection when she attended after surgery to remove her gallbladder.

We took independent advice from a nursing adviser and from a consultant physician. We found that nursing care had not been of a reasonable standard and upheld this aspect of Ms C's complaint. However, as the board had already apologised for this matter and taken action to address it, we made no further recommendations. We did ask for evidence of the steps they said they had already taken.

We found that pain relief had not always been provided to Ms C in a timely manner. We upheld this aspect of the complaint and made a recommendation to address this.

Finally, we found that the treatment provided to Ms C for her wound infection was reasonable and we did not uphold this aspect of Ms C's complaint.

Recommendations

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

• Pain levels should be assessed regularly and pain relief provided in a timely way.

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 provided to his late father (Mr A) during his admission to Victoria Hospital. Mr A lacked capacity and had appointed Mr C as power of attorney for his care. In particular, Mr C complained that the board failed to give Mr A appropriate treatment for his heart attack and questioned why more invasive treatment was not considered in Mr A's case. Mr C also complained about a lack of communication with him about the care and treatment Mr A was given, despite having power of attorney. In their response to the complaint, the board accepted that Mr A lacked capacity and that there were failings in their communication with Mr C.

We took independent advice from a consultant geriatrician (a doctor who specialises in medicine of the elderly). The adviser considered that it was reasonable that more invasive treatment was not considered appropriate for Mr A, given his age and pre-existing health conditions. We considered that the care provided to Mr A was reasonable, and we did not uphold this aspect of Mr C's complaint.

The adviser considered that there was an unreasonable failure to discuss Mr A's care and treatment with Mr C, as power of attorney. The adviser also said that there was a failure to follow the required Adults with Incapacity process after Mr A's admission, as an Adult with Incapacity certificate and treatment plan were not prepared. We accepted this advice, and upheld this aspect of Mr C's complaint. In light of our findings, we made some recommendations.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for the failure to communicate appropriately with him. The apology should comply with the SPSO guidelines on making an apology, available at: www.spso.org.uk/leaflets-and-guidance.

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

• Decisions about care and treatment should be discussed with a welfare power of attorney, in the same detail they would be discussed with a patient who has capacity to understand the decision themselves.
• An Adult with Incapacity certificate and treatment plan should be prepared for all patients who lack capacity.

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 made a number of complaints about the care and treatment that his late wife (Mrs A) received in University Hospital Crosshouse. Mrs A had a complex medical history and was admitted in relation to a skin condition. Mrs A became increasingly unwell during her admission and developed hospital acquired pneumonia (an infection of the lungs). Mr C complained about the nursing care that Mrs A received. Mr C also complained about the medical care that Mrs A received in relation to the insertion of a central line (a tube placed by needle into a large, central vein in the body to administer drugs or take blood samples), prescription/management of fluids, how she came to develop hospital acquired pneumonia and the prescription of pain relief. Mr C was also concerned about the DNACPR (do not attempt cardiopulmonary resuscitation) that was in place for Mrs A and that no post-mortem was carried out following her death. Mr C also considered that the handling of his complaint by the board was unreasonable.

We took independent advice from a nurse in relation to Mrs A's nursing care. While we did not find failings in relation to many aspects of Mrs A's care, we found that the appropriate skin assessment had not been carried out following her admission. The adviser highlighted that appropriate care and assessment could have avoided a pressure ulcer that Mrs A later developed. We upheld this aspect of Mr C's complaint.

We took advice from a consultant in acute medicine in relation to Mrs A's medical treatment. We noted that most aspects of Mrs A's care had been reasonable and that Mrs A's very low weight on admission to hospital made management of her fluid balance difficult. We found no failings in relation to the prescription of pain relief. The adviser highlighted that hospital acquired pneumonia is a risk for all patients, but particularly those who are frail and bed-bound. However, we found that there was a lack of evidence of an appropriate consent process for the insertion of the central line. Therefore, we upheld this aspect of Mr C's complaint.

In relation the DNACPR decision, we found that this was appropriate in Mrs A's case and that there was evidence that it was discussed reasonably. We also found that there was no clear answer as to whether or not a post-mortem should have been carried out for Mrs A. Therefore, we did not uphold these aspects of Mr C's complaint. However, we did note that a care after death checklist had not been completed and made a recommendation to the board in light of this.

Finally, we found that the board's complaint response was not issued within the prescribed timescales and did not address all the concerns that 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 for failing to carry out appropriate pressure area assessment and care, for the failures around the consent process for the central line, and for failing to handle his 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:

• The board should ensure that all registered nursing staff carry out appropriate assessment and monitoring of patients at risk of pressure ulcers.
• Appropriate consent should be obtained and documented or an adults with incapacity form completed to cover the insertion of a central line.
• The board should ensure that all relevant staff are aware of and complete the care after death checklist for every patient who dies.

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 late father (Mr A) about the care and treatment Mr A received from his GP practice. Mr C complained that Mr A was not referred to dermatology (the branch of medicine dealing with the skin, nails, hair and its diseases) when he first attended the GP Practice, even though his facial lesion had changed shape and colour. Mr C was later diagnosed with skin cancer. Mr C also complained that Mr A was not given appropriate treatment when he later developed health issues, such as a persistent cough, in the last months of his life.

We took independent advice from a GP. We found that the practice should have referred Mr A to dermatology at the outset. The adviser considered that Mr A's lesion was of concern because it had enlarged and changed character. Therefore, we upheld that aspect of Mr A's complaint and we made recommendations to address this. We found that the practice gave Mr A appropriate treatment for the health issues he experienced later and we did not uphold this aspect of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for not referring Mr A to dermatology. 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:

• Patients with suspicious lesions should be referred to dermatology.

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 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.