Some upheld, recommendations

Summary

C complained about the way that the council had handled a planning application related to a development of new homes adjacent to their home. In particular, C expressed concern about the position and proximity of one of the plots to their home and the detriment this would cause in terms of overshadowing and loss of daylight.

On first receiving C’s complaint, we considered that the council’s complaint response had not fully addressed the issues C had raised, and we therefore asked the council to write to C again at stage two of their complaint handling procedure. As C remained unhappy with the council’s response on the matters of overshadowing, and on their conservatory and kitchen/diner not being considered as habitable rooms when determining any loss of amenity, they returned their complaint to us for further review.

We took independent advice from a planning adviser. We found that the council had managed the planning application in keeping with the relevant guidance and we did not uphold this aspect of C’s complaint. However, we provided feedback to the council on the way in which the impact on amenity had been recorded in the Report of Handling, and in relation to retention of records, particularly when known objections had been raised. On the matter of complaint handling, we found that the council had unreasonably failed to respond to C’s original complaint on the planning application and we therefore, upheld this aspect of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to fully address the complaint of overshadowing in their complaint response, and of not ensuring the investigation was undertaken by someone with no prior involvement in the circumstances being complained about. 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 council should comply with their complaint handling procedure and ensure matters complained about are fully responded to.

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 on behalf of their spouse (A) about the care and treatment that they received from the board.

A initially presented with a locally advanced cancer which at the time of presentation had already spread to their lymph nodes. A underwent treatment, however, went on to develop progressive disease in their lymph nodes and also evidence of spread to the bone. While further treatment was given, A's general condition deteriorated and after a number of admissions to hospital, A died of a progressive cancer.

C raised concerns that the board had failed to provide reasonable, timely and appropriate medical care and treatment to A during their admission to the treatment centre.

We took independent advice from an oncologist adviser (cancer specialist).

We found that the treatment A had received conformed to current guidelines from the European Urology Association and Medical Oncology Associations, and overall, we found that the management of A’s care was reasonable and that there were no significant failings in relation to the care and treatment given to A. However, we found that, while there was little, if no, evidence that earlier CT scans would have influenced the final outcome, given the circumstances of A's case, the CT scans carried out could have been done sooner.

With regard to C's concerns about the way that A's prognosis was communicated to them, while we found that overall the communication had been reasonable, we acknowledged that the method of communicating A's diagnosis to them had not met their needs and we provided feedback to the board about this.

While we found that the majority of the care and treatment given to A was reasonable, given that the CT scans could have been done sooner, on balance, we upheld this complaint.

C also raised concern about the medical care and treatment given to A during their admission to hosptial. In particular, that there had been clinical failures to pay attention to which medications had previously failed, which led to the same medications being prescribed to A again. Also, that there had been an unnecessary delay in moving A to the hospice.

We took advice from an independent oncology adviser. We found that A had been treated with appropriate anti-cancer therapies and symptoms relieving treatments, that the choice of antibiotics had been reasonable and that there had been no unreasonable delay in transferring A to the hospice.

We considered that the overall care and treatment provided to A was reasonable. As such, we did not uphold this complaint.

C also complained that the nursing care and treatment given to A in the hosptial had been unreasonable. We took independent advice from a nursing adviser. We found that a number of aspects of the nursing care and treatment given to A had been reasonable and that, in particular, the nursing care provided for A had been delivered in a person centred way. However, we considered that it would have been reasonable to expect that a skin assessment to establish the extent of any skin damage would have been carried out and documented prior to A's move to the hospice, especially given that A was a high risk patient at end of life care. We considered that this aspect of A's nursing care was unreasonable and therefore on balance we upheld this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failings identified in this case. 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:

• In patients presenting with significant symptoms, the need for an urgent referral for a CT scan should be considered.
• Pressure area care should be given in line with National Institute for Health and Care Excellence (NICE) Clinical guidance CG179.

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 on behalf of their spouse (A) regarding the care and treatment A received from the board. A has serious health issues and has had multiple surgeries over a number of years.

Following a scan of A’s abdomen, it was identified that they had staples attached to their bladder. A considered that these had been left behind following surgery to remove their J-pouch (a pouch made from part of the small intestine and attached to the anal canal to form a pathway for the passage of stool). C complained that A experienced recurring infections and other complications as a result of the staples being left in their abdomen. A said that these had a detrimental impact on their long-term health.

We took independent advice from a general and colorectal surgeon (specialist in conditions in the colon, rectum or anus). While it was not possible to establish exactly which operation the staples came from, we considered that the staples were a likely source of A's infections. We found that the staples were clearly visible on previous scans but that these had not been reported on by radiology and therefore the clinical team did not consider these when they were assessing A’s likely source of infection and future treatment. Therefore, we upheld this aspect of C's complaint.

C also complained about the handling of their complaint. Whilst we found that there were some delays to the board’s investigation, we recognised that many years had passed between the events complained about and the complaint being submitted to the board. This meant that some issues were reasonably time-barred and some parts of the investigation were delayed due to difficulties sourcing the records and staff comments. Overall, we were satisfied that communication was generally reasonable with C and A, and that the board’s complaints procedure was followed appropriately. Therefore, we did not uphold this aspect of C’s complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the issues highlighted 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 provide us with an update as to any procedural changes that have been made to ensure patients’ individual needs are considered when handling a complaint.
• The board should share this decision with their radiologists as a reminder of the importance of fully reporting on scans to reduce the chances of important omissions.
• The board should share this decision with their surgical team with a view to ensuring that the origin of infection is included when considering treatment of chronic infection.

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 their spouse (A) received over a number of years by the board.

C submitted a complaint to the board expressing A’s concern that they did not take reasonable care when carrying out two surgeries. C and A were dissatisfied with the board’s investigation and response to their complaint.

A underwent surgery in their abdomen in an attempt to resolve recurring infections and said they suffered significant pain afterwards. We took independent advice from a general and colorectal surgeon (a surgeon who specialises in conditions in the colon, rectum or anus). We were satisfied that this surgery did not cause the pain that A had linked to the procedure. However, we were critical of the board for failing to recognise that scans taken prior to the surgery had shown evidence of staples in A’s abdomen from previous surgeries. We found that the staples were a likely source of A’s infections and that this should have been identified prior to the surgery taking place. Had it been identified, A’s management plan may have been different. Therefore, we upheld this aspect of C’s complaint.

A also underwent a procedure on their reproductive organs. C complained that the procedure that was carried out, as described in the record of the operation, was not the one to which A had consented. We found that it had not been possible to complete the planned procedure due to an issue in the affected area, which had not been apparent until the procedure began. Whilst we were critical of the way that the procedure was described in the records, we found that the procedure itself was reasonable and appropriate in the circumstances. Therefore, we did not uphold this aspect of C’s complaint.

C and A complained that despite the board’s complaints procedure stating that complaints could be submitted in writing, in person, or over the telephone, the board insisted that A’s complaint was submitted in writing. A explained that they found it difficult to put their complaint in writing and had specifically requested a meeting with the board to discuss their concerns. This request was denied. We found that although there were reasonable reasons for asking A to submit the complaint in writing, these were not explained clearly by the board, and A was given no explanation as to why their request for a meeting was refused. We were critical of the board’s communication with C and A regarding the complaint, and of delays in the early stages of the board’s investigation. Therefore, we upheld this aspect of C’s complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the issues highlighted 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 clinical staff involved in A’s treatment with a view to identifying ways of avoiding similar issues in the future.

In relation to complaints handling, we recommended:

• The board should provide us with an update as to any procedural changes that have been made to ensure patients’ individual needs are considered when they make a complaint.

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 a complaint on behalf of their advocacy partner (A). Following A’s arrest, C complained that A’s child (B) had been removed by social work services (SWS) from A’s care and placed with their non-custodial parent (D) without legal authority, against B’s express wishes and without taking account of A’s views. C also raised concerns that during B’s residency with D, SWS had not appropriately facilitated contact between A and B, had unreasonably requested A complete a parenting assessment and had failed to reasonably respond to A’s further concerns about B’s welfare.

In their response, the council explained that D had enacted their parental rights and responsibilities (PRR) and assumed care of B when A had been arrested which they had helped support. They said that a range of professionals had been actively involved and utilised different approaches in obtaining B’s views. They noted that contact between A and B had not been straightforward, and that the regularity of contact had been disrupted by decisions of both A and B. They said that the requirement that A complete a parenting assessment had been reasonable given the longstanding issues of concern and more recent issues involving A and that the concerns A had raised about B’s welfare while in D’s care had been treated seriously and resulted in prompt attention.

We took independent advice from two social work advisers. We found that there was a lack of recording of the discussions and the process by which the decision was taken to place B in D’s care and that there was a failure to convene a formal interagency referral discussion (IRD) to plan the approach on a multi-agency basis to assess the suitability of D as alternative care for B. We upheld the complaint as a result of the failings identified.

We found that once B had moved to D’s care, their conflicting and changing views should have prompted a referral to independent advocacy sooner. However, the council had taken reasonable steps to ensure B’s views were appropriately sought and taken regular account of. Therefore, on balance, we did not uphold this aspect of the complaint.

We also found that once B had moved to D’s care, SWS’ approach to facilitating contact between A and B had been in line with national guidance and social work practice at that time, that SWS were justified in their decision to request that A complete a parenting assessment given the long-standing concerns regarding A’s parenting capacity and history caring for B and that SWS had responded reasonably to the welfare concerns A had raised. We did not uphold these aspects of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to A, Band C for the failings identified. Theapology should meet the standards set out in the SPSO guidelines on apologyavailable at www.spso.org.uk/information-leaflets.

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

• Ensure the findings of this investigation have been reflected on, and learning is shared, with the relevant department and externally with Police partners to ensure effective future practice.
• In child protection matters, it is important that all multi-agency decisions and discussions with those affected, and their views, are clearly recorded.

Summary

C complained on behalf of their client (A) about Fife Health and Care Partnership's (HSCP) assessment of A’s needs and the level of support being provided by the HSCP. A is registered blind and has a number of other health conditions, including diabetic neuropathy (nerve damage) requiring A to use a wheelchair.

C complained to the HSCP that support previously available for C to access the community or go shopping had been withdrawn. C also believed that the HSCP operated a blanket policy not to fund services to support service users to access the community or go shopping.

In response to the complaint, the HSCP said that the arrangement to go shopping was via an unregistered cleaner and that the Care Inspectorate identified issues with this, and the worker was removed. They explained that a worker taking A shopping was not deemed as critical care criteria, that they could not offer funding for it and that alternative options were not taken up by A.

We took independent advice from an adult social work adviser. We found that, whilst there was evidence that the HSCP undertook an assessment of A’s needs, the assessment was unclear about what needs were assessed as being critical and substantial, and therefore eligible for funding. We also found that the Assessment and Support Plan failed to offer sufficient detail about the discussions with and options available to A with respect to the support available. We upheld the complaint that the assessment of A’s care plan was unreasonable.

With respect to complaints made about the operation of a blanket policy, it was noted that a number of statements and comments in A’s case notes and assessments gave the impression that this may be the case. However, whilst we found failings with respect to the assessments in this case, there was no evidence available which demonstrated that the HSCP operated a blanket policy not to fund access to social supports or the community. We did not therefore uphold this aspect of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to A via their representative C for the failings. 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:

• Reflect on this decision, and the relevant Assessment and Support Plan, in this case and ensure that assessments are clear with respect to the needs of the individual and the assessment of needs according to the relevant eligibility criteria for support.

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 parent (A) by their GP practice whilst they were resident in a care home. A suffers from dementia and fell in the care home. A was reviewed and treated by several GPs in relation to their pain and urinary infection. C’s complaint is concerning the care and treatment of A, the standard of communication from both the GPs and the partnership, and the partnership’s handling of the complaint.

C said that A had been left for almost two weeks with two broken vertebrae following their fall. C complained that A’s pain was not appropriately managed as they had become 'toxic' from the high levels of morphine in the Butec patches (pain-relief patches) provided and that they continued to suffer urinary infections. C complained that they did not have adequate communication from the GPs about A’s condition and that the record of the discussions that did take place were not accurately documented in the medical notes. C also complained about the communication from the partnership during the investigation of their complaint. C raised concerns about the handling of the complaint, stating it was chaotic and confused and that the partnership did not respond to their further points of concern.

We took independent advice from a GP adviser. We found that A’s pain and urinary infections were appropriately managed and as such, we found that the care and treatment provided was reasonable. We did not uphold this complaint.

With regards to communication from the GPs with C, whilst we noted that there were differing accounts of the same interactions, we found that, overall, communication from the GPs was of a reasonable standard. However, we found that communication from the partnership when C first raised their complaint fell below the expected standard. As such, we upheld this complaint. In addition to this, we upheld C’s complaint about the partnership’s handling of the complaint as we found multiple complaint handling failures, including a failure to address all of C’s concerns and to indicate whether complaints were upheld or not.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to communicate with them reasonably about their complaint and the partnership’s investigation into it. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.
• 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.
• The partnership should include with their apologies the learning points from the Significant Event Analysis.

In relation to complaints handling, we recommended:

• Staff dealing with complaints should be familiar with the Model Complaints Handling Procedure, understanding the importance of communication and the need to demonstrate thorough investigation of the points raised.
• Staff dealing with complaints should be familiar with the Model Complaints Handling Procedure, understanding the importance of recording consistently whether complaints have been upheld or not, and communicating this to the complainant.

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 by the board to their parent (A), who was admitted to hospital with a suspected liver problem. Ascites (a build-up of fluid in the abdomen) was diagnosed and paracentesis (a drain of the fluid) was performed, during which it was noted that A had accidentally bumped the drain. The following day A reported being in pain and, after a CT scan, it was determined that A was suffering from an un-operable arterial bleed. Shortly thereafter A died.

C complained that A’s consent was not properly obtained, that staff had failed to carry out the drain procedures reasonably, that A’s pain was not managed appropriately, that a CT scan was delayed, that communication from the board had been poor and inconsistent and that the level of review undertaken after the incident was not sufficient.

We took advice from an independent medical adviser in gastroenterology (medicine of the digestive system and its disorders). We found that the timescale for the CT scan was reasonable, that pain medication was appropriate, that the case had ultimately been appropriately reviewed and that the drain procedure appeared to have been carried out by appropriately trained staff under adequate supervision.

However, we found a number of failings. Firstly, the board had obtained verbal consent but failed to adequately record this. Secondly, the board’s complaints response had unreasonably focused on A having bumped the drain as being the cause of the arterial bleed. This was something that could not have been known with any certainty. Additionally, this explanation was not consistent with the post-mortem examination and internal case review, both of which found that the more likely cause of the bleed was as a recognised complication of the drain insertion. Therefore, we upheld these aspects 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:

• Patients and their families should be given clear, consistent and accurate information about the patient's care and treatment, including any complications. Complaint responses should be accurate, and evidence based.
• In future, the board will get formal written consent from patients for this type of procedure. They will also prepare a consent booklet, which will be reviewed by their gastro clinical governance group and their clinical guidelines group.

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 to the board on behalf of their partner (A) about the length of time taken to arrange a lumbar puncture test (LP, a procedure used to collect a sample of fluid from the spine) following assessment by a neurologist (specialist of the nerves and the nervous system). C had regularly contacted the board requesting an update on C’s appointment and eventually decided to complain when they were told to ask A’s GP to re-refer them. On complaining, A received their LP appointment. The board advised that the delays had been caused by the Covid-19 pandemic and that A had now been appointed to see a neurology consultant.

We found that the board had separate processes in place for arranging LPs depending on whether a patient was seen by a locum consultant or a member of the board’s own staff. As A was seen by a locum consultant, they were required to be added to an anaesthetist’s (administer of drugs) list which ran every three-four months. Had they been seen by the board’s own staff, they would have arranged the LP test directly without the need to refer them to a separate list. In A’s case, the original anaesthetist’s list that they were appointed to was cancelled, as was the second due to the onset of the pandemic, which meant that A was required to wait 10 months for this test. We upheld this complaint.

C also complained that the board failed to provide pain relief to A while waiting for the LP test. While we considered C’s expectations to be reasonable in respect of the results of the LP test confirming A’s diagnosis and informing decisions about future care and treatment, including management of their pain, we considered that this aspect of their care to remain the responsibility of A’s GP at this time. As such, we did not uphold this part of C’s complaint.

Finally, we found that the board’s complaint handling was unreasonable, particularly in relation to the failure to act on the lack of equivalence in service provision despite this problem being known following the board’s own investigation of C’s complaint. We upheld this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C and A for failing to arrange the LP test reasonably and for failing to reasonably respond to 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:

• The board should implement a sustainable model for listing the patients of locum doctors to ensure that they timeously receive LP tests. This should include a contingency plan to prevent long delays for patients when lists are cancelled.

In relation to complaints handling, we recommended:

• The board’s complaint handling monitoring and governance system should ensure that complaints are appropriately investigated and that failings (and good practice) are identified and learning from complaints are used to drive service development and improvement. All staff dealing with complaints should be familiar with the Model Complaints Handling Procedure, understanding the importance of communication and the need to demonstrate thorough investigation and action taken on the points raised.

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 late parent (A) who had a number of medical conditions. During an admission to hospital, A’s condition deteriorated, and they died.

C complained that A’s deterioration was not appropriately managed and that they contracted Listeria Meningitis (a serious disease in which there is inflammation of the membranes of the brain and spinal cord, caused by bacterial infection) and Clostridium Difficile (C-Diff; infection of the large intestine triggered by long term use of antibiotics). C also complained that a medication to treat diarrhoea was inappropriately prescribed because A had a diagnosis of ulcerative colitis. C further complained that staff did not communicate with A’s family that they were suspected of having sepsis. C also raised concerns about the board’s handling of their complaint and the standard of record keeping which was referred to in their complaint response.

The board acknowledged that the medication to treat diarrhoea should not normally be prescribed in patients with ulcerative colitis and that there was no clear record of the discussions that were held with A’s family. The board confirmed that Public Health investigated the source of listeria meningitis and concluded it was not likely a hospital-based transmission.

We took independent medical advice from a consultant gastroenterologist (a doctor specialising in the treatment of conditions affecting the liver, intestine and pancreas). We found that A’s overall care and treatment was reasonable. A was appropriately treated with intravenous steroids and antibiotics and the decision to not provide surgical intervention was reasonable. It was noted that A was at high risk of developing C-Diff given that they had been prescribed a strong immune suppressant. With regards to the listeria meningitis breakout, we found that the board appropriately sought external review and specialist public health and microbiology advice. We also found that the standard of record keeping was reasonable. Therefore, we did not uphold these aspects of the complaint. However, we found that there was insufficient evidence of clear communication with A’s family about their condition and the fact that they had sepsis, and that the board failed to provide a full response to the complaints raised. We upheld these aspects of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to communicate with A’s family that they were suspected of having sepsis and for failing to provide a full response to the complaints raised. 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:

• Staff should understand the importance of, and ensure that they communicate clearly with patients and their families about their condition.

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.