Some upheld, recommendations

Summary

Ms C, who is a council tenant, complained that the council failed to ensure that her new bathroom was installed correctly as she had to report a number of leaks in the months following the installation. Ms C said that she had to report a leak on a number of occasions, and that the council and their contractor unreasonably delayed in establishing who was responsible for the leak, which led to her being left without adequate facilities for a lengthy period of time. Ms C also complained that the council delayed in completing the repairs.

The council was unable to provide accurate records in response to our investigation. It was difficult to establish exactly what happened and the reasons for the delay. We found that Ms C was left to chase up both the contractor and the council to progress the repairs and we did not find this to be acceptable. In response to our investigation, the council explained that the bathroom installation was signed off as per their normal procedures and that the leak was not related to the installation as it was not reported until one month later. We accepted that the council did ensure the bathroom was installed correctly and we did not uphold this aspect of the complaint.

However, we found that the council did not provide an adequate explanation for what happened. There did not appear to be a coordinated response from the council and Ms C was left with a leaking toilet for an unacceptable period of time. The council failed to provide evidence of a thorough investigation into Ms C's complaint. We concluded that the council unreasonably delayed in establishing who was responsible for the leak and in completing the repairs. Therefore, we upheld these aspects of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms C for failing to respond appropriately to the issues she was experiencing and for the delay in completing the repairs to her toilet. 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:

• Reflect on the findings of this complaint and consider how to improve their recording systems. The council should also ensure that their contractor provides accurate records and is reminded of the council’s responsibilities towards their tenants to complete repairs within a reasonable timescale.

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 way in which the council dealt with his application for payment of a home improvement grant for his mother. Mr C had not received a receipt from the contractor who had carried out the work, so he had submitted other evidence as proof of payment. Mr C complained that the council:

unreasonably refused to make payment of the full grant, despite receiving evidence that he had paid the contractor in full

failed to advise him that the documents that he had provided as evidence of payment were insufficient

unreasonably failed to verify whether his documents, or the documents that they had received from the contractor, were accurate in order to establish if payment for the works had been carried out

unreasonably failed to clarify in their response to his complaint why he had not been advised of what would have been an acceptable proof of payment.

We found that it was reasonable that the council did not accept the proof of payment provided by Mr C, as it was not an official bank statement, and that they therefore did not pay the full grant until further evidence was received. We did not uphold this aspect of the complaint. However, we considered that the council could have been more helpful in that they could have advised Mr C of what documentation they would accept as proof of payment. We upheld this aspect of the complaint.

We found that it would not be reasonable to expect council staff to seek to independently verify the legitimacy of any document it received which did not meet the requirements set out in the booklet issued with every grant awarded. This would be impractical and in some cases, not possible, due to data protection restrictions. We did not uphold this aspect of the complaint.

We also noted that the failure to advise Mr C of what would be acceptable proof of payment was not identified in the council's handling of the complaint and so we upheld this aspect of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for failing to advise him of what would constitute sufficient evidence of payment. Also apologise for failing to acknowledge this in their response to his complaint.

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

• Staff should advise service users who are unable to obtain a receipt from a contractor exactly what may be accepted as sufficient proof of payment in the absence of a receipt, rather than telling them what will not be accepted.

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 matters at her school. Ms C's mother had complained to the council about a number of issues on Ms C's behalf, including alleged bullying and the way the council investigated this matter. Ms C's mother was unhappy with the council's response to her complaint and Ms C then complained to us.

Ms C complained to us that the council failed to conduct their investigation of the complaint to a reasonable standard. We found that the council had taken the step of taking Ms C out of a class in which she had made allegations of racial discrimination against the teachers. We found that this was reasonable as, in taking this step, the council had regard for both Ms C and the teachers against whom the allegations were made. We found that the relevant people had been interviewed and that measures had been taken to try to resolve matters by way of offering mediation and counselling. As such, we did not uphold this aspect of Ms C's complaint.

Ms C also complained that the council had failed to communicate appropriately with herself and her family in relation to her complaint. We found failings in the way the council had communicated with Ms C and her family. English is not Ms C's first language, or the first language of her family. We found that the council had, on some occasions when a translator was not available, allowed Ms C to translate for her family. However, we found that this is in breach of their policy on interpreting and translation. We found that the council could have considered other options when a translator was not available, such as using a phone translation service. We also considered that the council's communication in their stage two complaint response was poor. We found that they did not explain the steps taken to investigate the complaint in order to justify their decision. We also found that they should have been clearer about the steps they were taking to resolve matters. We upheld this aspect of Ms C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise for the failings in communication. This apology should be in line with the SPSO guidelines on making an apology.

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

• Council staff should ensure that they comply with the terms of the interpreting and translation policy. Consideration should be given to the use of phone translation services on occasions when there is an immediate, unexpected need for translation.

In relation to complaints handling, we recommended:

• Stage two complaint responses should be detailed, setting out information about the investigation and showing clear reasoning for the decisions reached.

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's mother (Mrs A) broke her ankle in a fall. Although Mrs A had a complex medical history, including cancer and diabetes, the decision was taken at Ninewells Hospital to fix the ankle surgically. After a period of care in the hospital, Mrs A was discharged to a nursing home. During an out-patient review, it was discovered that the ankle wounds had broken down and that the metal work used to fix the fracture had become exposed. Mrs A was admitted to hospital again and underwent further surgery to remove the metal work. Mrs A was discharged back to the nursing home a few weeks later. At a further out-patient follow up, it was found that Mrs A had an infection in the ankle wound and that the bone had not grown back together. She was admitted to hospital again for treatment with antibiotics and wound care. It was considered that amputation could be necessary to control Mrs A's pain and to improve her quality of life. Amputation surgery did not take place and Mrs A was later discharged back to the nursing home.

Mrs C complained about the skin and pressure care that her mother received at the hospital across these admissions as Mrs A had developed pressure ulcers on her heel and lower back. Mrs C also complained about communication with the family in relation to amputation surgery. Mrs C and her siblings held power of attorney for Mrs A and they were concerned that the surgery was planned to go ahead without appropriate discussions with them. During their own consideration of this complaint, the board identified areas for improvement in relation to a number of areas, including pressure and skin care.

After taking independent advice from a nursing adviser, we upheld Mrs C's complaint about skin and pressure care. We found that there was a lack of evidence to demonstrate appropriate skin and pressure care had been provided. The advice we received highlighted that pressure injury to Mrs A's foot could have been avoidable with different care and that pressure area risk assessment documentation had not been properly completed for Mrs A. The board's policy on pressure ulcer prevention was not considered to have been appropriately followed in this case. The nursing adviser was asked to review the improvement plan implemented by the board following their own consideration of this complaint. The advice we received was that this did not adequately address all the failings identified. We made a number of recommendations about this as a result.

In relation to Mrs C's complaint about the board's communication with the family regarding amputation surgery, we took additional independent advice from a consultant orthopaedic surgeon. The advice we received was that it was reasonable to consider amputation in Mrs A's case, although this was not the only option available for her care and treatment. Mrs C was concerned that Mrs A had been listed for theatre and that surgery would have proceeded if she had not happened to visit her mother at the hospital. Mrs C was shocked to be told by nursing staff that Mrs A was listed for theatre the next day and spoke to a doctor to explain that she did not consider amputation to be the right thing for her mother. The advice we received was that it was reasonable to list Mrs A for theatre when the final decision on surgery had not yet been made as this avoids delay. We found that there was no evidence that amputation surgery would have gone ahead without Mrs C or her siblings being consulted further. We did not uphold this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C for the failings in pressure care. The apology should meet the standards set out in the SPSO guidance on apology, available at www.spso.org.uk/leaflets-and-guidance.

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

• We said that:
• The appropriate risk assessment documentation should be correctly completed by nursing staff caring for patients.
• Pressure injuries and moisture lesions should be accurately diagnosed and graded.
• Wound assessment should be carried out for pressure ulcer care and wound assessment charts should be completed.
• Accurate records should be maintained in relation to nursing care, in line with the Nursing and Midwifery Council Code on record-keeping.

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 have set.

Summary

Mrs C complained about the care and treatment provided to her at Perth Royal Infirmary when she had back problems. Mrs C complained that when she attended the A&E department on two occasions, she was not appropriately assessed before being redirected to another service. Mrs C also complained that, when she was admitted to the hospital, she was not provided with appropriate pain relief medication and that there was a delay in her being given surgery. Mrs C further complained that the information passed from A&E to her GP was not appropriately detailed.

We took independent advice from an A&E consultant and from a neurosurgeon. We found that the first time Mrs C had presented to A&E she was appropriately assessed. However, we found that the second time she presented there was a failure to accurately document the assessment undertaken, which meant that it was not possible to say whether it was appropriate to have redirected Mrs C to another service. We upheld this aspect of Mrs C's complaint. We also found that when Mrs C was admitted to hospital, there was an unreasonable delay in providing her with pain relief, particularly as she had been recorded as being in severe pain. We also upheld this part of Mrs C's complaint.

With regards to her surgery we found that, based on Mrs C's symptoms, there was no unreasonable delay in her having surgery. We found that the time between Mrs C being admitted to hospital and undergoing surgery was unlikely to have had any negative impact on her outcome. We also found that the information passed from A&E to Mrs C's GP was reasonable and included all of the necessary information. We did not uphold these two aspects of Mrs C's complaint.

Mrs C had also complained that the board did not answer her question regarding whether her current condition could have been avoided had she received emergency surgery at an earlier point. Whilst we recognised that this was an important matter to Mrs C, we did not consider this question to have been clearly asked of the board when she initially complained. We did not uphold this aspect of Mrs C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C for failing to properly document her assessment during her second attendance at A&E. 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:

• Appropriate pain relief should be provided to patients, and staff should check with patients whether they require pain relief medication.

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 that the board unreasonably removed her from a waiting list for orthodontic treatment. She also complained that they had failed to tell her that she had been removed from the waiting list and had not provided her with a reasonable explanation of why she had been removed.

We took independent advice from a dental surgeon. The adviser explained that there are two different types of orthodontic referral, one for consultation and the other for actual treatment. The advice we received was that Miss C's initial appointment was to assess whether she met the criteria for orthodontic treatment. The adviser said that Miss C had not met the required criteria and, therefore, she had not been placed a waiting list for orthodontic treatment. The adviser said that this decision was reasonable. The adviser also said that the board's decision not to provide Miss C with orthodontic treatment in subsequent years was reasonable and was in keeping with relevant guidance. We found that, as a result, Miss C had not been put on a waiting list for orthodontic treatment, which we found was reasonable. As she had not been put on a waiting list, she could not have been told that she had been removed from such a list. Therefore, we did not uphold those aspects of Miss C's complaint.

However, we found it concerning that, over a period of several years, Miss C appeared to be under the impression that she had been placed on a waiting list for orthodontic treatment. The adviser commented that Miss C may not have understood that there were two different types of waiting lists and that she did not appear to have been informed about the option of private orthodontic treatment until she complained to the board. We considered that it is essential that a patient understands their treatment plan and that this did not appear to have happened in Miss C's case. For this reason, we upheld Miss C's complaint that the board had not provided her with a reasonable explanation of why she had been removed from the list.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Miss C for failing to appropriately communicate with her about her treatment and for failing to ensure that she fully understood her treatment plan, the different types of orthodontic waiting lists and the option of private orthodontic treatment. 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:

• Dental staff should explain to patients and ensure that they understand:
• their treatment plan
• the different types of orthodontic waiting lists
• the option of private orthodontic treatment when they are not entitled to NHS orthodontic treatment.

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's late partner (Ms A) was given drug treatment for multiple sclerosis (a condition which can affect the brain and/or spinal cord). During the treatment, Ms A experienced stomach pain. After this she was referred for tests and she was diagnosed with cancer. Ms A underwent surgery to treat the cancer, however her condition deteriorated after the surgery and she later died.

Ms C complained that Ms A was not appropriately monitored during her multiple sclerosis treatment. Ms C considered there was a delay in diagnosing the cancer and that cancer treatment options were not fully discussed with Ms A. In addition, Ms C complained that the risk of surgery was not fully explained to Ms A and that the decision to go ahead with the surgery was unreasonable. Ms C also had concerns about the nursing care Ms A received after the surgery and about how the board dealt with her complaint.

We took independent advice from a consultant neurologist, a consultant gynaecologist and a nurse. We found that Ms A was appropriately monitored during her multiple sclerosis treatment. We found that there was no unreasonable delay in diagnosing Ms A's cancer. We also found that the decision to proceed with surgery was appropriate and that the nursing care Ms A received afterwards was of a reasonable standard. Therefore, we did not uphold these aspects of Ms C's complaint.

However, we did find that the discussions with Ms A about the cancer treatment options available to her were not properly recorded. We found that the consent form she signed for the surgery did not document all of the risks. We also found that the board did not respond appropriately to all of the concerns that Ms A raised and that there were delays in investigating the complaint, which the board had acknowledged. Therefore, we upheld these aspects of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms C for failing to properly document any discussions with Ms A about the cancer treatment options available. Also apologise that the consent form Ms A signed for the surgery did not document all of the risks. Also apologise for failing to appropriately address all of Ms C's concerns in their response to her complaint. These apologies 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:

• Every discussion with a patient about treatment options should be documented in the medical records.
• The risks of surgery discussed with a patient should be documented, in order to reduce the likelihood of a miscommunication or misunderstanding.

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, who is an advocacy and support worker, complained on behalf of her client (Miss A) about the clinical treatment Miss A received for her urinary problems. In particular, Miss C complained about the board's decision to withdraw support from community nursing services. Miss C also complained about a delay in actioning Miss A's request for a second opinion from the urology service.

We took independent advice from a consultant urologist. We found that a number of clinicians involved in Miss A's care had taken the decision to withdraw the support from community nursing services as the care being provided was no longer clinically appropriate. We found that there was no evidence of failings in the urology care provided to Miss A. We were also satisfied that Miss A's needs had been taken into account in arriving at the decision. As such, we did not uphold this aspect of Miss C's complaint.

We found that there had been a delay in actioning Miss A's request for a second opinion from urology services. We considered this to be unreasonable and we upheld this part of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Miss A for the delay in actioning the request for a second opinion.

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

• Requests for second opinions should be actioned timeously.

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 palliative care and treatment provided to her late husband (Mr A) at Cowal Community Hospital. Mrs C highlighted concerns about the prescription of pain relief, arrangements for a blood transfusion and communication with the family. Mrs C particularly felt that meetings with staff had been misrepresented in his medical records. She also complained that the board had failed to handle her complaints reasonably.

As the doctors who cared for Mr A at the hospital were general practitioners, we took independent advice from a GP adviser. The advice we received was that Mr A's pain relief had been appropriately reviewed and adjusted, and that there had been no indication that a blood transfusion was necessary. We did not uphold these aspects of Mrs C's complaint.

We did not uphold Mrs C’s complaints about communication or meetings. We found evidence that there had been regular and appropriate communication with Mr A's family, although we acknowledged that Mrs C's recollection differed from that recorded in the medical notes and other records. The advice we received was that the actions taken by the board were reasonable, on the basis of what was recorded in the relevant records.

We upheld Mrs C's complaint about the way that the board had handled her complaint. We found that there was an inaccuracy in the final response around the timeframe of Mr A dying and the complaint being raised. We also found that an issue Mrs C had raised had not been fully addressed when the board responded to her concerns. We made two recommendations to address these issues, including one regarding the new model complaints handling procedure introduced in April 2017.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C for the complaints handling issues identified. 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:

• In keeping with the new complaints handling procedure, complaint responses should be accurate and address the points made by the complainant.

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

Summary

Mrs C, who has a background of lupus (an autoimmune condition that affects the body's defences against illnesses and infections) had a tumour detected during a scan. Her case was discussed by the multi-disciplinary team (MDT) and she was given an appointment with an oncologist to discuss chemotherapy (a treatment where medicine is used to kill cancerous cells) and radiotherapy (a treatment using high-energy radiation). The oncologist was concerned that, due to her background of lupus, Mrs C could suffer significant side effects from this treatment. The oncologist asked for further discussion of the case at a second MDT, where the possibility of surgery was also discussed.

Following this, the oncologist outlined the options of surgery or oncology treatment (chemotherapy and radiotherapy) to Mrs C and Mrs C agreed to have surgery. The surgery was carried out, but did not remove enough of the tumour to give a good chance of a cure. Mrs C was then offered oncology treatment as well.

Mrs C complained to the board that she was not told before the surgery that there was a high risk that she would also need oncology treatment. She said that she would not have chosen to have major surgery if she had known that she might still need the full oncology treatment. The board took several months to respond to Mrs C's complaints, because the surgeon and oncologist disagreed about some parts of the response. Eventually, the response was sent without the surgeon's agreement. Mrs C remained dissatisfied and brought her complaints to us.

Mrs C complained that the communication with her about her condition and treatment options was unreasonable. She also complained that the care and treatment provided was unreasonable. We took independent oncology and surgical advice. We found that, whilst the oncology treatment carried a high risk of significant side effects, the surgery also carried a high risk of being unsuccessful, and Mrs C would then need the oncology treatment as well. We found that there was insufficient evidence that these two options had been fully explained to Mrs C. We also found that consent for the surgery had only been sought on the day of the operation, and there was no evidence that the risks of the surgery had been discussed with Mrs C before this point. We also found that there was an occasion where Mrs C could have been given an update on her pathology results more quickly. We upheld these two aspects of Mrs C's complaint.

Mrs C also complained that there were unreasonable delays in her treatment. We found that the timeframes were reasonable and that quicker treatment would not neccesarily have impacted on Mrs C's outcome. We did not uphold this aspect of Mrs C's complaint.

Mrs C also raised concerns about the board's handling of her complaint, and particularly raised concern that she was unable to contact the complaints team by phone at certain points. We found that the board's complaint response was delayed for several months, that they had misunderstood part of her complaint and that Mrs C was not kept updated in this time. We upheld this part of Mrs C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C for the failings in communication, care and treatment and 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:

• Patients should be given full information about all their options before deciding on a treatment.
• Consent should not be sought on the day of surgery, unless there is an emergency situation.
• Consultants should be mindful of the need to communicate clearly and avoid misunderstandings.
• Patients should be fully informed and kept up to date on information relevant to their illness. Information should not be withheld unless they specifically request this, or if there is a potential risk of harm.
• In a similar situation, surgery should not be offered as a first line treatment without a full discussion of the multi-disciplinary team's views (both for and against) and options with the patient.

In relation to complaints handling, we recommended:

• The board should have a clear process for escalating disagreements about complaints responses, with senior management involvement, to ensure a whole-of-board response to the complaint.
• The board should contact the complainant to confirm the issues complained about as the first step in their investigation, in line with the Model Complaints Handling Procedure.
• The complaints team should be contactable by phone, with the facility to leave a message if there are no staff available.

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.