Some upheld, recommendations

  • Case ref:
    202204103
  • Date:
    January 2024
  • Body:
    Tayside NHS Board
  • Sector:
    Health
  • Outcome:
    Some upheld, recommendations
  • Subject:
    Admission / discharge / transfer procedures

Summary

C complained about the care and treatment provided to their adult child (A). C complained that actions taken shortly before and after A’s discharges were unreasonable as was the board’s response to the complaint.

We took independent advice from a consultant in general medicine and a registered general nurse. We found that appropriate assessments were carried out prior to discharge and that the board reasonably discharged A. As such, we did not uphold these parts of C’s complaint.

We considered C’s complaint regarding the level of support offered after A’s falls. We found that the board’s response to these falls were reasonable. Action taken after the fall in the car park were in line with policy and the level of staffing available on the day, and in relation to the fall while being admitted, the care as documented was considered to be reasonable. As such, we did not uphold these parts of C’s complaint.

In relation to the complaints handling, we found that there were failings in the response to C’s verbal and written complaints, with no response issued to the verbal complaint, and not providing a full response to the written complaint. While there were some aspects of the board’s response which were reasonable, overall we upheld this part of C’s complaint.

Recommendations

What we asked the organisation to do in this case:

  • Apologise to C for failing to reasonably respond to the complaints regarding A’s discharges and the response to A’s fall in the car park. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

In relation to complaints handling, we recommended:

  • All staff must be aware of the complaints handling procedure and how to handle and record complaints at the early resolution stage.
  • Complainants should be advised prior to the deadline if the board will not meet the 20 working day target for responding to a complaint, and be advised of the reasons for the delay.
  • Responses to complaints should be clear and answer the points of concern raised.

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.

  • Case ref:
    202202079
  • Date:
    January 2024
  • Body:
    Grampian NHS Board
  • Sector:
    Health
  • Outcome:
    Some upheld, recommendations
  • Subject:
    Admission / discharge / transfer procedures

Summary

C complained about the care and treatment they received from the board. C suffered a subarachnoid haemorrhage (a form of stroke caused by bleeding on the surface of the brain). Following a period of admission to different hospitals, C was discharged home. C complained that the board failed to communicate appropriately with them after their admission, that they were not fit for discharge and that inadequate rehabilitation plans were made in the community. C chose to stay at a relative’s property and was eventually admitted to a rehabilitation unit but believed this had affected their prognosis. C also complained that the board failed to respond reasonably to their concerns about the COVID-19 vaccine they had received.

We took independent advice from a consultant neurologist (specialist in the diagnosis and treatment of disorders of the nervous system) and an occupational therapist. We found that communication with C was unclear and confusing and did not always address the main points C was raising. Therefore, we upheld this part of C’s complaint.

In relation to C’s discharge, we noted that more consideration could have been given to supporting C prior to their discharge, given C’s concerns at the time. However, we found the decision making to be appropriate and did not uphold this part of C’s complaint.

In relation to plans for C’s rehabilitation, we found that the board made reasonable plans and attempted to commence the initial assessment that would have established what support C required. However, we found that there was a failure to provide C with written information about the plans for their rehabilitation. C was unable to retain this information when given verbally which meant they were unaware of the plan and could not access the support available to them when they were unable to return to their property as quickly as anticipated. Therefore, we upheld this part of C’s complaint.

We also found that the board failed to follow up on a commitment given to C to explore any potential link between the COVID-19 vaccine and C’s brain injury. They also failed to support C’s attempts to gather information to assess the risk of further vaccine doses. Therefore, we upheld this part of the complaint.

C also complained about the board’s handling of their complaint. We found that although there were some failings, in the circumstances the board were operating under at the time these were apologised for and reasonably addressed. We did not uphold this part of C’s complaint.

Recommendations

What we asked the organisation to do in this case:

  • Apologise to C for the issues identified in this decision. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

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

  • That the board confirm what action they have taken to ensure patients with brain injuries are provided with discharge information in a format they can understand and refer back to after leaving hospital. The Board should share this decision with the clinical team involved in C’s care with a view to identifying points of learning.

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.

  • Case ref:
    202107467
  • Date:
    December 2023
  • Body:
    The Highland Council
  • Sector:
    Local Government
  • Outcome:
    Some upheld, recommendations
  • Subject:
    Child services and family support

Summary

C complained about the council’s handling of allegations that their child made against them, including decisions taken to remove their child from the family home on the evening of the incident, but then considered safe to return the following day. C also complained about a lack of support for their family following the incident. C made a subsequent complaint about the council’s handling of disclosures made by their child to social workers regarding a previous overdose.

In response to the complaints, the council said that once a child protection issue was raised by C’s child, this was responded to quickly and in line with child protection procedures. Decisions about where C’s child should stay whilst police investigations were ongoing were taken in collaboration with the family and it was determined following a risk assessment that there was no grounds to require C’s child to stay away from the family home. The council explained the nature and purpose of follow up meetings.

With respect to disclosures made by C’s child that they had previously taken an overdose, the council said that the social worker’s professional opinion was that it was not necessary to pass this information on to the child’s parents, and instead recorded a note of the incident. The council did however acknowledge that there was no record of why the social worker had come to this determination and course of action.

We took independent advice from a social work adviser. We found that whenever information is provided concerning actual or alleged abuse, this must be investigated and we considered that actions taken by the council’s social worker to be reasonable in this regard. With respect to decision making around removing C’s child from the family home, whilst the circumstances are disputed, the records indicated that there were discussions with the family about the decision making in this regard and additional factors, including the lateness of the day, were taken into consideration. The approach in the circumstances was therefore considered to be reasonable.

With respect to C’s child returning to the family home the following day, we found that there was no immediate risk to C’s child should they stay at home and it was reasonable for them to return home the day following the incident. On this basis, we did not uphold C’s complaint about the appropriateness of the council’s Child Protection investigation.

In considering C’s concerns about the handling of their child's disclosure of a previous overdose, we acknowledged the council’s position that it may be appropriate in some circumstances not to share such information with a child’s parents, such as in circumstances where the child does not want the information shared. However, we found that there was no evidence of such a discussion having taken place, or of the reasoning behind decisions taken not to share this information with C or their partner. We therefore found that there was a failure by the social worker to record a discussion with C’s child and the reasons for not informing their parents of the overdose. On this basis, we upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

  • Apologise to C and their partner for the issues highlighted. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

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

  • That the council share this decision with the social work team with a view to reminding them of the importance of recording all discussions and decision making considerations in child protection case notes.

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.

  • Case ref:
    202008929
  • Date:
    December 2023
  • Body:
    Fife Council
  • Sector:
    Local Government
  • Outcome:
    Some upheld, recommendations
  • Subject:
    Rights of way and public footpaths

Summary

C complained to the council about a local access route that was closed off by the landowner. C said that the route had historically been asserted as a right of way (RoW) and a planning condition imposed to protect it. In response, the council declined to take action to re-open the route. They explained that, notwithstanding the route being referred to a RoW in the planning process, the route had not been asserted and had no legal status. They explained that the planning condition (to provide an upgraded alternative route through the site) had also been removed on appeal. However, in a further response, the council stated that the condition remained valid but was found to be ultra vires and unenforceable as the alternative route was not in the landowner’s ownership. They declined to take any further action on the basis a suitable alternative route, in their ownership, had been provided and remained open.

C complained that the council had failed to take reasonable action to keep open the claimed RoW. C said that the council had been very clear in the planning process that the claimed route had been established as a RoW, and Scotways had also considered the route had met the criteria to be a RoW. They said that the council had also failed to take reasonable enforcement action in respect of the planning condition and had provided contradictory responses to their complaints about these matters.

We took independent advice from a planning adviser. We found that the council had provided a reasonable explanation regarding the status of the route but highlighted that it would be for the courts to determine the status of a disputed RoW if C disagreed with the council’s position. We also found that the decision not to take any further action to keep the claimed route open was a discretionary matter which the council were entitled to take. For these reasons, we did not uphold this aspect of C’s complaint.

However, we provided feedback to the council in respect of the original planning application. Specifically, we noted that the council had appeared to determine the application as including the diversion of a claimed RoW without confirming the status of that route. We reminded the council that, when dealing with planning applications which make reference to a RoW, to firstly confirm the actual status of such route and where required, to amend the application description if it is deemed that the route is not a RoW prior to making any determination.

Notwithstanding the unenforceability of the planning condition itself, we found that there had not been any failure by the council in respect of enforcement matters. We found that the council’s position that the planning condition had now been complied with as a suitable alternative route through the site had been provided, to be acceptable. For these reasons, we did not uphold this aspect of C’s complaint.

We also found that the council failed to provide a clear and consist explanation in their response to C’s complaints and had incorrectly applied terminology and/or language. We upheld this aspect of C's complaint. We also reminded the council to ensure that where responses cannot be provided within the timescales set out in their Complaint Handling Procedure, they should write to a complainant to explain the reasons for the delay and provide a revised timescale for response, and that where they are unable to respond to a request for information from our office within the timescale specified, they should contact us as soon as possible and without delay.

Recommendations

What we asked the organisation to do in this case:

  • Apologise to C for the failings identified. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

In relation to complaints handling, we recommended:

  • Ensure that all relevant staff are reminded of the need to use the correct terminology when referring to matters in which the terminology has a particular meaning.

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.

  • Case ref:
    202207277
  • Date:
    December 2023
  • Body:
    Lothian NHS Board - Acute Division
  • Sector:
    Health
  • Outcome:
    Some upheld, recommendations
  • Subject:
    Clinical treatment / diagnosis

Summary

C complained about the care and treatment that they received in respect of their cancer. C was diagnosed with colorectal cancer which had spread to their liver and required surgery. The surgery was to be performed in two stages. C complained that the second surgery was not performed within a reasonable timescale and about poor pain relief following the second surgery.

The board apologised to C for the poor communication about the arrangements for the second surgery and explained that repeating imaging was required before arranging the surgery and that they did not consider the delay to be significant. The board provided an overview of the pain relief provided and noted that any issues identified were addressed at the time.

We took independent advice from a colorectal and surgical consultant. We found that communication with C about when they could reasonably expect to have their second surgery was poor and there was an unexplained delay in their case being reviewed by the multi-disciplinary team. This resulted in a delay of around one month, however we did not consider this would have caused further spread of C’s cancer. We upheld this complaint.

We noted that there were some issues with the equipment used to deliver pain relief post surgery, however these were rectified and appropriate additional pain relief was provided promptly. We found the post surgical care and treatment provided to be reasonable and we did not uphold this complaint.

Recommendations

What we asked the organisation to do in this case:

  • Apologise to C for the issues identified. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

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

  • That the board review their approach to communication with patients to ensure that cancer patients are proactively kept informed of progress in their treatment plan.
  • That the board review their processes for prioritising the review of important cases by the MDT to ensure that such cases are progressed without delay.

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.

  • Case ref:
    202206050
  • Date:
    December 2023
  • Body:
    Lanarkshire NHS Board
  • Sector:
    Health
  • Outcome:
    Some upheld, recommendations
  • Subject:
    Clinical treatment / diagnosis

Summary

C, an advocate, complained on behalf of A about treatment that they received after sustaining a knee injury. A ruptured the anterior cruciate ligament (ligament connecting the thigh bone to the shin bone) and underwent an arthroscopy of the knee (a type of keyhole surgery). This was followed up with a second surgery at a later date to complete the reconstruction of the ligament.

During the surgery, the surgeon’s scalpel snapped and to remove the tip of the blade, the surgeon had to create a larger incision. C raised concerns about the actions taken following the incident. The board acknowledged the incident and explained that damage to instruments is a rare but known complication of surgery.

We took independent advice from a consultant orthopaedic surgeon. We found that when the blade snapped, appropriate care was provided to A. It was appropriate to create a larger incision and the incident was appropriately communicated to A. However, we found that whilst a datix incident report was completed, a more in-depth investigation could have been carried out. There was no evidence that the board considered either the possibility of improper use of the instrument or that there was a defect in the instrument. We also considered that the board should have discussed the incident at a departmental level. In conclusion, we upheld C’s complaint about care and treatment in relation to the initial surgery. We did not uphold the complaint about the post operative care provided to A as we were satisfied it was reasonable.

Recommendations

What we asked the organisation to do in this case:

  • Apologise to A for failing to thoroughly investigate the adverse event where by the scalpel broke during A’s surgery. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

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

  • Operation notes should be sufficiently detailed, particularly when an adverse event has occurred.
  • The board should ensure that adverse events are thoroughly investigated and that appropriate reflection and learning is identified.

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.

  • Case ref:
    202101013
  • Date:
    December 2023
  • Body:
    Greater Glasgow and Clyde NHS Board - Acute Services Division
  • Sector:
    Health
  • Outcome:
    Some upheld, recommendations
  • Subject:
    Clinical treatment / diagnosis

Summary

C complained about the care and treatment that they received from the board following a stillbirth. C complained that the board had failed to provide them with adequate support following the birth of their child. C also complained that a consultant had acted unreasonably by discussing their child’s post mortem results with them, without prior warning and without the presence of their partner, during a consultation several months later to discuss the progress of a new pregnancy.

The board did not identify any failings with the support provided to C. However, they apologised for the distress caused to C during the meeting with the consultant. They said that the consultant was required to make a plan of care for the new pregnancy and that this inadvertently led to the discussion and counselling of C’s previous pregnancy. The Board said that C’s partner was unable to attend the meeting due to restrictions on hospital visiting in force at the time due to the pandemic.

C remained unhappy and asked us to investigate. C complained that the support provided to them was inadequate. C also complained that the consultant had acted unreasonably.

We took independent advice from a consultant obstetrician. We found that inpatient care discharge arrangements, including handover of C’s care to community midwives was as expected. We did not uphold this complaint. However, we found that there had been a failure to adequately prepare for C’s consultation. In the circumstances, we found that it was unreasonable to have progressed with C’s consultation without offering them the choice of re-scheduling so that consideration could have been made to their partner attending, or offering a remote appointment. We upheld this complaint.

Recommendations

What we asked the organisation to do in this case:

  • Apologise to C for the failings identified. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

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

  • The findings of this investigation should be fed back to the staff involved, in a supportive manner, for reflection and learning.

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.

  • Case ref:
    202100839
  • Date:
    December 2023
  • Body:
    Ayrshire and Arran NHS Board
  • Sector:
    Health
  • Outcome:
    Some upheld, recommendations
  • Subject:
    Clinical treatment / diagnosis

Summary

C’s parent (A) was receiving palliative chemotherapy, following a diagnosis of terminal cancer, which was suspended as the COVID-19 pandemic worsened. A was admitted to hospital following a prolonged period of vomiting that had not responded to treatment. A remained in the hospital for several weeks before passing away. C raised complaints with the board detailing C’s family’s concerns about A’s cancer diagnosis, decisions about A’s chemotherapy, aspects of the care and treatment of A, and communication with C and their family during A’s hospital admission. The board’s responses indicated that they considered A’s care and treatment had been reasonable overall, but accepted that there had been some aspects that could have been improved. They accepted that there were aspects of their communication that could have been improved, particularly that they should have contacted A’s next of kin when A’s condition deteriorated over a particular night.

C was dissatisfied with the board’s responses and brought their complaint to us. We took independent advice from a specialist in palliative care. We found that A’s treatment had been reasonable overall and that while there were certain aspects of A’s care that could have been improved, overall the board provided reasonable care to A.

In relation to the aspects of the complaint about the board’s failure to contact A’s next of kin when A’s condition deteriorated over a particular night and about the board’s responses to C’s complaints, we upheld these aspects of the complaint. In relation to the board’s handling of C’s complaints, we found that there were delays in responding, failure to address various clearly raised issues in responses, unreasonable action around the arrangement of a promised meeting within a reasonable timescale and the inclusion of statements that were not supported by evidence. We upheld these aspects of the complaint.

Recommendations

What we asked the organisation to do in this case:

  • Apologise to C that they did not respond reasonably to their complaints. The apology should include specific reference to the board’s failure to address various issues raised in the complaints, failure to maintain reasonable action around the arrangement of a promised meeting, and inclusion of statements in the complaint response that were not supported by evidence. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets. The board should consider C’s request that the apology be provided at an in-person meeting at which C has an opportunity to read a personal statement.

In relation to complaints handling, we recommended:

  • Complaints are properly investigated and responded to in line with the board’s Complaints Handling 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.

  • Case ref:
    202203587
  • Date:
    November 2023
  • Body:
    Lothian NHS Board - Acute Division
  • Sector:
    Health
  • Outcome:
    Some upheld, recommendations
  • Subject:
    Communication / staff attitude / dignity / confidentiality

Summary

C complained about the attitude of a doctor during an inpatient admission. C stated that the doctor had treated them in a dismissive, derogatory and unprofessional manner. C further complained that the doctor removed their diagnosis, stopped their medication and made no arrangements for them to receive support following their discharge. C told us that the actions of the doctor had resulted in them not receiving a reasonable standard of care.

We found that the inpatient doctor's communication and documentation did not meet the required professional standards and impacted on the board's overall communication of C's care and treatment needs. The clinical records evidenced a dismissive and disrespectful attitude towards C. The doctor's documentation lacked a clear clinical rationale for the decisions that they made about C's diagnosis and medication. Therefore, we upheld this part of C's complaint.

In relation to the standard of care C received, we found that board staff had ensured that C's care and treatment needs were met. The decision to discharge C from inpatient care was reasonable and the community-based care that was provided was appropriate to C's identified needs at the time. When it was clinically indicated, the board arranged a further inpatient admission and reviewed C's diagnosis and treatment plan. There was evidence that the doctor did not stop C's medication. Therefore, we did not uphold this part of C's complaint.

Recommendations

What we asked the organisation to do in this case:

  • Apologise to C for the unprofessional language used by the doctor, the doctor's communication regarding diagnosis and medication, the impact the doctor's communication had on C and not adequately reflecting that the board recognised that the doctor's communication was unreasonable in the complaint response. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.
  • The board should review the support being provided to C to assess whether the current level of support is appropriate and sufficient; and ensure that C is able to access medical assessment and review from a doctor other than the doctor at the subject of the complaint, if required.

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

  • Communication with patients is professional and respectful. Documentation evidences that clinicians work in partnership with patients. Concerns and disagreements are documented using professional, non-judgmental language.
  • There should not be a pattern of poor practice.

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.

  • Case ref:
    202107141
  • Date:
    November 2023
  • Body:
    Lothian NHS Board - Acute Division
  • Sector:
    Health
  • Outcome:
    Some upheld, recommendations
  • Subject:
    Clinical treatment / diagnosis

Summary

C complained about their care and treatment following a hysterectomy (a surgical procedure to remove all or a part of the uterus). C complained that they were not provided with adequate pain relief following the surgery, and that they were not fitted with an abdominal drain (a thin plastic tube which is inserted into an abnormal collection of fluid to help remove it from the body). C was discharged a few days later but disputes whether they were fit to be discharged home at this point. C was later readmitted suffering from a blood clot and an infection. C was discharged with oral antibiotics and again disputes whether they were fit to be discharged at this point.

A few days later, C began to bleed heavily. An ambulance was called but the wait was likely to be significant and C was taken to hospital by their partner. C was triaged but asked to sit on a chair in a corridor, despite suffering from obvious heavy vaginal bleeding. C was reviewed by a consultant and sent up to the gynaecology ward where they were then taken for emergency surgery.

We took independent advice from a consultant obstetrician (specialists in pregnancy and childbirth) and a consultant in emergency medicine. We found that C received a reasonable standard of care following their surgery and was appropriately discharged on both occasions. Therefore, we did not uphold these parts of C's complaint.

In relation to C's attendance at A&E, we found that they were not triaged sufficiently quickly and the way C was asked to wait was not appropriate given their condition. C was medically assessed within an appropriate timescale within A&E and appropriately transferred. The board had accepted there were failings in C's care, but they had not set out clearly how they planned to address these issues. Therefore, we upheld this part of C's complaint.

C also complained that the board failed to handle their complaint reasonably. We found that the board handled C's complaint appropriately and did not uphold this part of their complaint.

Recommendations

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

  • Complete an assessment of the delay in triaging C.
  • The board should consider what it can do to improve the experience of patients who require privacy when awaiting medical assessment.

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.