Some upheld, recommendations

Summary

Mrs C complained about the care and treatment her mother (Mrs A) received in the Glen O'Dee Hospital following a hip operation. The initial plan was for Mrs A to return to her own home following physiotherapy, but after a fall she said she wanted to be discharged into a care home. Mrs C complained that after the fall, staff at the hospital failed to recognise that a screw in Mrs A's hip had become displaced and that a further fall was not recorded in Mrs A's records. Mrs C also said that communication with her and her mother was inadequate and that the board failed to take her views into account when reaching a decision to discharge Mrs A into a care home.

We took independent advice from a physiotherapist, a GP and a nursing adviser. We found that after her fall, Mrs A's physiotherapy treatment continued and she said she was not experiencing any pain. It was only when Mrs A began to feel pain that the situation was brought to the attention of a doctor who referred her to another hospital where she was x-rayed and the displaced screw was diagnosed. While Mrs C believed that there had been a subsequent fall, we found no evidence of this. However, we found that communication between the hospital and Mrs C had been poor as she had not been alerted to the fact that her mother had experienced a fall and we upheld this part of the complaint.

However, we also found that Mrs A had been quite definite in wishing to be discharged to a care home despite her daughter's wishes. While the board took Mrs C's wishes into account, Mrs A had capacity to make her own decisions and the board had to acknowledge this. It was only later that Mrs A changed her mind and agreed to be discharged to Mrs C's home. We did not uphold this complaint.

Recommendations

We recommended that the board:

• apologise to Mrs C for the failings identified in this report; and
• ensure that the nursing staff concerned are fully aware of their responsibilities regarding communication under the relevant section of the Nursing and Midwifery Council Code.

Summary

Mr A had lung cancer and was receiving end of life care at home. Mr A's wife (Mrs C) complained to us about the care he received from district nursing staff, about the standard of communication, and about the board's response to her complaints.

Mrs C was concerned about a dose of medication given to Mr A by the nurses and about record-keeping. We took independent advice from a nursing adviser and a medical adviser. They found that there was no evidence that the standard of record-keeping affected the management of Mr A's symptoms. They also found no error in the prescription or administration of the medicine. We did not uphold these aspects of Mrs C's complaint.

Mrs C also complained about a decision to move Mr A in bed. She said that this caused him pain and was concerned that a bathroom towel was used. We found that moving Mr A in bed was a good way of assessing pain control and that both the decision to move Mr A and the way he was moved were reasonable.

Mrs C complained that she had not received a good standard of communication from the nurses. The nursing adviser said that Mrs C had not been offered support and there was no evidence that staff had listened to Mrs C's concerns. However, given the available evidence, it was not possible to reach a judgement on other aspects of Mrs C's complaint about communication.

Mrs C also said that the board failed to respond reasonably to her complaints and that their response was accusatory. We found that while the board's response addressed every clinical issue, there was no evidence of compassion or empathy. We therefore upheld this aspect of Mrs C's complaint.

Recommendations

We recommended that the board:

• bring the failings in complaints handling to the attention of relevant staff and review their processes to ensure sensitive and appropriate responses to complaints; and
• apologise for the failings this investigation identified.

Summary

Ms C, who works for an advocacy and support agency, complained on behalf of Mr B regarding the care and treatment provided to Mr B's father (Mr A) during his admission to Forth Valley Royal Hospital. Ms C complained that Mr A's falls risk was not appropriately assessed on two different wards, that the nursing care provided to him was not reasonable, and that staff attitude and communication with Mr A's family was unreasonable.

During our investigation, we obtained independent advice from a nursing adviser. We found that whilst Mr A's assessment and care in relation to falls on the first ward he stayed on was reasonable, on the second ward his levels of confusion were not taken into account when assessing the risk of falls. We considered this to be unreasonable. We also found that whilst the nursing care provided to Mr A was reasonable in terms of personal care and administration of medication, the nursing care plans had not taken into account Mr A's need for emotional support. We also found that the use of bedrails for Mr A had been inconsistent. We did not consider this to be reasonable and upheld this complaint. In terms of staff attitude and communication with Mr A's family, we found that communication had often been unplanned and ineffectively co-ordinated, but that this was often due to short-notice changes to plans for Mr A given his fluctuating physical state. We considered that a planned approach to communication may have been beneficial, but that there was no evidence of unreasonable staff attitude towards the family. We made several recommendations to the board to address the failings identified.

Recommendations

We recommended that the board:

• take steps to ensure that the impact of cognitive impairment on patient safety on the relevant ward is appropriately assessed and that measures to minimise harm are a prominent aspect of care plans;
• apologise to Mr B for the failings identified in relation to the falls assessment and care provided to Mr A;
• take steps to ensure recording and use of bedrails is consistent;
• take steps to ensure that emotional support is identified as a care need and planned for where appropriate;
• apologise to Mr B for the failings identified in relation to the nursing care provided to Mr A; and
• consider whether a planned approach to communication, agreed between patients' families and staff, should be put in place.

Summary

Ms C complained about care she received from her medical practice. When Ms C received a copy of her medical notes she found that during a previous consultation two years earlier, the GP had noted a mild vaginal prolapse and had not told her about this. Ms C complained that she should have been told about the prolapse and treated for it, and that the practice had not reasonably responded to her complaint.

We sought independent medical advice and found that while the failure to inform Ms C of this incidental finding had not caused significant harm to her, the GP should reflect on this decision further. We upheld this complaint.

However, the adviser's view was that the decision not to provide treatment at the time was reasonable, as was the response to Ms C's complaint. We therefore did not uphold this aspect of Ms C's complaint.

Recommendations

We recommended that the practice:

• reflect on the decision not to inform the patient of an incidental finding.

Summary

Mrs C complained about the care and treatment given to her mother (Mrs A) at University Hospital Crosshouse prior to Mrs A's death. At the time of her admission, Mrs A had been very unwell with pneumonia and sepsis. Mrs C said that she and her family were not alerted to the seriousness of Mrs A's condition and were not prepared for her death. Mrs C said that Mrs A was not cared for appropriately, specifically that she was left in soiled clothes and bedding, not given medication in a timely manner, that there was a delay in moving Mrs A to the high dependency unit and that fluid was removed from Mrs A's lung in an incorrect way. Mrs C said that it was only after Mrs A's death that it was disclosed that she may have been suffering from leukaemia. Mrs C also complained that the board's response to her complaint was inadequate.

We took independent advice from a nursing adviser and a consultant physician and geriatrician. We found that overall, Mrs A's care had been reasonable. Mrs A had wanted to be independent regarding personal hygiene, with help from family members rather than from staff. Mrs A's medication was administered appropriately and in a timely manner. The procedure to remove fluid from Mrs A's lung was reasonable, as was the timing of moving her to a high dependency unit. We found evidence that Mrs C and her family had been kept updated about Mrs A's condition. We also found that it was only after Mrs A's death that it was determined that she had leukaemia. We did not uphold these aspects of Mrs C's complaint. However, our investigation did raise concerns about the facilities on the ward and we made a recommendation to address this.

We found that the board's response to Mrs C's complaint had been poor in that it failed to provide sufficient detail in a timely manner. We therefore upheld this aspect of Mrs C's complaint.

Recommendations

We recommended that the board:

• confirm that action has been taken to improve the facilities concerned. If nothing has been done, they should provide details of the action they intend to take to remedy the situation;
• apologise to Mrs C for the shortcomings identified in their correspondence to her; and
• emphasise to relevant staff the importance of supplying information to allow a timely response to complaints.

Summary

Mr C, who works for an advocacy and support agency, complained on behalf of his client (Mr A). Mr A attended the A&E department at Glasgow Royal Infirmary where he was assessed as having had a transient ischemic attack (TIA), a condition where the blood supply in part of the brain is temporarily disrupted. After being assessed, Mr A was discharged with aspirin and a referral for an appointment at the TIA clinic. However, Mr A had a stroke the following day and was readmitted to the hospital. Mr C complained that Mr A should not have been discharged and that the doctor who had assessed Mr A on his first admission had failed to note that he had on-going symptoms which would have indicated admission. Mr C said that Mr A was concerned that he could have suffered a more severe stroke as a result of the discharge the day prior to his stroke.

We took independent advice from a consultant in emergency medicine. We found that the doctor performed reasonable observations of Mr A during his attendance at A&E. However, the adviser found that the doctor who assessed Mr A had not recorded the time of onset, or the duration, of Mr A's symptoms. The adviser was critical of this but said that whilst this information may have led to Mr A being admitted rather than discharged, it was not possible to say if admission would have prevented his stroke.

Recommendations

We recommended that the board:

• remind A&E staff of the need to accurately assess and document the nature and duration of TIA symptoms and report back to this office on action taken; and
• apologise to Mr A for the failure to accurately assess and document his TIA symptoms.

Summary

Mr C complained about issues with his mail coming into the prison. He said that he was having to wait at least a week to receive mail, that he was being made to sign for letters, and that the prison was unreasonably opening some of his mail and sealing it again with tape.

In our investigations we asked the Scottish Prison Service (SPS) to provide copies of their policies regarding mail coming into the prison. We found that according to policy, mail should always be received by the addressee by the end of the day it comes into the prison. The SPS accepted that Mr C was having to wait unreasonably for his mail. We upheld this aspect of the complaint.

The SPS told us that the reason Mr C had to sign for mail was because it was classified as a parcel and prisoners must sign for parcels when they pick them up at reception. We found that the classification of mail as a letter or parcel is a discretionary decision for the SPS and therefore decided that it was reasonable that Mr C had to sign for his mail. However, we found that the SPS had given contradictory responses in the two internal complaints handling stages regarding this issue, the Internal Complaints Committee and the Residential Front Line Manager stages. We upheld this aspect of the complaint.

Finally, we found that according to policy, the SPS is entitled to open a prisoner's mail in the prisoner's presence unless it is privileged mail. The SPS told us that Mr C had been present when his mail was opened and as there was no evidence to suggest otherwise, we did not uphold this aspect of Mr C's complaint.

Recommendations

We recommended that SPS:

• apologise to Mr C for the delay in giving him his mail;
• apologise to Mr C for giving him contradictory information throughout the complaints process;
• ensure that complaints are dealt with in a consistent manner throughout the complaints process, and if the decision taken by the Internal Complaints Committee is different to the decision made by the Residential Front Line Manager then a full explanation is given; and
• provide this office with evidence of the reviewed Standard Operating Procedures which clarify how staff are to classify incoming mail.

Summary

Mrs C complained that before a class reorganisation, the head teacher of her daughter (Miss A)'s school failed to consult in a reasonable way with Mrs C. Mrs C said that the need to consult was important because Miss A had previously been bullied and had health issues. Mrs C said that when she complained about this to the council, the council failed to handle her complaint reasonably.

We investigated the complaint and found that the council had followed their stated policy. The head teacher informed parents of the forthcoming changes as soon as possible and meetings were held with them. While Mrs C was concerned about her daughter's health, there was no evidence that she had raised this or bullying issues with the school. Once the council became aware of these issues, they looked into them. We therefore did not uphold this aspect of Mrs C's complaint.

However, the council's response to Mrs C's complaint was confused and took too long. We therefore upheld this aspect of Mrs C's complaint.

Recommendations

We recommended that the council:

• make a formal apology for their delay; and
• remind relevant staff of the importance of adhering to the stated complaints process.

Summary

Mr C, who works for an advocacy and support agency, complained on behalf of Mr A. Mr A had approached the council for assistance in caring for his mother. Mr A was dissatisfied with the way in which his requests were handled by the council. He complained to the council and this was handled through the social work complaints procedure. As Mr A's complaint had been heard by a Complaints Review Committee (CRC), we were limited to considering complaints about the way in which his complaint had been handled. Mr C said that Mr A's complaint had been unreasonably put on hold because Mr A had said he was seeking compensation, that the council had failed to consider and respond to Mr A's comments on the draft report and that it was unreasonable that the council's legal representative stayed with the CRC panel when they broke up for recess.

Following investigations, we concluded that the statutory social work complaints procedure and associated guidance indicated that the council had to receive a clear indication that the subject of the complaint was actively being pursued by legal action before a complaint could be suspended, rather than there being a verbal expression of intention. Therefore we upheld this aspect of Mr C's complaint. We also had concerns that the council's own complaints procedure did not reflect the wording of the statutory social work complaints process and recommended that the council review this.

In relation to Mr C's concerns that the council had not adequately considered and responded to Mr A's comments on the draft report, we could see no indication that a full response to the comments was required or that Mr A had been given an indication that this would be given. Therefore, we did not uphold the complaint. We were concerned that by being invited for comments, this had potentially raised Mr A's expectations that a detailed response would be given and that the matter would be investigated further.

In relation to Mr C's concerns that the council's legal representative stayed with the CRC panel when they broke up for recess, we established that the person in attendance was acting as legal adviser to the CRC and, as a matter of standard practice, they normally remain in the room. Therefore, we did not uphold this complaint.

Recommendations

We recommended that the council:

• remind staff involved in handling social work complaints of the circumstances in which complaints can be suspended and that if there is any uncertainly regarding whether the complainant is taking legal action against the council, this should be confirmed with them, preferably in writing;
• review the Social Work Resources Complaints Procedure with a view to ensuring that the wording reflects the contents of the directions and guidance on this point; and
• provided the council still wish allow to complainants the opportunity to comment on CRC recommendations, add to the relevant template letter that comments will only be passed to the CRC for consideration and will not be individually responded to.

Summary

Ms C removed her child from school and requested a transfer to a new school as she was concerned about the impact of the school environment on her child's wellbeing. The school raised concerns about her child's absence and scheduled a meeting to discuss this. Ms C subsequently found out that the school nurse had contacted her child's GP to request information just before this meeting and a report had been faxed to the school. Ms C complained that the head teacher inappropriately made this request. In particular, the GP records stated the requested information was required for an inter-agency meeting with child protection concerns involved, when the meeting did not involve other agencies and there were no child protection concerns.

The council said the request was made by the school nurse who only asked the GP practice if someone could call the school to discuss if there was anything in the child's medical history relevant to concerns about their ongoing wellbeing and absence from school. The council said there were no child protection concerns but it was not possible to seek this information from Ms C as she refused to have any contact with them. However, when we asked for evidence of the lack of communication, the council acknowledged that in fact Ms C did have contact with both the school and council officers during this period.

After investigating these issues and reviewing the records from the school and GP we found that although it was clear that inaccurate information was received by the GP about child protection concerns, it was not clear that this was due to the actions of the head teacher and we did not uphold this aspect of Ms C's complaint. However, we were critical that the council did not make any record of the request for information and did not inform Ms C or the child about this. We also found failings with the council's complaints handling.

Recommendations

We recommended that the council:

• take steps to ensure that decisions to seek sensitive information about a pupil are adequately recorded and the pupil and/or parents are consulted (unless there is a clear recorded reason for not doing so);
• apologise to Ms C and her child for the failings identified;
• remind staff of the definition of a complaint in their complaints handling procedure;
• review their complaints handling tools to ensure staff are prompted to identify relevant evidence when planning an investigation; and
• audit a sample of recent correspondence to ensure that correspondence meeting the definition of a complaint is being handled under the correct process.