Some upheld, recommendations

Summary

Mrs C's daughter complained to her primary school of being bullied. The school took some action but the bullying continued. This was repeatedly reported to the school but the situation was not resolved. Mrs C decided to remove her daughter from the school due to the situation and recalled the head teacher saying that she was 'more than happy' for Miss C to move school. Mrs C complained to the council that the school had not taken reasonable action in response to the reports of her daughter being bullied and about the head teacher saying she was 'more than happy' for Miss C to move school. The council's investigation concluded that the school had acted reasonably. Mrs C raised complaints about this with us.

We found that the school had not made any reasonable record of the reports of bullying, the actions taken or the subsequent outcomes. The school's policy and the council's related strategy indicated that this should have been done, and monitoring take place. We decided, therefore, that the school had not taken reasonable action in relation to the complaints of bullying and we made recommendations to address this.

The council told us that the head teacher's remarks had been made in the context of Miss C obtaining a new start from moving schools. We decided that there was no evidence to reasonably conclude that the head teacher had made the remarks Mrs C alleged. We also decided that the council had not responded reasonably to the specific matters raised in Mrs C's complaints and had included irrelevant information in their responses and we made a recommendation to address this.

Recommendations

We recommended that the council:

• apologise to Mrs C and Miss C that the school did not take reasonable action in response to complaints that Miss C was being bullied;
• finalise development of the reporting procedures mentioned in their strategy and implement these;
• assure us that the anti-bullying policies of all schools have been reviewed to ensure that they are in line with their strategy regarding the recording of reports of bullying, action taken and subsequent outcomes;
• assure us that a monitoring system has been put in place to ensure that schools are recording reports of bullying, action taken and subsequent outcomes in line with their strategy;
• apologise to Mrs C that they did not respond to her complaint reasonably; and
• remind relevant staff of the importance of responding directly to specific points raised in complaints and that only information relevant to the complaint being considered should be included in complaint responses.

Summary

Ms C complained to us about the council's handling of her complaint about the direct payments awarded to her for the care of her mother (Mrs A). Mrs A has Alzheimer's disease and is cared for in Ms C's home. We found that the council should have dealt with Ms C's initial correspondence as a complaint, but had failed to do so. When Ms C then made a further complaint, there was a delay in acknowledging this and in letting her know how it would be handled. In view of these failings, we upheld this aspect of Ms C's complaint.

Ms C had then taken her complaint to a social work complaints review committee (CRC), as she was unhappy with the council's response. She complained to us that the CRC had failed to adequately consider some of the points she had raised. In social work cases, there is a separate social work complaints procedure that has been set up by law and ends in an appeal to the CRC. We can look at the CRC process to ensure it has been properly followed, however, this does not include looking at the subject of the complaint to the CRC or reviewing their decision. Whilst we can look at whether or not the CRC took evidence into account, we cannot review how they used this evidence in reaching their own conclusions.

In Ms C's case, we were satisfied that the CRC had considered the points she had raised. It was for the CRC to decide on the issues presented to them and on how much weight to give to the information they received from Ms C and the council. We did not uphold this aspect of Ms C's complaint.

Finally, Ms C complained that the council had not complied with the CRC's recommendations. Whilst we recognised that Ms C was unhappy with the action taken by the council in response to the CRC's recommendations, we were satisfied that they had complied with the recommendations. We did not uphold this aspect of Ms C's complaint.

Recommendations

We recommended that the council:

• issue a written apology to Ms C for the failures identified in relation to their handling of her complaint.

Summary

Ms C complained about the dental treatment she received on a tooth that was infected. The tooth had previously had root canal treatment and a crown. Ms C said the dentist had been clear that after two courses of antibiotics, they would take the tooth out and apply the antibiotic directly and replace the tooth temporarily to allow the infection to clear completely. Ms C understood that she would then be able to return in two months and that it would be refitted permanently. Ms C said that she was not made aware that the integrity of the tooth might be compromised or consented to the treatment that was carried out by the dentist. Subsequently, the dentist was unable to replace the root filling and later the tooth fell out.

We took independent advice from a dental adviser. We found that the evidence from Ms C's dental records showed significant failings around the consent process and shortcomings in relation to the prescription of antibiotics and taking of x-rays. We also found that the dentist failed to offer and discuss alternative treatments with Ms C and so opportunities to save the tooth were missed. In view of the poor outlook of the tooth, we recommended that the dentist refund the cost of treatment available on the NHS to remedy the situation (a bridge), as well as the costs of the treatments Ms C received during this period.

Recommendations

We recommended that the dentist:

• refund Ms C the cost of a bridge (in line with the statement of dental renumeration) on receipt of an appropriate invoice when treatment has been completed;
• refund Ms C the cost of treatments provided during the period in question;
• review their consent process, prescription of antibiotics and taking x-rays, in line with relevant guidance and standards; and
• apologise for the clinical failings this investigation identified.

Summary

Mrs C complained about the care and treatment provided following an injury to her shoulder. Mrs C complained that A & E staff at Raigmore Hospital failed to promptly diagnose that she had multiple fractures to her arm. Mrs C also raised concerns that on her subsequent attendance at the fracture clinic, staff failed to carry out a CT scan (a scan which uses x-rays and a computer to create detailed images of the inside of the body) as a matter of urgency. Mrs C complained that the board failed to ensure that she received surgery for her shoulder within a reasonable timescale. Mrs C linked these concerns with subsequent complications in her shoulder, which led to further surgery. Mrs C complained that the board failed to provide reasonable care and treatment at the further operation she received approximately nine months after her shoulder injury. Mrs C also raised concerns about whether the board appropriately investigated her complaints.

The board said A & E had assessed and managed Mrs C appropriately. The board also considered Mrs C received a CT scan within a reasonable timeframe. The board said emergency admissions impacted on the timescale for Mrs C's surgery; however, they said she ultimately received treatment within an appropriate timescale. The board said the timescales did not impact on Mrs C's recovery. The board did not comment on Mrs C's concerns about the care and treatment provided at the second operation.

After receiving independent advice from an orthopaedic surgeon, we did not uphold Mrs C's complaints about her care and treatment. We found the A & E diagnosis had been reasonable as documented in the medical records. We found the timescales for receiving the CT scan and the surgery were reasonable. We found that it was not likely that these timescales caused Mrs C's slow recovery. We also found that the care and treatment provided at the second operation was reasonable.

We upheld Mrs C's complaint about the board's handling of her concerns. We found that, given the nature of the concerns raised, the board should have investigated further. We recommended that the board apologise to Mrs C, and remind staff of the requirements of the Scottish Government's 'Can I help you?' guidance.

Recommendations

We recommended that the board:

• apologise for the failings identified by this investigation; and
• remind relevant staff of the complaints handling requirements under the 'Can I help you?' guidance.

Summary

Mr C complained about the care and treatment received by his daughter (Miss A). Mr C raised concerns that there was not a reasonable care plan in place to address Miss A's borderline personality disorder (BPD) diagnosis and that the input she was receiving was not sufficient and was not in line with recognised guidance in this area. He also raised concerns that Miss A had been prescribed anti-psychotic medication despite this not being recommended for the treatment of BPD.

We took independent medical advice from two consultant psychiatrists. We were advised that there was a reasonable care plan in place for Miss A over the period in question. However, there was no evidence that this had been appropriately reviewed on a regular basis. It also noted that the care plan might have benefited from the inclusion of additional information. While a more structured approach to Miss A's care planning (known as the Care Programme Approach) might reasonably have been deemed unnecessary given her circumstances, we saw no evidence of this having been considered. We were advised it would have been good practice for this to have been considered and for any decision not to utilise this approach to have been documented. On balance, we upheld this aspect of the complaint.

With regards to the level of intensity of treatment provided to Miss A, we were advised that she had been considered for a range of additional therapies but deemed unsuitable at the time of each assessment. As such, the advisers considered that the current level of provision was appropriate to her circumstances. Mr C also complained that group treatment sessions had not been provided but we noted that Miss A had also been assessed, and deemed unsuitable, for therapies that could have been delivered as group sessions. We did not uphold these aspects of the complaint.

We were advised that it was common practice for anti-psychotic medication to be used to help alleviate some of the effects of BPD, despite there being very little evidence for such an approach. We concluded that this was reasonable in Miss A's circumstances and did not uphold this aspect of the complaint. However, we noted that the rationale for this should have been discussed with Miss A and that it would have been helpful for this to have been recorded in her care plan.

Recommendations

We recommended that the board:

• remind Community Mental Health Teams (CMHTs) to ensure that review dates are set and adhered to for care plans and that reviews should be clearly documented in the records;
• remind CMHTs to consider the use of the Care Programme Approach in complex cases and clearly document any decision not to utilise this approach; and
• ask CMHT staff to reflect on the advice we received and consider enhancing the level of detail included in future care plans.

Summary

Mrs C, who is an advocacy worker, complained on behalf of Mrs A about the care and treatment provided to her husband (Mr A). An abnormality was noted on a brain scan Mr A received and he was not informed of this until five years later, when he was told he had a tumour. A biopsy was then carried out but Mr A suffered a bleed in his brain as a result of the biopsy operation and was left significantly incapacitated and in need of residential care.

Mrs C complained that Mr and Mrs A were not informed about the existence of the brain tumour when it was first noted and that no follow-up action had been taken. The board noted that the abnormality was first thought to have been a stroke and it had not been confirmed as a tumour until more recently. We obtained independent medical advice from a consultant neurosurgeon and a general medical consultant. It was considered that the tumour could have been diagnosed much earlier had prompt follow-up been arranged. However, we were assured that treatment would only have been proposed if the tumour had grown in size or Mr A's condition deteriorated, meaning that this would have happened around the time treatment was ultimately considered anyway. We noted that Mr A was not informed of the findings of the initial scan and we concluded that this should have happened. We also concluded that these findings should have been followed up to allow a confirmed diagnosis to be made and communicated to Mr A. While we were satisfied that this delayed diagnosis did not significantly impact on his treatment, we upheld this complaint.

Mrs C also complained that the board had failed to explain to Mr A the risks attaching to the biopsy procedure. We observed that discussions surrounding the risks, including bleeding and brain damage, were documented in a clinic appointment note prior to the biopsy, and also on the consent form which Mr A had signed. We did not uphold this complaint.

Mrs C also complained about the board's handling of the complaint, including the timeliness and comprehensiveness of their response. We considered that the board's replies were unreasonably delayed and that they failed to adequately address all of the issues raised. We also noted that their complaint file did not appear to contain a full account of their investigation. We upheld this complaint.

Recommendations

We recommended that the board:

• ask the relevant clinicians to reflect on the findings of this investigation and ensure that appropriate action is taken in future to follow up on unexplained abnormalities, particularly when the clinical signs do not support the suspected diagnosis;
• ask the relevant clinicians to ensure that any unusual scan results are shared with the patient;
• apologise to Mr and Mrs A for the failure to share with them the findings of the initial scan, for the failure to follow this up, and for the consequent delay in confirming, and informing them of, Mr A's tumour diagnosis;
• ask complaints staff to reflect on the complaints handling failings this investigation has identified and take steps to ensure that their feedback and complaints handling procedures are fully adhered to;
• ask complaints staff to ensure that all correspondence relevant to their investigation of a complaint, including internal correspondence, is filed on their complaint file; and
• apologise to Mr and Mrs A for the failure to provide a clear, comprehensive and timely response to their complaint.

Summary

Mrs C, who works for an advice agency, complained on behalf of her client (Mrs B) who was concerned about the care and treatment given to her late mother (Mrs A) in Aberdeen Royal Infirmary. Mrs A had multiple sclerosis and was fed through a tube. Before her death in late 2014, she had been admitted to hospital on a number of occasions, mainly with breathing difficulties.

In mid-November 2014, Mrs A was admitted to hospital again, this time with diarrhoea and vomiting. Tests showed that her feeding tube was displaced and that she had colitis (inflammation of part of the large intestine) with a possible perforation (penetration of the organ wall). The situation was discussed with Mrs B and her mother and it was agreed that no surgery would be carried out. After being given antibiotics, Mrs A was noted to be improving although during her stay in hospital she also required treatment for a cyst.

Mrs A was discharged home in late November, but died later the same day. Mrs B believed that her mother had not been fit for discharge. She also complained that Mrs A had not been provided with appropriate care and treatment during her hospital admission and had not received a reasonable standard of nursing care.

We took independent advice from consultants in obstetrics and gynaecology and in gastroenterology, and from a nurse practitioner. We found that all of Mrs A's clinical care had been reasonable and appropriate but that aspects of her nursing care (particularly concerning washing and showering which led to a doctor asking the family to wash Mrs A) had not been, so we upheld that aspect of the complaint. Nevertheless, we found that Mrs A had been fit to go home on the day of discharge. While her death was unexpected, because of the number of diseases and conditions from which she suffered, there was no action that could have been taken to have prevented this.

Recommendations

We recommended that the board:

• make Mrs B a formal apology for the shortcomings identified in Mrs A's nursing care;
• advise us of the actions taken to ensure that patients with mobility issues can access shower facilities; and
• bring this complaint to the attention of the doctor who approached family members to wash Mrs A in order for the doctor to reflect on it as part of their appraisal/training plan.

Summary

The mother and partner of Mr A complained about the care and treatment that he received from Dumfries and Galloway Royal Infirmary following a lung biopsy. The biopsy was carried out after a scan indicated the spread of cancer to the lungs and Mr A was later diagnosed with testicular cancer. Mr A's mother and partner were concerned that he did not receive timely treatment following the biopsy. They also felt that Mr A should have been admitted to hospital, rather than being discharged home to await the biopsy results.

After taking independent advice on this case from a consultant physician and a consultant urologist we upheld the complaint that Mr A had not received timely treatment. The advice we received was that the pathology team had not been provided with all the relevant clinical information to help them accurately report the primary site of Mr A's cancer. The advisers also both considered that there had been an unreasonable delay in arranging a specific blood test that can highlight testicular cancer. We considered that the delay in arranging this test was unreasonable as earlier scans had pointed towards testicular cancer and clinicians should have been aware of the potential for this diagnosis. The advice we received was also critical that there was not a more proactive approach to Mr A's care following a urology referral and that his case was not discussed with oncology when it became clear that there would be a delay in the biopsy result becoming available. We made a number of recommendations to address these findings.

We did not uphold the second complaint regarding the decision to discharge Mr A following his biopsy. The advice we received was that it was clinically safe to discharge Mr A and that the board should have been able to manage his care as an urgent patient without admission being necessary.

Recommendations

We recommended that the board:

• apologise for the failings identified in this investigation;
• take steps to ensure that all relevant clinical information is supplied to pathology to assist their analysis of biopsy samples;
• discuss this case at an appropriate clinical governance meeting and highlight the findings of this investigation to relevant staff for reflection; and
• take steps to ensure that referrals are acted on in an appropriate and timeous manner.

Summary

Mr C was admitted to University Hospital Crosshouse with a suspected infection following shoulder surgery a few days earlier. He complained that he received poor care in relation to the infection that developed in his wound, which required treatment under three separate general anaesthetics. Mr C was dissatisfied with the nursing care in terms of the lack of access to a bathroom and a shower, as well as the way in which his medicines were administered. He also complained about the board's delay in responding to his complaint.

We took independent advice from medical and nursing advisers on the care and treatment Mr C received. We were critical of a lack of evidence showing that Mr C's wound had been examined by three different doctors who had reviewed him on the day of admission to hospital. We made a recommendation to address this failing. However, we considered the assessments and treatment carried out thereafter were reasonable. In terms of the nursing care, we found that there was good reason (because of infection control and the facilities in the high dependency unit) for Mr C not having specific access to a bathroom and shower.

We did not uphold Mr C's complaints about his medical and nursing care, although we did identify shortcomings in the prescribing of his medication and made two recommendations to the board about this. There was also an unreasonable delay of four months in the board responding to his complaint and we made a further recommendation to address the matter.

Recommendations

We recommended that the board:

• review their medicines reconciliation process to ensure that medication is prescribed and checked in a systematic manner;
• draw to the attention of the medical staff involved in Mr C's care the failure to review his heart rhythm to check whether he required to continue with the existing treatment or have any additional medication prescribed;
• review their handling of Mr C's complaint in order to identify ways in which they can ensure regular updates are given and keep any delays to a minimum; and
• share the adviser's comments with the three doctors involved in Mr C's care.

Summary

Ms C raised a complaint about the educational support offered to her son while he was absent from school and when he returned to school on a phased basis. Ms C was also unhappy with the handling of her complaint.

We noted that the council had apologised for the delay in Ms C's son's return to school, for the failure to send work home while he was absent from school, and for the delay in securing a technical teacher to assist her son. However, we were concerned that we were provided with no evidence of any structured approach to Ms C's son's return to school, any mechanism for monitoring the work he had missed, or a plan in place to ensure he could catch up with the work missed.

We were also concerned that when Ms C's son returned to school, while there was a willingness to offer support, there appeared to be no structured plan in place to monitor how well he was catching up and whether any changes had to be made to the support being offered to him. We were also concerned that, while meetings to discuss Ms C's son continued during his senior phase of education, Ms C remained unclear about the support being proposed for her son. We upheld this part of Ms C's complaint.

We were satisfied that the council had reasonably considered and responded to Ms C's complaint, and we did not uphold this part of her complaint.

Recommendations

We recommended that the council:

• reflect on this case with a view to introducing a structured approach to ensuring pupils' education is maintained where pupils are unable to attend school and that this is properly recorded; and
• if they have not already done so, implement a learning plan for Ms C's son as a matter of urgency, and confirm in writing to Ms C what support is being offered to her son for his senior phase of education.