Some upheld, recommendations

Summary

Ms C complained about the urological surgery care provided to her son (child A). At birth, child A was diagnosed with hypospadias (a condition where the opening of the urethra is on the underside of the penis). He also had severe chordee (where the penis is curved) and a right side hydrocele (accumulation of fluid in a body sac). He underwent a number of operations over several years to attempt to correct these issues. Ms C complained that her son was now in a worse condition that when the treatment began, and she felt that the multiple operations he had been through had not been done correctly.

We took independent advice from a paediatric urological surgeon. We found that the type of surgeries child A had undergone have a high rate of complication and that there was no evidence that the surgeries had not been carried out to a reasonable standard. However, we found that there was at one point a delay of over a year between child A being reviewed and him being listed for further surgery. We considered this delay in adding child A to the waiting list to be unreasonable. We upheld this aspect of Ms C's complaint.

Ms C also complained that the board had failed to provide a response to her complaint within a reasonable timescale. We found no evidence that the board had failed to follow their complaints procedure or that there had been an unreasonable delay, and therefore we did not uphold this aspect of Ms C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms C for failing to enter child A onto the waiting list for further surgery after his review. 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:

• Robust mechanisms should be in place to ensure that patients are entered on the surgical waiting list in a timely manner.

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 to us that she had been given morphine both during and after an operation at the Royal Alexandra Hospital, despite refusing consent for this to be used because she was allergic to it. The board had disputed that Ms C had refused consent. They told us that the anaesthetist had explained to Ms C before the operation that she had a sensitivity to morphine, but was not allergic to it. They said that they also told Ms C that it would be almost impossible to give a general anaesthetic for an operation of this nature without the use of morphine or a derivative.

We took independent advice from a consultant in anaesthesia and intensive care medicine. We found that the anaesthetic technique used by the anaesthetist was appropriate for the procedure Ms C had, even with the risk of side effects. However, given Ms C's concerns about morphine, we found that there should have been an informed discussion about the risks and benefits, which should have been documented. The anaesthetist failed to adequately document such a discussion. Given the importance of this in relation to whether morphine should have been used, we upheld this aspect of Ms C's complaint.

Ms C also complained that the anaesthetist had failed to consider alternative anaesthetic for the operation. We found that the anaesthetist had acted reasonably by putting measures in place to treat any complications during the operation and by ensuring that anti-sickness drugs were available. However, we also upheld this aspect of the complaint, as the anaesthetist had failed to document any discussion with Ms C about alternative anaesthetic for the operation, in line with the relevant guidance.

Ms C complained that the board had lost images taken during the surgery. In their response to our enquiries, the board said that they had been unable to locate the images referred to and apologised for this. We, therefore, also upheld this aspect of the complaint.

Finally, Ms C complained about the board's handling of her complaint. We found that although there had been a short delay in responding to her complaint, this delay had not been unreasonable. We did not uphold this aspect of her complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms C for:
• not adequately documenting any discussion about the risks/benefits of using morphine and any alternatives
• being unable to locate the images taken during the operation.
• 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:

• Discussions about the risks and benefits of using medication that the patients is concerned about, and discussions about any alternatives, should be documented appropriately.

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, who works for a voluntary agency, complained on behalf of the family of Miss A. Miss A had suffered complex medical problems from birth. Mr C complained that Miss A had not been provided with appropriate care and treatment at the Southern General Hospital and Yorkhill Children's Hospital. He said the family believed there had been repeated failures by medical and nursing staff. They believed that they had not been communicated with appropriately and the board had failed to action their complaint in accordance with the NHS procedure. Miss A had had to undergo surgery on her windpipe and had multiple medical complications, which required on-going medical treatment.

We took independent advice from a consultant paediatrician and a paediatric nurse (specialists in the care of infants, children and young people). They concluded that the main failing on the part of the board was the failure to appoint a lead clinician to oversee Miss A's treatment. While we found that the clinical care and treatment provided to Miss A had been appropriate, this failure to appoint a lead clinician had contributed to the communication failures with the family. The nursing advice we received was that staff had not monitored Miss A's oxygen saturation levels appropriately and that the family had been forced to request that oxygen monitoring be provided.

We found that the board had failed to communicate adequately with the family and, although they had acknowledged this, we found that the board had provided no evidence to show that they had taken steps to avoid a reoccurrence. We also found that the board's response to the complaint had taken an unreasonable length of time and that the responses the family had received had been inaccurate.

We asked the board to apologise for their failings and take a number of actions to address them.

Recommendations

We recommended that the board:

• provide evidence that they have reviewed their oxygen saturation monitoring policy to ensure it corresponds with national guidance for children;
• review care planning for children with respiratory vulnerabilities to ensure that pulse oximetry values (used to measure the oxygen level of the blood) are monitored;
• review care planning to ensure that parental concerns for the child are recorded;
• remind the nursing staff involved in Miss A's care of the importance of comprehensive respiratory care plans to ensure less experienced staff are able to monitor patients effectively;
• provide evidence of the outcomes of the multi-disciplinary review considering continuity of care between acute and community services;
• provide evidence of the outcomes from the multi-disciplinary review of the allocation of lead-care coordinators;
• provide evidence of the changes made to the process for feeding back sleep study results to the parents of children undergoing treatment;
• review their processes in relation to complaint handling of complex cases where more than one department is involved to ensure that a single clinical lead is appointed to oversee the response; and
• apologise for the failings we identified.

Summary

Miss C complained that the medical practice had failed to carry out an appropriate assessment or refer her late father (Mr A) to hospital when he attended a consultation. Mr A was very breathless and suffered from pulmonary fibrosis (scarring of the lungs). The GP did not take Mr A's temperature or provide medication, as they felt that no further treatment was required at that time. Mr A was told to wait until his next scheduled respiratory clinic at the hospital, which was in nine days time. When Mr A attended the clinic, a clinician arranged an immediate hospital admission. Mr A deteriorated and died a few days later. Miss C felt that the GP should have referred Mr A to hospital sooner.

We took independent advice from an adviser in general practice medicine. We concluded that, although the GP had arranged for an ECG (electrocardiogram - test to check the rhythm of the heart), the GP failed to record Mr A's oxygen saturation, temperature and blood pressure. We found that the GP had failed to carry out an examination of the heart, which would have been appropriate for a patient who had presented with increased breathlessness and chest pains. We also concluded that, while it was possible that the GP's decision for Mr A to wait until his clinic appointment may have been reasonable, we were unable to establish this as the standard of record-keeping for the consultation was inadequate. We upheld Miss C's complaint that the GP failed to provide Mr A with appropriate treatment in view of his reported symptoms. However, in view of the inadequate record-keeping, we could make no finding on the complaint that the GP should have referred Mr A for a hospital assessment.

Recommendations

What we asked the organisation to do in this case:

• Send Miss C a written apology for the failure to carry out a thorough assessment in view of Mr A's reported symptoms.
• Send a written apology to Miss C for the inadequacies in record-keeping which meant we could not determine whether a hospital referral was required.

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

• The GP involved should ensure that a thorough assessment is carried out in view of a patient's reported symptoms.
• The GP involved should ensure that their record-keeping meets the standard of what would be expected under the General Medical Council's Good Medical Practice guidance, in terms of clinical assessment, record-keeping and safety netting.

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 late wife (Mrs A). Mrs A had amyloidosis (a condition caused by abnormal deposits of a protein called amyloid around tissues and organs in the body) and Mr C felt that the diagnostic process for this was slow. Mr C had concerns that biopsies undertaken by the board were found to be negative for amyloidosis, but were later found to be positive when tested at the UK's National Amyloidosis Centre. We took independent advice from a consultant physician, a cardiologist, and a pathologist. We did not find that there were any unreasonable delays in determining that Mrs A had amyloidosis. The advice we received was that it was reasonable that the National Amyloidosis Centre was able to make a diagnosis when the board did not, as the National Amyloidosis Centre is more experienced in the techniques for testing. We did not uphold this complaint.

Mr C also complained about failures in communication and failures in providing adequate support to Mrs A and her family during Mrs A's illness. We took independent advice from a consultant physician and found that the board's communication with the family throughout Mrs A's illness, and the support provided to Mrs A, was unreasonable and insufficient. We considered that a protocol for earlier involvement of specialist nurses, and consideration of how to access information from the National Amyloidosis Centre, would have minimised this issue. We made recommendations regarding this.

Finally, Mr C complained about the board's handling of his complaint. We found that the board had failed to meet deadlines and had failed to provide clear explanations to Mr C. We upheld this complaint. However, we found that the board had implemented a new complaints handling procedure since Mr C's complaints and so we did not make any recommendations around this issue.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for failing to communicate with the family properly during Mrs A's illness, for failing to provide Mrs A with adequate support and for failing to handle Mr C's complaints about Mrs A's treatment reasonably.

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

• There should be a protocol for how to involve specialist nurses in the care of patients with very rare conditions, and where to get specialised information and support.
• The board should consider how they could access information and support from the National Amyloidosis Centre to provide to 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

Ms C complained about the care and treatment her father (Mr A) received at University Hospital Crosshouse. Mr A had cancer and was suffering from jaundice, requiring him to have bile drained from his body. Mr A had an Endoscopic Retrograde Cholangiopancreatography (ERCP) procedure (a procedure that examines the pancreatic and bile ducts) to try and drain the bile. After this he developed sepsis (a blood infection) and died in the hospital several days later.

We took independent medical advice from a consultant in gastroenterology and an intensive care consultant. We found that an ERCP procedure was the recommended and appropriate treatment to attempt to drain the bile and relieve Mr A's jaundice. Whilst we found that it was reasonable for staff to have carried out this treatment, we found that the procedure was unsuccessful as a result of the invasion of the cancer. The resulting undrained bile had led to Mr A developing sepsis, which is a recognised complication of this procedure. We also found that, although there were some delays in carrying out investigations, including the ERCP procedure, these delays were not unreasonable and did not affect Mr A's outcome. We noted that the surgical team could have recognised the deterioration in Mr A's condition more quickly, however, we found that this did not affect his outcome and found his overall medical management was acceptable. Taking account of the evidence and the independent advice we received from both advisers, we considered that, on the whole, the care and treatment Mr A received was reasonable and we did not uphold this complaint.

Ms C also complained that hospital staff had failed to communicate adequately with her and her family about the seriousness of Mr A's clinical condition and prognosis. We found that there should have been better communication with Mr A's family regarding the risks of an ERCP procedure and also regarding the severity of his illness and prognosis, in particular, when Mr A's condition deteriorated after the ERCP procedure. The board acknowledged that there were shortcomings in their communication with Mr A's family, for which they had apologised. They said that they had taken action to address these failings and we asked the board to provide us with evidence of this. We upheld this aspect of Ms C's complaint but, in light of the action the board had said they had taken, we did not make any further recommendations on this issue.

The gastroenterology consultant who we took advice from on this case commented that there were shortcomings in the level of detail and clarity of documented discussions with Mr A about his diagnosis and its management. We made a recommendation for action in relation to this.

Recommendations

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

• Discussions with a patient should be clearly documented with the relevant amount of clarity and detail.

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 support her child (child A) received from the Child and Adolescent Mental Health Service (CAMHS). During a period of absence of child A's regular therapist, child A was transferred to a new therapist who was not trained in the approach that the first therapist had used. The second therapist then left the service, and Ms C was told that, if child A wished to wait for the first therapist to return, they would need to be discharged in the meantime. Ms C also complained that CAMHS did not provide support to child A in response to a recent traumatic event, or in relation to a decision about child A's future schooling.

In response to Ms C's complaint, senior members of staff met with her, and it was agreed that child A would remain a patient with CAMHS, but that support would be provided by phone to Ms C until the first therapist returned. The board sent a written response to Ms C's complaint five months after this meeting, which confirmed these arrangements and apologised for the tone of a phone call with the CAMHS team leader. Ms C was not satisfied with the response, or the board's handling of her complaint, and she brought her complaint to us.

We took independent advice from a psychologist. In relation to the proposal to discharge child A while waiting for the first therapist to return, we found that staff acted reasonably, and so we did not uphold this complaint. However, we noted that it would have been helpful for them to have discussed Ms C's concerns and explored alternative options to discharge at an earlier stage, as we found that this was only done in response to her complaint.

We found that, whilst it was appropriate for the therapist not to raise the subject of a traumatic event with child A, they should have raised this with Ms C separately in order to explore the issues and offer indirect support. We also found that, although CAMHS was not responsible for the schooling decision, they had agreed to provide an assessment to support this decision and that there was an unreasonable delay in providing this. We upheld these aspects of Ms C's complaint.

Whilst the board had already apologised for the delayed complaint response, we were critical that Ms C was not kept updated during this delay, and that the board's response did not address key points of her complaint. We upheld this part of Ms C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms C for:
• not providing support in response to the recent traumatic event
• not completing the agreed assessment in time
• failing to update her regularly during their complaint investigation
• not responding to all of her points of complaint.
• 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:

• Where a recent traumatic event is reported in relation to a child currently under the care of CAMHS, the therapist should seek to provide support, for example by raising the issue separately with the parent/carer.
• Agreed assessments should be carried out timeously.

In relation to complaints handling, we recommended:

• Where a complaint response takes longer than 20 days, the complainant should be kept updated on progress.
• Complaints should be responded to in full.

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 attended a course at the college. There were verbal interactions between Mr C and his tutor over the course of two tutorials. Subsequently, the college suspended Mr C and instituted a disciplinary process against him. The disciplinary process made no findings against Mr C. Mr C complained about the actions of his tutor, which were also investigated by the college.

In investigating Mr C's complaints, we reviewed the material Mr C and the college provided, as well as the relevant policies. Mr C made four complaints about the college, of which we upheld three.

Mr C complained that the college's tutor acted unprofessionally towards him at the tutorials. We found that there were opposing views on what occurred at the two tutorials. We considered there was insufficient evidence to conclude that the tutor acted unprofessionally, and did not uphold this complaint.

Mr C said that at the first tutorial he was not provided with written material on yellow paper (as required under his personal learning support plan). The college acknowledged this was not provided, and we upheld Mr C's complaint in this regard.

Mr C raised a number of concerns about the way the college brought and handled the disciplinary investigation against him. We had concerns about delays in the disciplinary process, the procedure followed, and the decision to immediately suspend Mr C. Therefore, we upheld Mr C's complaint on this point.

Mr C said the college's complaints process was unreasonable. We found that while the college had taken interviews as part of this process, their investigating officer did not consider transcripts previously obtained during the disciplinary process. We considered that this evidence should have been taken into account. We upheld Mr C's complaint in this respect.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for the failings in the disciplinary process and the failings in the complaints process. This apology should comply with 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:

• Staff should be aware of the requirements of the student disciplinary procedure.

In relation to complaints handling, we recommended:

• Complaints investigation staff should consider the transcripts of disciplinary processes as evidence when dealing with 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

Ms C, who works for an advocacy and support agency, complained on behalf of her client (Mrs A). Mrs A was referred by her GP to hospital as she had an umbilical hernia. She had tests involving her chest, abdomen and pelvis which led to a suspicion of cancer, and a letter was sent to her GP advising that at the same time as her hernia was repaired, a biopsy would be taken. After these procedures, Mrs A was advised that it was likely that she had cancer. She was reviewed at a subsequent appointment where it was confirmed that she had advanced malignant disease.

Ms C complained about the way in which Mrs A had been told about her diagnosis and that she had not been given full information about the surgical procedures she was to undergo. She also said that the board had delayed in reaching a diagnosis and delayed in responding after Ms C made these complaints to them.

We found that Mrs A had been alone when her diagnosis was given to her and that no effort had been made to try to contact her husband before she was given bad news. We found little evidence that the procedures and the risks had been fully explained to Mrs A, despite the fact that she had signed the consent form as having understood. We upheld these aspects of the complaint. Although Mrs A felt that there had been a delay in diagnosing her, we found no evidence of this. She was seen within a month of referral, and tests were carried out in a timely way. We did not uphold this aspect of the complaint. However, we did find that when the board came to consider Ms C's complaints, they took too long, so we upheld this aspect of the complaint.

Recommendations

What we asked the organisation to do in this case:

• The board should send Mrs A a formal letter apologising for failing to attempt to involve her husband or another supporter when she was given bad news.
• The board should send Mrs A a formal letter apologising for failing to discuss the risks of surgery with her.
• The board should send Mrs A a formal letter apologising for the delays in responding to her complaint.

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

• The board should ensure as far as possible that when patients are receiving bad news, they are personally supported by a friend or family member.
• The board should ensure that prior to elective surgery, a full explanation is given to the patient including information about the risks entailed. This conversation should be documented.

In relation to complaints handling, we recommended:

• The board should complaints should be responded to within the stated timeframes. Where this is not possible, the complainant should be updated.

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 a number of concerns about the service he received from Scottish Water. Mr C lived in a property which is not served by a typical mains water supply, but instead involves a private pump system drawing water from a Scottish Water storage tank. Mr C experienced issues with this system and replaced his pump with a new one. When this did not resolve the supply issue, Scottish Water agreed to investigate the problem. We found that Scottish Water provided Mr C with an alternative supply of water throughout their investigation, and after almost three weeks the source of the supply issue was identified. Scottish Water replaced the pump Mr C had installed with a different kind, which restored the system to its original design. After a short delay in commissioning this pump, the supply issue was resolved.

Mr C felt that Scottish Water was responsible for his pump failing in the first place and complained that there was an unreasonable delay in Scottish Water reinstating his water supply. We took independent advice from a chartered engineer who has experience in the water industry. The adviser noted that the pump was owned by Mr C and was his responsibility. They did not find evidence that Scottish Water was responsible for the pump failing and said that Scottish Water was not obliged to replace the pump, but did so in good faith. The adviser considered that there were good reasons for the delay in investigating the cause of the supply issue and did not consider that the delay in commissioning the new pump was unreasonable. We did not uphold this complaint.

Mr C complained that Scottish Water unreasonably contaminated his water supply during their investigation of the supply issue. Scottish Water acknowledged that, during the investigation, an operative failed to follow correct water hygiene practice, which resulted in the contamination of Mr C's water supply. Scottish Water said that an apology was offered to Mr C at the time and they confirmed that the operative's training record showed that training in water hygiene and operating processes was up to date. The adviser found that once Scottish Water became aware of the incident, it followed the expected procedures and appropriately escalated the issue. The adviser noted that Scottish Water took and analysed three sets of samples, flushed the system between each sample, and provided bottled water to Mr C property in the meantime. In view of the failing, the adviser said that they would have expected the operative to have undergone further training and reassessment. On balance, we upheld this aspect of Mr C's complaint.

Mr C also raised concern that Scottish Water staff failed to appropriately communicate with him regarding the supply and contamination issues. We did not find evidence of significant delays in staff returning Mr C's calls or failing to call him back when this had been agreed. Based on the evidence available, we were unable to conclude that the communication maintained was unreasonable. While we did not uphold this complaint, we considered that Scottish Water's record-keeping of phone conversations with Mr C could have been better.

We also considered how Scottish Water handled Mr C's complaint. We were critical that Scottish Water's complaint response had not addressed all of the main issues that Mr C raised in his complaint and we upheld this aspect of his complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for the contamination incident, and for the complaints handling shortcomings. This apology should comply with SPSO guidance on making an apology, available at www.spso.org.uk/leaflets-and-guidance.

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

• Operatives should carry out their work in accordance with the Hygiene Code of Practice and Scottish Water Distribution, Operation and Maintenance Strategy procedures.

In relation to complaints handling, we recommended:

• Staff should appropriately respond to the points of concern within customers' complaints. Staff should ensure that each aspect of the correspondence is addressed.

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.