Some upheld, recommendations

Summary

Ms C was in the early stages of pregnancy when she had a miscarriage. Ms C complained about the care that she received when she contacted the board's early pregnancy service by phone and she was concerned that appropriate testing had not been carried out following the miscarriage. Ms C also complained about the way that staff had communicated both with her and between departments, as she had to explain to a member of staff carrying out a scan that the pregnancy had miscarried.

We took independent advice from a nursing adviser and from a midwifery adviser. We found that the clinical advice Ms C was given was reasonable and that the management of the miscarriage was in line with relevant guidance. We also found that some testing had been carried out following the miscarriage and that further investigations were not required in Ms C's circumstances. We did not uphold Ms C's complaint about the care provided to her by the early pregnancy service.

Regarding communication, we found that, on some occasions, it had been difficult for Ms C to reach someone at the early pregnancy service. We found that the board had identified a programme of enhanced communication training to be implemented as a result of Ms C's concerns. We also found that the board planned to change their process when referring women for scans so that more information was available to the scanning staff. 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 the failing in communication between staff. 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 have a 24 hour contact phone number for the early pregnancy service, in line with national 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 complained about a consultation that his brother (Mr A) had with an out-of-hours service doctor. Mr A was referred to the on-call doctor by NHS 24 when he called to report pain in his chest and both arms. Mr A was examined by the on-call doctor who considered that muscular pain was the likely cause. Mr A returned home, however, later that evening he was taken to the emergency department by Mr C and was ultimately diagnosed with a heart attack. Mr C complained to the board about the consultation with the on-call doctor as he considered that Mr A's condition should have been identified sooner. Mr C was also concerned that the board's response to his complaint was unreasonable.

We took independent advice from a GP experienced in out-of-hours care. We found that Mr A did not have the typical presentation of a heart attack and consequently, this could not have been foreseen by the on-call doctor. We found that arriving at what later turned out to be an incorrect diagnosis did not mean that the on-call doctor was at fault and we found that there was evidence that they had adequately and appropriately assessed Mr A. We did not uphold this aspect of Mr C's complaint.

Regarding Mr C's complaint about the board's response to his concerns, we found that there was a minor inaccuracy in the response and that there was a lack of evidence that Mr C had been kept properly updated when the timescale for responding to his complaint passed. We upheld this aspect of Mr C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C that the timescales for responding to his complaint were not made clear. The apology should meet the standards set out in the SPSO guidelines on apology available at https://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 complained about the care and treatment provided to his mother (Mrs A) during her admission to University Hospital Crosshouse. He raised particular concerns about an initial cancer misdiagnosis for what was a chest infection / pneumonia. We took independent medical advice from a consultant physician who considered that it was reasonable for medical staff to have considered the possibility of a cancer diagnosis given Mrs A's presentation and background. They advised that this did not impact on the treatment provided as reasonable steps were taken to continue to treat for infection, while planning appropriate investigations. However, the adviser said it appeared that communication with the family may have been unduly weighted towards the likelihood of cancer. In addition, they noted that there was a delay in the clinical team receiving an x-ray report, which might have contributed to the lack of clarity and prolonged the apparent overestimation of the probability of an underlying cancer. On balance, we did not uphold this aspect of the complaint but we made some recommendations.

Mr C complained that the focus on a cancer diagnosis led to a delay in commencing appropriate treatment. He noted that Mrs A's blood pressure rose unchecked resulting in her suffering a stroke. While the adviser reiterated that treatment for infection was appropriately continued, they identified that the treatment choice for the initial 24 hours was unreasonable. They noted that Mrs A's CURB 65 score (a score which guides treatment for community acquired pneumonia) should have been calculated and this would have indicated the need for a second antibiotic. After the initial 24 hours, however, the adviser noted that a stronger antibiotic was appropriately administered. The adviser noted that there were factors preventing optimal monitoring and treatment of Mrs A's blood pressure, but they considered the management of this was reasonable in the circumstances. They noted that there were other potential factors which might have contributed to Mrs A's stroke and could not solely attribute this to her blood pressure. On balance, we did not uphold this aspect of the complaint but we made a recommendation for action by the board in relation to the initial choice of antibiotic.

Mr C also raised concerns about the board's handling of his complaint. We were critical of the board in this regard. We did not consider there to be sufficient evidence to demonstrate that the issues raised were thoroughly investigated. In particular, no written report of the investigation was produced. A meeting was held and this was followed by a short letter detailing some action points. This was issued outwith the required 20 working day period and no explanation for the delay was given. Mr C then had to chase on several occasions for updates on actions taken and, even then, the board did not sufficiently demonstrate learning from the complaint. There was also an oversight by the board in terms of timely further contact with Mr C, for which they had already apologised. We upheld this aspect of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to the family for the failings in relation to communication, medical treatment, and 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.

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

• Medical staff should be guided by the CURB 65 score when treating for community acquired pneumonia.
• Medical staff should communicate clearly with patients and relatives to ensure they understand any diagnostic uncertainty, and the purpose and aims of the treatment options being explored.
• Clinicians should know how to easily ask for a radiology opinion and, where a formal x-ray report is required, this should be returned to the clinical team within a reasonable timeframe.

In relation to complaints handling, we recommended:

• The board should review their handling of this case with a view to making improvements and ensuring compliance with their statutory responsibilities regarding complaints handling, as set out in the Can I help you? 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

Mrs C was studying for a PhD at the university. She was concerned about the conduct of her final oral examination. She complained that her supervisor was asked to leave the examination, contrary to university regulations. She also complained that she was not permitted to finish her answers during the examination and alleged that the external examiner had made comments to her supervisor that indicated he had a bias against students of her nationality.

Mrs C complained to us that there were administrative errors in the conduct of her oral exam, that some communication with her had been incorrectly headed and that the university did not respond reasonably to her complaints.

We found that it would have been reasonable for Mrs C to raise concerns about her supervisor being asked to leave the examination at the time, not after the fact, and we could not reach a finding in relation to her remaining concerns about the conduct of the examination. As such, we did not uphold her complaint of administrative errors in the conduct of the examination.

We found that there were two occasions where the university sent letters to Mrs C that contained incorrect headings, so we upheld the aspects of her complaint regarding this. However, we found that the university had already offered their apologies for these mistakes, and so we made no further recommendations in relation to this.

We found that the university's handling of Mrs C's complaints was unreasonable. We found that the university had not properly investigated the alleged statements of the external examiner which may have indicated that he had a bias against students of Mrs C's nationality. We also found that the university had not responded reasonably to Mrs C in relation to the other matters she raised. We upheld this part of her complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C that they did not respond reasonably to her complaints about the conduct of an oral examination. The apology should meet the standards set out in the SPSO guidelines on apology available at https://www.spso.org.uk/leaflets-and-guidance.
• Properly investigate Mrs C's allegation that an external examiner made comments to her supervisor that indicated he had a bias against students of Mrs C's nationality, and advise her of this.
• Following the conclusion of the investigation of Mrs C's allegation that an external examiner made comments to her supervisor that indicated he had a bias against students of Mrs C's nationality, consider what impact, if any, this may have had on the outcome of Mrs C's oral examination. Take any reasonable steps as a result and advise Mrs C of this.

In relation to complaints handling, we recommended:

• Respond to all specific and relevant points raised in 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 C bought a second property with a view to renovating it and eventually moving into it. It took Mr C some time to bring the property up to habitable standards, and he moved into the property two and half years after buying it. When he moved in, he received a notification from the council about a council tax levy that was imposed on him from seven months earlier. Mr C complained to the council that they failed to inform him of this levy in writing at that time. He also believed the legislation from the Scottish Government gave local authorities flexibility and discretion when imposing the levy. We asked the council if the policy to impose a council tax levy on unoccupied properties was a blanket decision and whether they considered that they were not using their discretion when they could have been. The council confirmed that it was a blanket decision as they wanted to treat all home owners equally, and therefore it was not unreasonable to not consider Mr C's individual circumstances.

Following our investigation, the council accepted that they failed to take the Scottish Government's 2015 guidance into account when they originally drafted their policy. However, we also found that the council were correct in how they interpreted the relevant regulations and that they had the discretion to impose the levy on all cases and not take into account individual circumstances. Our investigation found that the Scottish Government's 2015 guidance on the regulations was not accurate and conflicted with the regulations. As a result, the Scottish Government has agreed to amend the guidance. We did not uphold this complaint, however we recommended that the council review their policy for council tax levies for unoccupied dwellings.

The council explained there was an administrative error when processing Mr C's account which explained why he did not receive notification of the council tax levy in writing. We upheld this aspect of Mr C's complaint.

Recommendations

What we asked the organisation to do in this case:

• The council should review Mr C's council tax account and reconsider his individual circumstances.

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

• The council's policy for council tax levies for unoccupied dwellings should include a provision to exercise discretion when considering whether to apply the levy on a case by case basis, in line with Scottish Government guidance on the regulations.

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.

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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.