Some upheld, recommendations

Summary

C is the parent of two children, A and B, who complained about the council's handling of child protection concerns raised in respect of A and B. C is concerned that due to lack of proper procedure, decisions made by the Court in respect of contact between their ex-partner and the children were based on inaccurate information provided in social work reports.

The council's own investigation of the complaint identified that there was inadequate recording of the child protection concerns reported by C and that a welfare report compiled by the social worker was not of an acceptable standard.

We took independent advice from an experienced social work adviser. We found that there were failings to make a verbatim record of the child protection concerns raised by C, that the welfare report prepared for the Court was below an acceptable standard, and that there was a poor record of the interviews conducted with the children. Based on the evidence available, it was agreed that given that the children did not make a further disclosure to the social worker when interviewed, there were no grounds to pursue a child protection investigation. However, on balance, we concluded that, in light of the failings identified, there was a failure in the overall handling of the child protection concerns raised and as such, we upheld this part of C's complaint.

C also complained about the council's handling of their complaint. We found this to be reasonable and did not uphold this part of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to conduct their enquiries in a clear and transparent way, failing to keep adequate records of their contacts with C, the child protection concerns reported by C, and of the interviews conducted with the children; and for the poor standard of the welfare report. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

Summary

C is a former patient of the medical practice. C complained to the practice that they failed to address their enquiries about their healthcare, which they submitted to the practice in writing and by email. The practice decided that they could not meet C’s expectations and concluded that there was a breakdown in the doctor/patient relationship. The pracitice subsequently removed C from their patient list. C complained to the practice but were dissatisfied with the response that they received.

C complained that the practice failed to respond to C's complaint and earlier correspondence, and that the practice did not follow reasonable process when removing C from their patient list.

In respect of how they responded to C’s correspondence, we agreed that the situation became complex. While C did not always get a response to their correspondence, we concluded that the practice acted reasonably overall. We recognised that the practice were trying to meet the individual needs of their patient, but the situation had become untenable. We did not uphold this aspect of C’s complaint, however we provided feedback to the practice on their handling of the complaint.

With regard to the decision to remove C from the patient list, we concluded that the practice failed to follow General Medical Council (GMC) guidelines as they did not warn C that they were considering removing C from the patient list. We upheld this aspect of the complaint and recommended that the practice apologise to C and take steps to ensure they have an appropriate policy in place.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to follow GMC guidelines and warn them that they were considering de-registering them from the patient list. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

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

• All staff should be familiar with the requirements of the GMC guidelines for ending the professional relationship with a patient.

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

C complained that the council had failed to handle their planning application correctly. C said that the council had failed to communicate appropriately with their agent, adversely affecting their application. C also said that the council had prevented the Local Review Body (LRB, deals with requests from applicants for a review of planning decisions) from considering correspondence submitted by their councillors in support of their application. They were also concerned about the way the council had responded to concerns about a conflict of interest. C said that the objector to their application was an immediate relative of a senior planning officer. They believed this had not been properly addressed by the council. C's final concern was that the LRB had not considered the correct plans, noting the decision issued by the LRB had referenced incorrect plans.

We took independent advice from a planning adviser. We found that although there was evidence of some delays in responding to C's agent, the standard of communication was reasonable. There was no evidence that the LRB were prevented from considering correspondence from C's councillors. However, the correspondence was not part of the original application and the LRB would have had to determine specifically that it was relevant in order to include it in their decision making. The council were also able to demonstrate that the LRB had access to all the relevant plans when reaching their decision. Therefore, we did not uphold these parts of C's complaint.

In relation to the conflict of interest, we found that there was no evidence the decision on C's application had been affected by a conflict of interest. However, the council had not kept adequate records of how the acknowledged conflict of interest had been identified and managed. We upheld this part of C's complaint and asked the council to apologise but made no further recommendations as the council were able to show they had already taken action to address this.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the error identified in this decision notice. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

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

C complained about the care and treatment provided to their adult child (A) by the board. A had an extensive history of epilepsy and was diagnosed with ictal asystole (a rare but potentially devastating complication of epileptic seizures). A was referred by the board's neurology service (specialists in disorders of the nervous system) to the cardiology service due to ongoing seizures with loss of consciousness which could not be controlled with medication. A was fitted with a pacemaker but later developed severe headaches and a rash. A was advised to stop taking recently prescribed tablets and that the rash was likely caused by the ointment used when the pacemaker was fitted.

A few days later, A was finding it difficult to breathe and called NHS 24. Paramedics attended A at home but A was not admitted to hospital. A phoned NHS 24 again the following day and when paramedics attended, they took advice from an emergency medical consultant at the hospital who advised that A should take paracetamol and see the GP the following morning.

A was advised by the GP to attend the COVID-19 hub where A collapsed and was taken to hospital. A was admitted to hospital and died the following day from sepsis (a life-threatening reaction to an infection).

C complained that the board's cardiology service failed to provide reasonable care and treatment to A. We took independent advice from a consultant cardiologist. We found that there was a failure to provide a clear timeframe on the day of the pacemaker implantation and a failure to take reasonable action when A developed a rash following the procedure. We also found that the board failed to identify the asystole earlier but had already acknowledged this in their complaint response to C. Given these failings, we upheld this part of C's complaint.

C complained that an emergency medical consultant unreasonably told the paramedic that A should take paracetamol and see the GP the following morning. We took independent advice from a consultant in emergency medicine. We found that there were failings in the assessment of A and that given the deranged physiology (disturbance of normal bodily functioning), repeated presentation and symptoms, the advice provided by the emergency medical consultant was unreasonable. Therefore, we upheld this part of C's complaint.

Finally, C complained that a doctor in the COVID-19 assessment centre unreasonably told C to take A home and put them to bed. We found no evidence to support this. Therefore, in the absence of any supporting records, we did not uphold this part of C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failings identified. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

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

• Full and complete information should be obtained during any virtual assessment of a patient so that advice is appropriately provided and recorded on the basis of that information.

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

C complained about the care and treatment provided to their child (A). A developed facial weakness, which was initially diagnosed and treated as Bell's Palsy (temporary weakness or lack of movement affecting one side of the face). A's condition did not improve and MRI scans revealed a mass. It was considered this was likely a vestibular schwannoma (a rare, non-cancerous tumour) and follow-up in three months was arranged.

A later attended hospital with bleeding from the ear. C suspected this was related to the tumour but doctors treated A for an ear infection. A developed further ear symptoms and attended hospital again. Further scans showed significant tumour growth, requiring surgical debulking (removing as much of the tumour as possible). A's diagnosis was revised as para-meningeal rhabdomyosarcoma (a rare and aggressive form of cancer). A was treated with chemotherapy but they continued to deteriorate and died within a few months of this diagnosis.

C complained that the board's decision not to remove A's tumour when it was first detected was unreasonable. We took independent advice from four advisers: a paediatric neurologist (specialist in the diagnosis and treatment of disorders of the nervous system), a paediatric emergency medicine consultant, a paediatric neurosurgeon (specialist in surgery on the nervous system, especially the brain and spinal cord) and a paediatric oncologist (specialist in the diagnosis and treatment of cancer).

We found that there was inadequate documentation of the risks or benefits to A of performing a biopsy or resection of the tumour when it was initially detected. However, we considered that surgically it would not have been possible to carry out a full resection and that the risks of trying to obtain a biopsy in the specific circumstances were too high. We concluded that the decision not to remove the tumour when it was first detected was reasonable. Therefore, we did not uphold this part of C's complaint.

C also complained that the board's assessment of A's condition when they attended A&E was unreasonable. We found that the provisional diagnosis and management plan were reasonable, given the information available to the doctors at that time. Therefore, we did not uphold this part of C's complaint. We acknowledged that C had voiced their concerns that the appearance of A's ear related to the tumour, and noted the board had confirmed learning in terms of listening to parents' concerns.

Finally, C complained that there was an unreasonable delay in the board diagnosing A's condition. We took into account a number of factors including the fact that A's condition developed around the start of the COVID-19 pandemic, when services were severely restricted and face-to-face meetings were prevented from taking place. We found a number of shortcomings in A's care and treatment: insufficient record-keeping regarding the risks/benefits of resection or biopsy, failure to communicate clearly with A's family, the disputed position about whether it was reasonable to adopt a clear working diagnosis of schwannoma, the lack of opportunity of a second opinion, the delay in appointing the neurology referral, and a delay in writing to the GP following the initial multi-disciplinary team meeting. We considered that, taken together, these shortcomings were sufficient to have led to a delay in reaching an accurate diagnosis and upheld this part of C's complaint. Although the complaint was upheld, we acknowledged the advice from each specialism that earlier diagnosis would not have led to a different outcome.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failings identified. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

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

• Where treatment decisions are being made at multi-disciplinary meetings, there should be adequate documentation of consideration of the risks/benefits. There should also be evidence of discussion with family members in relation to diagnosis and management plan, where applicable. Where a patient appears to have a condition which is extremely rare, the patient records should reflect the differential diagnosis.

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

C raised complaints about the nursing and medical care their parent (A) received whilst in hospital. English was not A's first language and C also raised complaints about the board's communication with A and their family and whether appropriate follow-up care was provided by the board following C's discharge.

The board had accepted that A's nursing care fell below a reasonable standard in several areas, including the standard of record-keeping, the failure to discuss A's personal care with their family, and the assumptions that were subsequently made about A's preferences in relation to this. The board provided us with the nursing action plan they had developed following C's complaint. We took independent advice from a clinical nurse lead and a consultant geriatrician (specialist in medicine of the elderly). We found that the board's actions and action plan had been reasonable overall but there were some areas where the action plan could be improved. We upheld this part of C's complaint.

Similarly, the board accepted that the standard of communication with A and their family fell below a reasonable standard and had apologised for this. We found that the board's verbal and written communication could have been significantly improved, including their record-keeping. While the majority of issues were addressed by the action plan, there were some specific issues where staff could receive further feedback. We upheld this part of C's complaint.

C had been specifically concerned about modifications to A's medication and monitoring and treatment of A's feet. We found that the board's actions in relation to these had been reasonable and that A's medical care had been, overall, reasonable. We did not uphold this part of C's complaint.

Finally, the board had acknowledged their management of A's discharge and the communications associated with it, fell below a reasonable standard and had taken action with the aim of preventing any recurrence of this. We found that the actions proposed by the board largely addressed the issues involved. Therefore, we upheld this part of C's complaint and made only one further recommendation.

Recommendations

What we asked the organisation to do in this case:

• Apologise to A's family, via C, that they failed to communicate appropriately with A and their family during A's admission, that they failed to provide A with a reasonable standard of nursing care whilst in hospital and for the failure to respond fully to all the issues raised in their complaint. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

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

• Ward nursing staff communicate with patients and families appropriately, in line with the following sections of the NMC code: Prioritise people, Practice effectively, Preserve safety, Promote professionalism and trust. Keep clear and accurate records relevant to your practice.
• Ward nursing staff are aware of the need to properly document patients' foot care as detailed in the The Activities of Daily Living Assessment and reinforced in the NHS Education for Scotland online module for CPR for feet.

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

C complained that the board failed to provide their late spouse (A) with reasonable care and treatment during three attendances at A&E and an admission to hospital.

The board said that A complained of pain in their right forearm causing them sleep disturbance. However, there was no indication that imaging scans were required as an emergency. A was already under the care of orthopaedics (specialists in the treatment of diseases and injuries of the musculoskeletal system) which was appropriate for the muscle injury A had. Therefore, the assessments, plan, and discharge of A at the first two attendances in the emergency department were appropriate on the basis of what was known at the time. During the third attendance at the emergency department, the board said that investigations indicated that A had a raised marker for infection and inflammation which could have been an indication of underlying condition or malignancy. At this point it was identified that an MRI scan should be carried out, but there was no indication that this was required as an emergency. A was admitted to hospital for further investigations.

We took independent advice from a consultant in emergency medicine. We found that appropriate and timely emergency care was provided to A on each of their attendances at A&E. We also noted that a clinical significant event review was carried out. The issues were fully explored and the board had appropriately reviewed and reflected on learning. We considered that A received reasonable care and treatment at A&E and as an inpatient. Therefore, we did not uphold this part of C's complaint.

C also complained about the board's handling of their complaint. C said that the board did not contact them during their complaint investigation. They also highlighted that the board did not address all their concerns. We found that the board failed to address and respond to a significant part of the complaint raised by C until prompted to do so by this office. Therefore, we upheld this part of C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to handle their complaint reasonably. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

In relation to complaints handling, we recommended:

• The board's complaints handling system and their investigation should ensure that failings (and good practice) are identified, and enable learning from complaints to inform service development and improvement. Complaints should be properly assessed in line with the Model Complaints Handling Procedure and all points of complaint should be identified and agreed before the complaint investigation begins.

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

C, an MSP, complained on behalf of their constituent (B) about the care and treatment of their adult child (A). A had awoken with a cut and bruised face and no memory of how the injuries had been sustained. A attended a minor injuries unit before being sent by taxi to A&E for further assessment. A was assessed and discharged without further treatment or follow-up. A few months later, A died suddenly.

B believed that A had suffered a seizure on both occasions and that A's assessment had been inadequate. B felt staff had failed to consider whether A had suffered a seizure nor had they considered prescribing medication which could have prevented further seizures. B was also unhappy with the way their complaint was handled.

We took independent advice from a consultant in emergency medicine. We found that the examination of A was thorough. However, given the uncertainty over the cause of A's injuries and the symptoms they described, further investigation should have been carried out. We did not find that A's death could have been predicted, or that there was any definitive evidence that A had suffered a seizure. However, given that further investigations were justified and were not carried out, we found that the standard of care provided to A was unreasonable and that the cause of A's injuries was not adequately investigated or followed up. Therefore, we upheld these parts of C's complaint.

In relation to complaint handling, we found the board's investigation to be reasonable. We did not uphold this aspect of C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to B for the failings identified in this decision. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

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

• The board should share this decision with the departments involved for discussion at a team review with a view to identifying any points of learning and improvement.
• The emergency department should review their practices regarding the assessment of causes of head/facial injury and subsequent investigation of underlying conditions.

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

C’s neighbour was granted planning permission for the construction of an outbuilding in their garden. C complained that the council’s handling of the planning application was unreasonable. C complained that their objections had not been set out in full in the Report of Handling and that the report did not include an assessment of the impact of the proposed development on C’s garden.

The build site was on sloping ground and C complained that the change in land height on the build site had not been mentioned. They also complained that the Report of Handling did not accurately summarise the scale of the proposed development or its proximity to C’s garden.

We took independent advice from a planning adviser. We found that although the Report of Handling did not include reference to the assessment of the impact of the proposed development on sunlight in C’s garden, the council had been able to demonstrate that this formed part of their assessment. We found that there was a reasonable consideration of the impact of the build on the existing house, the surrounding area, and the amenity of C’s property.

Although we were critical of aspects of the council’s handling of the application, we did not consider the shortcomings sufficient to lead to a finding that the handling was unreasonable. We found no evidence that any material considerations which might have led to the refusal of the application were overlooked. Therefore, we did not uphold the complaint but we did provide feedback on matters the council could have dealt with better.

In relation to complaint handling, we found that the council failed to identify and respond to the key concerns raised by C. Therefore, we upheld this aspect of C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to investigate their complaint to a reasonable standard. The apology should meet the standards set out in the SPSO guidelines on apology available at HYPERLINK "http://www.spso.org.uk/information-leaflets" www.spso.org.uk/information-leaflets .

In relation to complaints handling, we recommended:

• Complaint handlers should identify the key aspects of complaints and ensure complaint responses address these matters, in line with the Model Complaints Handling Procedure.

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

C complained about the care and treatment that they received from the board. C was diagnosed with an ovarian cyst and admitted to hospital for a laparoscopy (a surgical procedure that allows a surgeon to access the inside of the abdomen and pelvis through a small hole in the skin) to remove the cyst. During the procedure, no cyst was found. However, an unusual mass was identified but not removed. An MRI scan was arranged to further investigate the findings of the laparoscopy.

C was discharged from hospital but became unwell. C attended the A&E with severe vomiting and diarrhoea and was admitted to hospital that same day.

An MRI scan was carried out and the results indicated that the previously identified mass was a haematoma (a collection of blood) and C was discharged home with antibiotics.

C became unwell again and attended a hospital in England where they were diagnosed with Clostridium Difficile Infection (CDI, a bacterial infection of the large intestine, a common healthcare associated infection). A CT scan also identified a cyst.

C commented that clinicians were surprised that C had not been screened for CDI when they previously attended hospital, having presented with diarrhoea several days after a laparoscopy. The clinicians also reportedly questioned why C’s haematoma was not removed when it was diagnosed given the likelihood of infection.

C complained that the board misdiagnosed their haematoma and failed to screen them for CDI, resulting in unnecessary complications and illness.

The board, in their response to C’s complaint, explained that there was no clinical indication that C was experiencing ongoing diarrhoea, and were satisfied that they did not therefore screen for CDI. The board said that having reviewed the care provided to C during their admission, they were satisfied that, whilst C suffered complications, the care provided was appropriate and reasonable

We took independent advice from a general surgeon adviser. We found that C presented with a history of diarrhoea prior to admission and that this was not identified or flagged to relevant clinicians on their admission to hospital. Given C's history prior to admission, C should have been screened for CDI and therefore, we upheld this aspect of the complaint.

With respect to the C’s diagnosis and treatment, we found that the conservative management plan which was adopted was reasonable in the circumstances. Whilst we identified some aspects of the clinical review undertaken of C’s condition which could have been better, they did not negatively impact on C’s outcome and we did not uphold this aspect of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failings identified. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

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

• That the board ensure that they implement, or have implemented, all of the recommendations of the Guidance on Prevention and Control of Clostridium difficile Infection (CDI) in health and social care settings in Scotland.
• That the board review their practices and ensure that all staff are operating in line with the Guidance on Prevention and Control of Clostridium difficile Infection (CDI) in health and social care settings in Scotland.

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.