Some upheld, recommendations

Summary

Mr C complained that he was unreasonably discharged from the Royal Infirmary of Edinburgh following hip replacement surgery, as he was unable to pass urine and was constipated at the time of discharge. Mr C eventually had a catheter fitted and was advised by a consultant at the Western General Hospital that he would be put on a waiting list for transurethral resection of the prostate (a surgical procedure that involves cutting away a section of the prostate - a small gland in a man's pelvis located between the penis and bladder). Mr C complained that the board misled him about the date for his surgery and that they failed to carry out his operation within a reasonable time.

We took independent advice from a nurse. They said that it was appropriate for Mr C to be discharged from hospital, as his notes indicated that he was not experiencing any issues with passing urine or that his bowels were not working. Therefore, we did not uphold this part of the complaint. However, we noted that the board recognised they should have provided Mr C with oral laxatives on discharge and will take action to address this issue in future.

Based on the information available we did not consider that the board misled Mr C about the date for his surgery and we did not uphold this part of the complaint. However, we noted that the board had indicated that they had taken steps to try to ensure that in future, the medical team and their secretaries were kept notified of waiting times for procedures and we asked the board to provide evidence of this.

The adviser said that Mr C's surgery was completed outwith the 12 week treatment time guarantee and as the procedure was classified as 'urgent', this appeared unreasonable. The board explained the steps that they had taken to try to reduce the waiting times for patients and identify alternative providers and we asked for further evidence of this. We also found that there was poor communication between the board and Mr C regarding the delay in his surgery, advice and support available to him and in their handling of Mr C's complaint. Therefore, we upheld this part of Mr C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for the unreasonable delay in providing surgery, not discussing the advice and support available to him and for the communication error in complaints handling. 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:

• The board should inform patients as soon as possible of any inability to meet treatment targets and provide them with all the required information. This should include options available to them in the circumstances and how to provide comments/feedback or make a complaint about the 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.

Summary

Ms C, who is an advocacy and support worker, complained on behalf of her client (Mrs B) about the care and treatment provided to Mrs B's son (Mr A) at the Royal Edinburgh Hospital. Mr A had a range of complex psychiatric and physical health conditions and spent long periods of time in hospital. Mr A's health deteriorated while he was in the hospital and he was transferred to another hospital for treatment and died the following day. Ms C complained that the board failed to provide Mr A with appropriate treatment for both his mental health and his physical health. She also complained that the board failed to respond appropriately to Mr A's deteriorating physical health in the two weeks leading up to his death.

We took independent medical advice from a psychiatrist, a mental health nurse, and a consultant in general medicine. We found that Mr A received appropriate mental health treatment and that the board had followed the relevant guidelines. We did not uphold this part of the complaint.

In terms of Mr A's physical health conditions, the psychiatric adviser said that a more systematic approach to assessing/managing Mr A's risk of infection should have been taken. We also found failings in Mr A's nursing care, including a failure to adequately complete charts to monitor his weight, food and fluid intake. We upheld this part of the complaint.

On the events leading up to Mr A's death, we found that his deteriorating physical condition was not responded to adequately, on occasion, by nursing staff and that there was a delay in requesting a medical review. Based on the evidence provided, we upheld the complaint. However, the advisers said that the remedial action taken by the board in relation to this part of the complaint was reasonable and we therefore had no further recommendation to make regarding this aspect of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs B and her family for the failings in care and treatment that Mr A received in hospital. 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:

• Charts used by nursing staff to monitor patients weight, nutritional screening and food and fluid intake should be completed in full and in line with organisational expectations.
• Nursing care should be effectively and transparently planned and evaluated.

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 husband (Mr A) who was treated for cancer at Aberdeen Royal Infirmary. Mrs C complained that there was a lack of communication about Mr A's care between the staff and his family and between the staff themselves. Mrs C also complained that Mr A was over-sedated which was causing periods of delirium and that his feeding and nutritional needs were not met.

We took independent advice from a nursing adviser and a consultant physician. We found that communication between hospital staff and Mr A's family and between hospital staff themselves was reasonable. However, Mrs C had raised concerns about Mr A having delirium and this was not appropriately acted upon in line with the Health Improvement Scotland (HIS) programme on identifying delirium in patients. On balance, we upheld this part of Mrs C's complaint.

In relation to over-sedation, the adviser said that the medication Mr A received is often accompanied by side effects and that it could have been a contributing factor to him developing a period of delirium. However, these side effects were not sufficient to say that Mr A's care was unreasonable or that he was over-sedated. Therefore, we did not uphold this aspect of Mrs C's complaint.

Finally, we found that Mr A was having difficulty eating and drinking and that this was due to damage to his mouth, a common consequence of the cancer treatment he was receiving. The adviser said that the hospital staff took reasonable steps to encourage and promote Mr A's nutritional care. There was evidence that Mr A had declined artificial feeding which would have improved his ability to eat. Therefore, we did not uphold this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C for not appropriately acting on her concerns raised about Mr A having delirium. 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:

• Ensure that staff are following the HIS programme by involving families or carers in identifying delirium in patients and in their use of assessment tools to identify delirium in patients.

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's mother (Miss A) had lung cancer which had spread to her brain. The steroid medication she was taking to alleviate the symptoms caused psychotic symptoms, requiring an admission to Dumfries and Galloway Royal Infirmary. One day when her family went to visit they were unable to find her. They subsequently found her in a stairwell, disorientated and upset. Miss C complained about the board's failure to ensure that Miss A did not leave the ward. She also complained that the board's complaints handling was unreasonable.

We took independent advice from a nursing adviser. The adviser highlighted the importance of the balance to be struck between weighing the risks of staff monitoring patients and promoting some independence and dignity. In their response to the complaint the board said that the ward was extremely busy and that, although staff did their best to ensure that vulnerable patients were monitored, they were extremely sorry and disappointed that on this occasion they were unable to prevent Miss A from leaving. We considered the board's response to the complaint to have been reasonable and did not consider that Miss A should have been under closer supervision. We did not uphold this aspect of Miss C's complaint.

We found the board's complaints handling to have been poor. The family's complaint was initially not taken forward because it was believed that Miss A's consent was required, and she lacked capacity to give consent. We found that the board failed to communicate their reasons for not taking the complaint forward, and did not investigate until the Patient Advice and Support Service became involved. We upheld this aspect of Miss C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise for the failings in their complaints handling. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/leaflets-and-guidance.

In relation to complaints handling, we recommended:

• Complaints handling staff should be confident about when consent is required before a complaint can be investigated. In this instance, matters could have been investigated without the need for Miss A's consent.

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 council after her child (child A) returned from a school trip abroad badly sunburned, requiring a hospital stay. She complained that the council had failed to take reasonable steps to ensure that her child would not get sunburned, that reasonable action was not taken when the severity of child A's condition was established, and that her complaint had been handled unreasonably.

We found that a full risk assessment had been carried out and that pupils were reminded several times a day to administer sun protection. We considered that the council's actions aimed at preventing pupils from getting sunburned were reasonable, even though they were not effective in preventing child A from becoming sunburned. We were critical of a decision to allow the child to wear shorts and no sun protection when their legs were uncomfortable. The council said child A was only exposed to 30 minutes of sunlight on that occasion. With hindsight, we considered this to have been a poor decision, but we noted that sunburn was not yet suspected at that point and the main concern was the child's comfort. On balance, we did not uphold this aspect of Mrs C's complaint.

We found failings in the council's actions once the severity of the child's condition was known. Staff initially took advice from a pharmacist then later took the child to a local hospital. They took the advice of doctors at the hospital and also kept Mrs C and her husband informed until the group returned to the UK. We considered these steps to have been reasonable. However, the child was bandaged from thigh to toe and was unable to mobilise independently and in need of a wheelchair. The return journey home was 36 hours by coach. We considered that staff, who could see the condition child A was in, ought to have explored with Mrs C and her husband other options for getting child A home more quickly, taking into account the child's dignity, privacy and comfort. We upheld this aspect of the complaint.

We were critical of the council's complaints handling. We found that they failed to treat Mrs C's complaint as a formal complaint, and failed to advise her of the their complaints process. We also considered that their response to her was lacking in empathy. We upheld this aspect of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C for the poor handling of 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.
• Apologise to Mrs C, her husband and child A for failing to explore other options for child A to travel home once the severity of their condition was established.

In relation to complaints handling, we recommended:

• The relevant staff should be reminded of the council's complaints handling procedure and re-familiarise themselves with how to apply it.
• Staff should be aware of the importance of providing an empathetic response to complaints.

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 and Mrs C complained about the licensing arrangements for licensed premises adjacent to their property. They requested a Licensed Premises Review hearing as they felt that the level of late night noise coming from the premises contravened a condition of the premises license. This review was considered by the licensing board. Mr and Mrs C complained about the actions of the licensing standards officer and the clerk to the licensing board prior to a licensing board meeting to consider the review. This meeting related to changes to the operation of the premises. We found that the council were unable to provide documentation to evidence that the administrative process of approval for these changes of operation had been followed. We upheld this aspect of the complaint.

Mr and Mrs C also complained about the Licensing Premises Review hearing and the information that had been considered during the review hearing. We found that Mr and Mrs C had been represented at the hearing and found no evidence that council officers had acted unreasonably in relation to the information presented to the review hearing. We did not uphold this aspect of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr and Mrs C that the administrative process of approval for changes to the operation of the premises adjacent to their property had not been appropriately followed. The apology should comply with the SPSO guidelines onmaking an apology available at https://www.spso.org.uk/leaflets-and-guidance.

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

• Licensing Standard Officers should document the administrative process of approval for applications for minor variations and the reasoning behind decisions.

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 council's management of a multi-use games area (MUGA) near her home. When the council provided Ms C with their formal response they said that they were unable to reach a conclusion on whether she and her neighbours were affected by anti-social behaviour from users of the games area. They also promised some specific actions as a result of their investigations. Ms C complained to us that a council employee had given details of her complaint to other members of the public. She also complained that the council's decision that they were unable to reach a conclusion about anti-social behaviour was unreasonable and that, almost a year after their response, the council had not undertaken the promised actions.

We found that there was no clear evidence that the council employee had given details about the complaint to members of the public and did not uphold this aspect of the complaint.

In response to our enquiries on their decision about anti-social behaviour, the council told us that there had been no indication of significant anti-social behaviour. We therefore concluded that it had been possible for them to reach a conclusion on that element of Ms C's complaints and we upheld her complaint about this.

We found that, in their complaint response, the council had said they would engage a specialist acoustic counsultant to undertake a further noise assessment and look into possible solutions to the noise. They also said that they would arrange for ball catch netting to be installed at the MUGA. We found that they had not fulfilled these actions. We upheld this aspect of Ms C's complaint.

Recommendations

What we asked the organisation to do in this case:

• The council should apologise to Ms C that they:
• unreasonably decided that it was not possible to reach a conclusion on whether Ms C and her neighbours were affected by anti-social behaviour from users of the multi-use games area;
• unreasonably failed to engage a specialist acoustic consultant to undertake a further noise assessment and look into possible solutions to the noise; and
• unreasonably failed to arrange for ball catch netting or any alternative to be installed at the multi-use games area within a reasonable timescale.
• The apologies should meet the standards set out in the SPSO guidelines on apology available at https://www.spso.org.uk/leaflets-and-guidance.
• Engage a specialist acoustic consultant to undertake a further noise assessment and look into possible solutions to the noise levels.

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 raised concerns about the way in which a social work review meeting, relating to his partner's elderly mother (Mrs A), was conducted. Mr C wanted the minutes of the previous meeting to be reviewed at the start so that he could raise points relating to that minute. This did not happen and Mr C raised this issue with the chairperson. Following discussions, the chairperson chose to suspend the meeting. Mr C complained that the council:

failed to reasonably address the genuine concerns raised by Mr C and his partner about inaccuracies in the previous minute;

unreasonably terminated the meeting stating that it was due to Mr C's behaviour;

unreasonably failed to obtain independent evidence of Mr C's behaviour at the meeting before responding to the complaint; and

unreasonably failed to confirm the council's policy on the roles and responsibilities of a chairperson when responding to the complaint.

We found that it was reasonable that a chairperson should be able to conduct a meeting as they saw fit, provided they met the purpose of that meeting. However, we considered that the chairperson should have clearly communicated how the meeting was to be conducted. This should have included reference to the fact that the previous minute of a meeting would not be addressed because the chairperson had not been present at that meeting. The chairperson should also have stated who would have been able to address any queries about the previous minute. We upheld this aspect of the complaint.

In relation to Mr C's behaviour, we agreed that the council were not required to seek a second opinion from another person present at the meeting. We found that if a chairperson felt they could not carry out the purpose of a meeting due to the actions of someone present then they were entitled to suspend that meeting. We did not uphold these aspects of the complaint.

We found that, whilst the council did not have a policy on how meetings should be conducted, it had an accepted practice. This included that the chairperson should read and make reference to previous minutes but recognised that this is not always possible. As the council does not have a policy on this, it was not able to provide Mr C with a copy. We did not uphold this aspect of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C, his partner and Mrs A for failing to address the concerns raised by Mr C about the previous minutes. The apology should meet the standards set out in the SPSO guidelines on making an 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 was diagnosed with motor neurone disease (MND - a rare condition that progressively damages parts of the nervous system) a number of years ago, and his health has been regularly monitored since then. When his condition did not progress in the way that would be expected of MND he was sent to another consultant neurologist for a further opinion as to the likely cause of his symptoms. This consultant told Mr C that they did not think he had MND. Following that consultation he was seen a few months later by his regular consultant, although the notes from the previous consultation were not available at that time. Once Mr C's regular consultant had obtained the notes, they followed up with a letter to Mr C's GP. In this letter the consultant advised that Mr C was thought to have distal hereditary motor neuropathy (a progressive disorder that affects nerve cells in the spinal cord which results in muscle weakness and affects movement). The letter, a copy of which the GP provided to Mr C, contained a lot of medical terminology. Mr C contacted the consultant's secretary, saying he did not understand the new diagnosis and wanted more information. He hoped to have another appointment at which he could ask some questions, but was given a routine appointment for a year ahead. He was unhappy about the refusal of an earlier appointment, as the matter was causing some anxiety. He also wondered why it had taken so long to reach the new diagnosis.

We took independent advice from a consultant neurologist, who considered the consultant's communications to have been clear and detailed. The adviser noted that a covering letter was sent out after Mr C expressed some confusion about the letter with a lot of medical terminology in it. The adviser considered that this covering letter could have been sent out with the inital letter. Although the adviser was not critical of the clinical care, they considered that it would have been better practice for the consultant to have agreed to seeing Mr C earlier, given that he had been diagnosed with a life-threatening condition and was expressing a lack of understanding about the implications of his new diagnosis. We noted that if this had been arranged it would likely have given Mr C some assurance and may have avoided the need for him to pursue his complaint. We also found that the board did not provide the consultant with clear detail of the complaint to us, and therefore an opportunity was missed to resolve Mr C's complaint at an earlier stage. We upheld this aspect of the complaint.

With regards to the new diagnosis, the adviser explained that there is no single exclusive diagnostic test for MND and that it remains a clinical diagnosis based on examination over a period of time. It was only as time passed, and Mr C's condition did not progress in the way that would be expected of MND, that other rarer conditions were considered. The doctors treating him were alert to this and our adviser had no criticism of his clinical care or the timescale of the diagnosis. We did not uphold this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for not providing an appointment sooner than his scheduled one to explain his diagnosis in more detail.
• Provide an appointment sooner than the one currently scheduled. This appointment should be with a different consultant.

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

• The consultant should reflect on their refusal of an earlier appointment, taking all of the circumstances into account and in particular the significant change in diagnosis and uncertainty about its implications.

In relation to complaints handling, we recommended:

• The board should reflect on their internal complaints handling, with particular focus on communication, to ensure that clinical staff involved in a complaint are fully aware of the exact nature of the complaint when they are responding to it.

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 nursing care that her father (Mr A) received whilst he was an in-patient at the Western General Hospital. During his admission, Mr A developed a pressure ulcer and Mrs C was concerned that this was not maintained hygienically or to a reasonable standard. Additionally, Mrs C complained that her father's discharge home was unreasonably delayed by a member of nursing staff.

We took independent advice from a nursing adviser. We found that Mr A's risk of developing a pressure ulcer had not been accurately assessed and that pressure ulcer care had not been provided in line with relevant guidance. The advice we received highlighted a number of issues with record-keeping in relation to pressure ulcer care and also hygiene, including that a wound assessment chart was not completed for Mr A. We also found that a pressure relieving mattress was not ordered for Mr A until he had already developed a pressure ulcer. There was also no evidence that appropriate specialist input was sought with regards to Mr A's care. We upheld Mrs C's complaint about maintaining Mr A's hygiene and the pressure ulcer.

Regarding Mr A's discharge, the advice we received was that the delay of a few hours was reasonable as nursing staff were concerned that there may not have been anyone at home to be with Mr A when he arrived. We did identify communication issues around this, which were drawn to the board's attention, however, we found that the actions of nursing staff were reasonable and we did not uphold this aspect of Mrs C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise for the failings in pressure care. The apology should comply with the SPSO guidelines on making an apology, available at https://www.spso.org.uk/leaflets-and-guidance.

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

• Appropriate risk assessments for pressure ulcers should be carried out accurately and all pressure care should be provided in line with the board's Pressure Area Care Pathway (2015).
• Patients should be nursed on a surface suitable to manage their risk of developing pressure ulcers, in line with the board's Protocol for Ordering Therapeutic Mattresses (2013).
• Wound assessment charts should be completed for patients like Mr A and injuries should be treated appropriately, in line with the relevant guidance.
• Appropriate referrals should be made for patients when specialist input is required.
• Full and accurate nursing care records should be kept for patients.

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.