Some upheld, recommendations

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.

Summary

Mr C complained on behalf of his neighbour (Mr A) about the care and treatment provided to Mr A for kidney stones at Raigmore Hospital. Mr A had a number of surgical procedures over the course of a year to remove his kidney stones, however none of these were successful and Mr A was referred to a different health board for further treatment.

We took independent advice from a consultant urologist. We found that both the medical and surgical management of Mr A's kidney stones had been reasonable, despite the procedures failing to be successful. Therefore, we did not uphold this aspect of Mr C's complaint. However, we did find that the referral to the other health board was not appropriately recorded in Mr A's medical records and we made a recommendation regarding this.

Mr C also complained about the board's communication with Mr A. He said that it had not been explained to Mr A what the treatment plans were, and that the surgeon failed to visit him after his most recent surgical procedure to explain the next steps. We found that, although communication throughout much of the time Mr A was receiving treatment was reasonable, it was not reasonable that the surgeon failed to make plans for post-operative discussions. We also found that there was a failure to make a note of a phone call the surgeon had with Mr A. Additionally, we found that the board's complaint response was poor as it failed to sufficiently cover the points complained about. We upheld this aspect of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr A for the failure to communicate with him reasonably. The apology should meet the standards set out in the SPSO guidelines on apology available at https://www.spso.org.uk/leaflets-and-guidance.

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

• Referrals to other health care providers should form a part of a patient's record.
• In similar situations, surgeons should proactively make arrangements to meet with patients post-operatively in order to discuss the operation and further management plans. Where this is not possible this should be raised with the patient in advance and an agreement on how to do this should be reached.
• Phone consultations which are part of clinical care should be recorded in writing in the patient's medical records.

In relation to complaints handling, we recommended:

• Complaint responses should fully address all issues raised by the initial complaint.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

Summary

Mr C complained about the care and treatment he received from the board in relation to a urodynamics assessment (a test which uses pressure readings to assess the function of the bladder) carried out at the Queen Elizabeth University Hospital. Although Mr C returned home on the day of the assessment, he later became unwell and was admitted to the hospital for over two weeks. Mr C considered that the urodynamics assessment had not been carried out appropriately and he complained that this resulted in his subsequent symptoms, including haematuria (blood in the urine) and urine retention (the inability to completely empty the bladder). Mr C also complained that, after he had received treatment as an in-patient, his discharge was unreasonably delayed.

After taking independent advice on this case from a consultant urologist, we upheld Mr C's complaint about the urodynamics assessment as we found that there were technical problems with the way that the assessment was carried out. We did not, however, find that these failings had resulted in Mr C's later symptoms. We found that verbal consent had been obtained from Mr C before the procedure, and we made a recommendation to the board that they consider obtaining consent in writing in the future. We made a number of further recommendations on the basis of our findings, including that the board review their patient information leaflet for urodynamics procedures.

Regarding Mr C's discharge, the advice we received was that there had been no unreasonable delay in discharging Mr C from hospital and we did not uphold this part of his complaint.

Recommendations

What we asked the organisation to do in this case:

• Provide Mr C with an apology for the failure to carry out the urodynamics assessment in line with relevant guidance and advise him if any re-assessment is necessary. The apology should meet the standards set out in the SPSO guidelines on apology available at https://www.spso.org.uk/leaflets-and-guidance.

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

• Staff should be aware of the guidance on good urodynamics practice.
• Consideration should be given to introducing a documented informed consent process for urodynamics assessments.
• The patient information sheets should be reviewed and consideration should be given to including reference to urinary retention and haematuria, plus advice on what to do if these symptoms are experienced.

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 had a vaginal hysterectomy (a surgical procedure to remove the uterus through the vagina) at the Royal Alexandra Hospital. Two weeks after the surgery, Ms C started to experience sharp pains in her vulva (the skin surrounding the entrance to the vagina). She attended the gynaecology clinic at Inverclyde Royal Hospital on three occasions over the following months for treatment and was seen by a consultant and an associate specialist. Ms C's pain persisted and by the following year was intolerable. Ms C continued to try to obtain treatment for her pain and, nearly three years after her hysterectomy, was diagnosed with vulvodynia (persistent unexplained pain in the vulva). She then started treatment for this condition.

Ms C complained that the board unreasonably failed to make her aware, prior to her surgery, that vulvodynia was a possible complication of the hysterectomy surgery. She also raised concerns that the consultant and the specialist at Inverclyde Royal Hospital failed to provide her with adequate care and treatment in the three months following her surgery. She also complained that in their response to her complaint, the board failed to adequately acknowledge that the pain she experienced, and continued to experience, was directly linked to the hysterectomy surgery.

We took independent advice from a consultant gynaecologist. The adviser said that vulvodynia following vaginal hysterectomy is rare, but that there is no data to quantify how rare it is. They said that the average surgeon might never encounter it and that they would therefore not have expected Ms C to have been made aware during the consent process that vulvodynia could be a possible complication of her surgery. We did not uphold this part of Ms C's complaint.

The adviser said that Ms C should not have been discharged from care after each of her appointments with the gynaecological team at Inverclyde Royal Hospital, as her core problem was still unresolved. We upheld this aspect of Ms C's complaint.

In relation to complaints handling, the adviser explained that although Ms C's pain being directly liked to her vaginal hysterectomy was a rare risk, the timing of her symptoms in relation to the surgery was undeniable. The adviser said that at least a strong association should have been acknowledged by the board. On balance, 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 discharging her from care after each of her appointments at Inverclyde Royal Hospital, as her core problem was unresolved. Also apologise for failing to acknowledge the strong association between the surgery and the pain Ms C experienced.

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 complained on behalf of her brother (Mr A) about the care and treatment provided to him across numerous admissions to Aberdeen Royal Infirmary. Mr A underwent various surgeries to treat spinal cord compression and a spinal abscess. After surgery to drain the spinal abscess, Mr A was left paralysed from his waist down and was left with only partial movement in his upper body.

Miss C complained to the board as she felt that Mr A had not been properly cared for and treated. She believed that opportunities were lost to treat him sooner, and that his outcome may have been different if these opportunities had been taken. The board responded, however Miss C remained unhappy and brought her complaints to us.

Miss C complained that the board did not provide reasonable treatment to Mr A across his numerous admissions to the hospital. We took independent advice from consultants in radiology and neurosurgery, and from a nurse. We found that there was an opportunity missed to drain the spinal abscess. Had the abscess been drained at that time we considered that Mr A's outcome may have been different. We found that a scan that was carried out by an outsourced company out-of-hours did not meet a satisfactory standard, however this was not identified as having impacted Mr A's outcome. We also found that Mr A's case could have been considered in a more holistic way. We upheld this aspect of Miss C's complaint.

In relation to Mr A's discharge home from hospital, Miss C complained that he was unreasonably discharged on one occasion, and that the board unreasonably failed to ensure that there was a suitable home care package in place for him following that discharge. We found no evidence to suggest that Mr A was discharged unreasonably. We found that the relevant paperwork had been completed, and that Mr A had capacity and was in agreement with the decision to discharge him at that time. We also found that there was no evidence of a need for Mr A to have a home care package in place on his discharge home. We therefore did not uphold these aspects of Miss C's complaint.

Miss C also complained that the board did not respond reasonably to her complaints. We found that the board delayed in providing a response to Miss C's complaints and that she was not kept updated. We upheld this aspect of her complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr A for not draining his abscess at an earlier time and for the lack of a holistic approach to his care. 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 Miss C for the failure to provide a timely response to her complaint and for failing to reasonably update her. 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:

• In circumstances similar to those of Mr A, consideration should be given to draining any abscess. The decision should be fully documented and care should be considered holistically.
• All outsourced advice on scans should reach the same standards as those provided in-house.

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 that his late wife (Mrs A) received from the board's out-of-hours GP service and the care she received from Victoria Hospital after she was admitted with symptoms of ongoing diarrhoea. Mr C was concerned that Mrs A's bowel cancer, which was at an advanced stage, would have been identified sooner had a CT scan been carried out sooner. He also raised concerns that there was a delay in pain relief medication being provided and that the board's response to his complaint was poor.

We took independent advice from a general practitioner and from a consultant in acute medicine. We found that the care provided by the out-of-hours GP service was of a reasonable standard because Mrs A's symptoms, and their duration, were in keeping with a working diagnosis of infective diarrhoea. We found that there was no evidence of an abdominal mass and that her vital observations (pulse rate, blood pressure and oxygen saturates) were stable with no indication of an acute emergency. We also considered that there were appropriate reasons for not carrying out the CT scan earlier. These reasons included the initial working diagnosis of infection, Mrs A's fluctuating kidney function, her warfarin (blood thinning) levels and Mrs A's preference to avoid further investigations. We did not uphold these aspects of Mr C's complaint.

We were critical that there was a delay in providing Mrs A with pain relief and we upheld this aspect of Mr C's complaint. The board have acknowledged and apologised for this. Whilst the board have taken some action, which we have asked them to provide evidence of, we made a recommendation for them to address the lack of available anticipatory medications (medicines that might be required at any time of the day or night in end of life care).

With regards to complaints handling, we found that the board's letter of response lacked clarity and should have been more accurate. We also found that some of their comments in the response letter were unneccesary. The board accepted that some of the information contained within their letter was conveyed inadequately and have taken action to ensure learning from this case. We upheld this part of Mr C's complaint. We have asked the board to provide evidence of the action they have taken and to apologise to Mr C.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for the complaints handling failings. 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:

• Staff should ensure that appropriate anticipatory medications are prescribed and administered for relevant patients in line with NHS Scotland's palliative care guidelines.

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.