Some upheld, recommendations

Summary

Mr C complained that his GP practice unreasonably failed to arrange a scan of his shoulder and that they failed to refer him to an external psychology service. Mr C also had concerns that the practice failed to consult with him following a review of his medication, and that they failed to act on a letter sent to them by a consultant neurologist regarding changes to his medication. Mr C also complained that the practice failed to provide adequate responses to his letters and that they failed to apply the correct complaints handling procedure.

Mr C required a cortisone injection in his shoulder and he requested that a scan be performed prior to receiving the injection. We took independent advice from a GP adviser and found that giving a scan prior to a cortisone injection is not standard practice in Scotland, therefore it was reasonable that the GP did not request this. We did not uphold this complaint.

We found the standard procedure would be for a clinician to make a referral to external services, such as an external psychology service, and that a GP would not usually make such a referral. We, therefore, saw no evidence of failure on the part of the practice in this regard, and did not uphold this aspect of Mr C's complaint.

We found that changes to Mr C's medication were discussed with him by his consultant, and that the GP correctly followed the consultant's instructions to amend the prescription. We found that when Mr C enquired with the practice about this change, they correctly advised him to make an appointment with his GP to discuss the review of his medication. We did not uphold this complaint.

We found no evidence that the practice had failed to respond to Mr C's queries in a reasonable manner, and we did not uphold this complaint. However, we did find that the practice failed to follow the correct complaints procedure, and that they provided Mr C with the incorrect complaints procedure. The practice acknowledged this mistake, and we upheld this aspect of the complaint. We asked that the practice send us a copy of their new complaints handling procedure and evidence that all relevant staff have received training on this.

Recommendations

In relation to complaints handling, we recommended:

• Information about the complaints procedure should be accessible and made easily available to patients by providing leaflets in the practice and information on their website.

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 orthopaedic care and treatment provided to her by the board. She complained that she was given facet joint injections (injections of anaesthetic to relieve pain) into her spine without being examined by the consultant first, and that at her review appointment she again was not physically examined despite having ongoing pain. Mrs C was also concerned that she was not referred for an MRI scan or CT scan by the orthopaedic consultant. She also complained that the orthopaedic consultant failed to communicate reasonably with her after her review appointment, and that they did not refer her to the pain clinic when they said they would.

We took independent advice from an orthopaedic consultant. We found that it was reasonable that Mrs C was not referred for an MRI or CT scan, as this was in line with national guidance. However, we found that it was unreasonable that Mrs C was not physically examined before the anaesthetic injections were administered, or when she was reviewed at a later appointment. On balance, we upheld Mrs C's complaint about care and treatment.

We found that the communication from the orthopaedic adviser to Mrs C after her review appointment was reasonable and did not uphold this aspect of the complaint. However, we found that there was an unreasonable delay in referring her to the pain clinic and we upheld this aspect of the complaint.

Mrs C also complained about the board's response to her complaint. We found that when Mrs C initially made her complaint, she made it to the complaints department as well as to the individual clinician. Therefore, we considered there had been some confusion regarding who would respond to her complaint. We also found that there had been delays in the response being issued and that Mrs C had not been kept reasonably aware of these delays. The board confirmed that they had already taken action to address this failing. We upheld this complaint.

Recommendations

What we asked the organisation to do in this case:

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

• Orthopaedic consultants should carry out physical examinations before administering facet joint injections, and at review appointments if the patient is complaining of ongoing pain.
• When patients are informed that a referral will be made, this should be done promptly.

In relation to complaints handling, we recommended:

• When a complaint has been made directly to a clinician as well as to the complaints and feedback team, efforts should be made to clarify who will be investigating and responding.

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 that the time his son (child A) had to wait to have treatment by the child and adolescent mental health services (CAMHS) was unreasonable. Mr C also complained that the board failed to take into account all of child A's circumstances before reaching a decision to refuse a referral to CAMHS a number of years earlier. Mr C also raised concerns about the board's handling of his complaint.

During our investigation we took independent advice from a CAMHS nurse. We found that whilst waiting times for CAMHS are long nationally, the government's waiting time target is for treatment to begin within 18 weeks of referral. In this case, child A had waited eight months from referral to treatment. We found this to be unreasonable. The board told us that families are encouraged to go back to the referrer whilst they are waiting for treatment if they are worried about a deterioration in a child's condition. However, we found no evidence that this had been communicated to Mr C or child A and we were critical of this. We upheld this aspect of Mr C's complaint.

In relation to Mr C's complaint about the board refusing a referral for his son to CAMHS at an earlier date, we found that the referral letter did not mention any mental health concerns. We found the letter only mentioned issues such as family relations and behavioural problems, which would not normally be treated by CAMHS. We therefore found that it was reasonable for the board not to have accepted a CAMHS referral for child A at that time. We did not uphold this aspect of Mr C's complaint.

We found that the board's handling of Mr C's complaint had been unreasonable. Whilst we considered the board to have taken reasonable steps to ensure patients are aware of the complaints process, we found that the board had failed to meet the 20 working day target for the full response to Mr C's complaint as set out by the Scottish Government's 'Can I help you?' guidance. The board stated that they considered the 20 working days to start running from when they had received child A's consent to investigate. However, this contradicts the guidelines around complaints handling. We upheld this aspect of Mr C's complaint.

Recommendations

We recommended that the board:

• provide information on what steps they are taking to meet government waiting time targets for CAMHS;
• give consideration to how they can ensure families are aware that, if they have concerns about increased risk or deterioration of symptoms whilst a child is waiting for treatment from CAMHS, they can go back to the referrer;
• apologise to Mr C for the failings in complaints handling identified by this investigation; and
• feed back the findings on complaints handling to the relevant staff.

Summary

Mrs C complained to us about the care and treatment provided to her late father (Mr A) at Wishaw General Hospital after he was diagnosed with cancer of the oesophagus (the tube that carries food from the throat to the stomach). Mr A had been admitted to hospital for an operation. During the operation a hole in one of his air passages was identified and he was transferred to another hospital outwith the board area. It was decided there that his cancer had spread and was inoperable. Mr A died four days later.

Mrs C complained that there had been delays in carrying out tests and in providing treatment to Mr A. We took independent advice from a consultant upper gastrointestinal surgeon and from a consultant radiologist. We found that, in general, the board had provided reasonable care and treatment to Mr A. However, there had been delays in carrying out two scans that Mr A needed. The board did not have the facilities to carry out these scans and had referred Mr A to another board. There was no evidence that the board had taken any action to escalate the matter when there were delays in carrying out the scans. In view of this, we upheld Mrs C’s complaint, although we did not consider that the delays in carrying out the scans would have influenced the ultimate clinical outcome for Mr A.

Mrs C also complained that the board did not take reasonable action to investigate the possibility of Mr A’s cancer spreading before the operation. We found that the investigations the board had carried out before the operation were appropriate and in line with standard practice. It had also been reasonable for them to carry out the operation. 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 the failure to act on the delays in the scans being carried out. 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:

• Ensure that there are adequate mechanisms in place to prevent delays in having scans carried out outwith the board.

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 events following an incident when he became ill at home and was taken by ambulance to Monklands Hospital. He said that the board incorrectly recorded that he underwent a loss of consciousness at home and then unreasonably assessed that he was unfit to drive. He said they failed to follow health guidelines on loss of consciousness in over 16s and that their actions resulted in an unnecessary ban on driving for him. Mr C also said that the board unreasonably failed to respond to his complaint.

Mr C said the board failed to communicate the basis of their diagnosis of his illness to him and how this affected his fitness to drive. He said they also provided him with incorrect information regarding the relevant Driver and Vehicle Licensing Agency (DVLA) regulations and his future prospects of driving. Mr C subsequently saw a cardiac consultant who said there was nothing clinically wrong with his heart and that he had undergone a simple faint and was fit to drive.

We took independent medical advice from a consultant in general medicine, who said it was not clear from the records whether Mr C did or did not lose consciousness. However, the adviser noted that there was no evidence that staff had asked for any witness accounts of what occurred from Mr C’s wife or daughter, which they considered to be crucial in such cases. The failure by staff to gather this information before assessing that Mr C was unfit to drive meant that their decision was based on incomplete information. We upheld this part of Mr C’s complaint.

We also found that the evidence available did not demonstrate that staff gave Mr C reasonable information about the basis for his diagnosis and how this affected his ability to drive. We upheld this part of the complaint. We asked the board to provide evidence of remedial action that they said they had taken and also made recommendations to address the remaining failings. We did not have sufficient evidence to say with certainty that Mr C was incorrectly advised of the relevant DVLA regulations and his future prospects of driving. Therefore, we did not uphold this part of his complaint.

We also found failings in the board’s handling of Mr C’s complaint and, therefore, upheld this part of his complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for failing to follow National Institute for Health and Care Excellence guidelines, the failings in communication about the assessment that he was unfit to drive and the failings in their complaint responses. 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 transient loss of consciousness (TLoc) is suspected, staff should question the person involved and any witnesses, and use this information in determining whether the person had TLoC.
• Patients found to be unfit to drive should be given clear information about the basis for this.

In relation to complaints handling, we recommended:

• Complaint responses should address the issues raised, clearly explain any areas of disagreement and give adequate apologies where things have gone wrong.

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 care and treatment provided to her late father (Mr A). Mr A suffered from advanced dementia, and was cared for at home by his daughters, with support provided by community mental health services and district nurses. Mrs C was concerned that Mr A was over-sedated and did not receive enough stimulation. Mrs C raised concerns that a decision was made to continue a three week trial of diazepam without a review by the psychiatrist. Mrs C complained that the decision to prescribe diazepam was inappropriate. Mrs C was also concerned that staff recommended continuous bed rest for Mr A, which meant that he was no longer able to get up or sit in his chair. Mrs C did not agree that Mr A could no longer mobilise and did not feel that he was at risk of falling, aside from being over-sedated from the diazepam. She complained that the decision to recommend Mr A remain on bed rest was inappropriate. Mrs C also complained that mental health services failed to appropriately assess Mr A's mental health problems. She felt that staff failed to address environmental factors that were contributing to his distress, such as poor personal care and lack of stimulation.

The board provided two written responses to Mrs C’s complaints, responding separately to her concerns about the district nurses and about the mental health services. The board considered that the care and treatment provided was appropriate. Staff from the board also met with Mrs C to talk through the issues. Mrs C was not satisfied with the board’s response and she brought her complaints to us.

After taking independent psychiatric, mental health and nursing advice, we upheld Mrs C’s complaint about the assessment of Mr A's mental heath problems. We found that there was an individual mental health care plan in place for Mr A. However, we found that this should have been a multi-disciplinary care plan, in view of Mr A’s challenging symptoms and the involvement of a number of health professionals. We also found the mental health care plan was not reviewed timeously. We did not uphold Mrs C’s other complaints as we found the decisions made regarding bed rest and diazepam to be reasonable. However, we found that Mr A's mobility and falls risk was not appropriately assessed and we made recommendations to address this.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C for the failings in mobility and falls assessment, and in multi-disciplinary care planning. 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 patient’s mobility is deteriorating, a Moving and Handling Assessment should be carried out to benchmark, and keep under review, how the patient might best be supported.
• Where there are concerns about a patient’s falls risk, a falls assessment should be arranged.
• For patients with distressing symptoms or challenging behaviour, where a number of health services are involved, a single multi-disciplinary care plan should be put in place and reviewed every six months.

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 that her late father (Mr A) was wrongly diagnosed with metastatic cancer (a cancer which has spread from a primary site elsewhere in the body) , and then had to wait an unreasonable length of time to be informed of the mistake. Ms C said that Mr A’s mental and physical health suffered as a result.

Mr A was diagnosed with prostate cancer. As part of the diagnostic process he was given a bone scan. As the results were indeterminate, a repeat scan several months later was carried out which showed some changes and was reported by the radiologist as being suggestive of possible metastatic cancer. This was communicated to Mr A at a review appointment by his consultant oncologist. A scan subsequently carried out concluded that Mr A did not have metastatic cancer.

We took independent advice from a consultant oncologist and found that it was reasonable that Mr A was initially assessed as having metastatic cancer, and that it was appropriate based on the evidence available at the time that his oncologist had communicated this to him. We also found that after it was discovered that Mr A did not have metastatic cancer, this was communicated to him within a reasonable time-frame. We did not uphold this aspect of Ms C’s complaint.

Ms C also complained that Mr A was not referred to any specialist cancer support services and he was not offered additional support for pain management. Whilst we acknowledged that the board had accepted this and had apologised to Mr A’s family, we were critical of these failings. We upheld this aspect of Ms C’s complaint.

We also found that the board failed to respond to Ms C’s complaint within a reasonable period of time and we upheld this part of her complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms C and her mother for:
• failing to make Mr A aware of specialist cancer support services
• failing to offer Mr A additional support for pain management
• failing to provide an update on Ms C's complaint when it became clear that the 20 day timescale could not be met
• the unreasonable delay in arranging a meeting and providing Ms C with the minutes of this.
• These apologies 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:

• Patients should be informed of the specialist cancer support services that are available to them.
• Patients should be provided with additional support for pain management, where appropriate.

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 that during her time as a PhD student at the university, the university unreasonably failed to follow the code of practice for supervisors and research students. She specifically complained that the university failed to appoint a second supervisor for her, and that her main supervisor had not organised a first year review to assess her progress. Ms C also said the university unreasonably failed to follow the postgraduate assessment regulations, as her principal supervisor did not tell her about of all of the assessment practice and requirements, or the code of practice. Ms C said that the delays and the non-performance of services, together with her loss of trust and confidence in the university, resulted in her withdrawing from the course. In addition, Ms C complained about the university’s investigation of and response to her complaint.

We found that there was a considerable delay in the university appointing a second supervisor for Ms C and that they failed to act in accordance with the code of practice. While we were critical of this, we noted that there were frequent supervisory meetings with Ms C’s main supervisor in line with the code of practice. The evidence also showed that the university unreasonably failed to carry out a review of Ms C's work within nine to twelve months of her enrolment, as set out in the code of practice. We therefore concluded that the university unreasonably failed to follow the code. We upheld this part of Ms C ’s complaint and made recommendations to address this.

In terms of the postgraduate assessment regulations, the evidence suggested that for Ms C’s first academic year of study, it was her responsibility to be aware of the assessment practices and requirements. We also noted that the university may have provided Ms C with information on the code and regulations, including assessment practice and requirements, in a joining instruction mailing sent before Ms C started her course. We therefore considered that the university did not unreasonably fail to adhere to the regulations and we did not uphold this aspect of Ms C’s complaint.

On the issue of complaints handling, whilst we did not see any evidence that the university’s investigation of Ms C’s complaint was inadequate, we considered that the university unreasonably failed to uphold Ms C’s final stage complaint, and in this regard we considered that their response to Ms C’s complaint was inadequate. 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 failing to adhere to the code of practice for supervisors and research students, for failing to appoint an assistant supervisor within a reasonable timescale and for unreasonably failing to uphold her final stage complaint.

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

• Assistant supervisors for students should be appointed in accordance with the requirements of the code of practice. One year reviews for part-time students should be carried out within nine to twelve months of their enrolment.

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 the council administered statutory notice works to a property he owned. The notice served by the council required work to be carried out to remedy various issues involving the roof and masonry. As these works were not carried out by residents, the council sent a further notice advising that they would arrange for the works to be carried out and informing residents of their right to appeal this decision. Following this, the council proceeded to appoint a contractor through competitive open tender. Once works commenced, further defects were identified and additional notices were served on residents in respect of these. Consequently, the cost of the project increased significantly compared to what was initially estimated.

Mr C complained that the council had failed to keep appropriate records of the tendering process and had failed to follow the correct tendering process for the works. We found evidence that the council held copies of four completed tender documents; a copy of a completed tender report, which detailed the basis for the council accepting the tender from one of the contractors; and a signed copy of the contractor's endorsement of the tender. We noted that the project had been tendered competitively and that the cheapest tender had been chosen by the council. We did not find evidence that the tendering process used by the council was inappropriate, or that the council did not hold appropriate records in relation to this. We did not uphold this aspect of the complaint.

Mr C also raised concern that the council was unable to produce a formal final account and a full breakdown of the costs. Mr C also felt that some of the costs had not been appropriately verified as reasonable. We were critical that the council failed to ensure that they obtained a signed and itemised final account, and we noted that this was a requirement of the council's procedures. In light of this, we upheld this complaint. However, we found that the council had instructed a financial services firm to carry out an independent review of the project. This review concluded that the costs of the project were reasonable and recoverable. We assessed the evidence considered within the review and we were unable to conclude that the process of verification carried out was not reasonable.

Finally, Mr C complained that the council failed to provide a roof guarantee within a reasonable time. We found evidence of a significant delay in the council requesting a guarantee from the contractor following the completion of the project. Although we upheld this complaint, we noted that a guarantee was belatedly provided to the owners, and we were satisfied that this met the requirements of the council's procedures.

The council informed us that the department that had administered the statutory notice project was no longer operational and had been replaced by a new service with a customer service approach. In view of this, we were satisfied that no recommendations for learning were required in this case. However, we asked the council to apologise to Mr C for the shortcomings we had identified.

In the course of our investigation, we found evidence that some of Mr C's complaints had not been appropriately acknowledged and logged as complaints. We were also critical that the council had advised that no complaints had been received from Mr C's wife when the council had in fact issued a complaint response to her. In light of these findings we made a recommendation.

Recommendations

We recommended that the council:

• provide Mr C with a written apology for the shortcomings identified in this investigation; and
• feed back our findings regarding the handling of this complaint to relevant staff.

Summary

Mr C complained that a housing officer unreasonably approached him in the street and accused him of causing nuisance. Mr C said he had previously told the council about a health issue, and had asked them to notify him in advance of any visit.

We found that Mr C had told the council about a disability, and had asked them to alert him in advance of any visit. The council said the officer who approached Mr C did not know who he was when they approached Mr C. We could not prove by means of the evidence available exactly what the officer who approached Mr C knew about the situation. We found that the officer was entitled to ask the kind of questions they put to Mr C. We therefore did not uphold this aspect of Mr C's complaint. However, we noted the officer could have been better informed and prepared in advance of the visit.

Mr C also complained that the council failed to follow the correct procedures when investigating the matter. We found that the council had in the main done what would be expected in similar situations. However, the council's tenancy management procedures were not followed, as no case closure letter had been sent. We upheld this aspect of Mr C's complaint.

Recommendations

We recommended that the council:

• review the existing tenancy management procedures and/or remind staff of their obligations under those procedures.