Upheld, no recommendations

Summary

C was an executor of their late parent's estate and were seeking to sell a property in line with their parent's will. However, there was a charge on the property which related to legal costs incurred many years ago by their other parent (B). B did not have capacity to agree that the sum should be paid, and as such, an intervention order (a court appointment which authorises a person to act and take a one-off action or make decisions on behalf of an adult with incapacity) was granted by the Sheriff Court for social work (with the support of the council's legal services) to act on behalf of B regarding the charges. C complained about the length of time being taken to execute the intervention order.

We found that there were delays in correspondence regarding the execution of the intervention order. We noted that both the partnership and the council had acknowledged and apologised to C for this. Some of the delays were outwith their control due to awaiting responses from C's solicitors and the impact of the COVID-19 pandemic. However, some of the delays could have been avoided (by having clear lines of responsibility between social work and legal services and by escalating the matter internally). We considered that, on balance, there had been an unreasonable delay in executing the intervention order. As such, we upheld C's complaint. However, we did not make any recommendations due to the action already taken by the partnership.

Summary

C complained that the Scottish Government failed to deal with their complaint over an extended period. C said they repeatedly had to chase the Scottish Government for a response.

When C first approached this office, they had not completed the Scottish Government's complaints procedure. Although we received assurances from the Scottish Government that the case was being progressed, C repeatedly informed us that they were not receiving updates, or responses to their correspondence. We chose to exercise our discretion and proceed to an investigation, even though C had not completed the Scottish Government's complaints procedure.

We found that the Scottish Government had failed to handle C's complaint in line with their published complaints procedure. They had not complied with the time scales set out in their complaints handling procedure, records had not been kept appropriately and C had not been kept informed of developments, nor had the Scottish Government responded to correspondence.

We upheld C's complaint, but because of a similar case, concluded just before theirs, further recommendations were not made to the Scottish Government who have since taken significant steps to improve their complaint handling.

Summary

C complained on behalf of their spouse (A) about the mental health care and treatment provided to A by the board. A has ongoing mental health difficulties and has been supported by both psychiatry and community psychiatric nurses, as well as more recently having psychology input.

We took independent advice from a psychiatrist (a doctor who specialises in the diagnosis, treatment and prevention of mental ill health conditions). We found that, whilst there were aspects of care and treatment that were reasonable, there had been a delay in A being given a psychiatry appointment. We upheld the complaint on this basis; however, as the board had previously acknowledged and apologised for this failing, we did not make any further recommendations.

Summary

C complained to us that staff from Greater Glasgow and Clyde NHS board had delayed in identifying that they had compartment syndrome (a painful and potentially serious condition caused by bleeding or swelling within an enclosed bundle of muscles – known as a muscle compartment). C was admitted to Glasgow Royal Infirmary after a fall in their garden where they sustained a tibial plateau fracture (a break in the upper part of the shin bone). They had surgery for this and the board stated that there was no evidence of compartment syndrome at that time. C continued to suffer problems including wound leak, foot drop and numbness in their leg. They were taken back to theatre and it was identified that they had developed compartment syndrome of the muscles of the anterior (front) compartment of their lower right leg. This has had a significant impact on C’s life.

We took independent advice from a trauma and orthopaedic surgeon (a specialist in the treatment of diseases and injuries of the musculoskeletal system). We found that, given C’s high risk injury, the symptoms of excess pain and numbness and the signs of reduced sensation and weakness, it was unreasonable for the board not to have either measured the compartment pressure or performed fasciotomies (the skin and fascial compartment are cut open so that the compartment pressure is relieved). This should have occurred after C’s operation and it was unreasonable for C to have been discharged home without this being carried out. If compartment syndrome had been recognised early, and swift decompression performed, on balance, the extent of the surgery performed subsequently would not have had to be so severe and the functional outcome not as bad. Therefore, we upheld this complaint.

However, consultants from the board had already met C to apologise that the onset of compartment syndrome was not identified earlier. The board had also outlined further action they had taken to prevent this issue recurring. In view of this, we did not make any recommendations to the board.

Summary

C complained on behalf of the child (A) about the care and treatment received by the board. A was referred to neurology (the branch of medicine concerned with the diagnosis and treatment of disorders of the nervous system) after reporting that they were experiencing upper body jerks and involuntary twitching. A review was undertaken by a private healthcare provider on behalf of the board as part of a neurology waiting list initiative. The neurologist agreed that an MRI scan and an EEG (electroencephalogram - a test used to evaluate the electrical activity in the brain) would be carried out. Some years later, A was admitted to hospital after a seizure. It was noted that the earlier EEG referral was not progressed. Another EEG was arranged and following that, A was diagnosed with epilepsy (a condition that affects the brain and causes frequent seizures).

C said that they considered the failure to carry out the EEG meant there was a delay in diagnosing A's epilepsy. The board said it was the neurologist's intention to have the scan carried out. An apology was given for the lack of follow-up in A's case.

The evidence available confirmed that the neurologist appropriately considered the possibility that A was suffering from myoclonic epilepsy (brief shock-like jerks of a muscle or group of muscles), and intended to order appropriate investigations. However, there was no evidence available to confirm that the request for the EEG was actioned or followed up. The relevant paperwork was not available to reflect back on what may have happened.

We took independent advice from an appropriately qualified adviser. We found that an EEG should have been carried out in A's case. The relevant guidance indicates the significance of arranging an EEG in cases of suspected myoclonic epilepsy.

We upheld the complaint but did not recommend any further action because the board had already apologised for not actioning the EEG. In addition, the board also told us they no longer used the services of the provider.

Summary

Ms C complained that the board delayed in arranging the surgery she needed. She was entered onto the list for surgery at a gynaecology (medicine of the female genital tract and its disorders) out-patient clinic, but said that she was told months later that they were only carrying out surgery for patients entered onto the list in the previous year. She decided that she could not wait for the surgery and had it privately.

We took independent advice from a consultant obstetrician and gynaecologist (a doctor who specialises in the female reproductive system, pregnancy and childbirth). We found that there had been a delay in arranging the surgery and we upheld the complaint. However, we also considered that the action the board were taking to reduce waiting times was reasonable. This included addressing their referral pathways and seeking to increase their consultant capacity. In addition, the board had apologised to Ms C that they had failed to meet the treatment time guarantee. When the board had received contact from Ms C's GP about the delay, they had acted on this quickly and a plan for escalation was commenced. We did not, therefore, recommend that Ms C was reimbursed for the costs of the operation, as we were unable to conclude that Ms C had no option but to arrange treatment privately. We did not make any recommendations to the board in relation to Ms C's complaint.

Summary

C complained to us that the partnership had failed to provide reasonable psychiatric care and treatment to their parent (A) before they completed suicide. We took independent advice from a psychiatric adviser. We found that there had been a number of failings in A's care:

There was no specific action taken to either address or mitigate the risks identified on A's care plan beyond continuation of the current treatment plan and referral to psychotherapy.

It was not clear from the record to what extent there was direct communication between the psychiatrist and the community psychiatric nurse (CPN), specifically with respect to A's management following an overdose.

The fact that A was neither reviewed medically or from a nursing perspective over a six-week period in the aftermath of their overdose was a significant shortcoming.

The lack of development of shared risk management plans within the community mental health team (CMHT) was not reasonable.

The fact that there was not a scheduled regular meeting to discuss complex cases was not reasonable.

There was neither a clearly understood protocol within the CMHT to annually review longer-term cases or a robust facility to provide the psychiatrist with regular consultant supervision for cases under their care.

It was not apparent from the case record exactly which consultant was responsible for A.

A did not receive appropriate annual review from the CMHT and that this was not reasonable.

In view of these failings, we upheld C's complaint. However, we considered that the action the partnership had decided to take in response to these failings had been reasonable, but asked for evidence that this had been completed. There was also no clear evidence that A's death could have been prevented.

C also complained that an officer from the partnership had failed to meet them in response to their complaint as previously agreed. Whilst it was not entirely clear if the officer had offered to meet C, overall, the handling of the matter was unacceptable given the nature of C's complaints. We also upheld this complaint, although we were satisfied with the action the partnership had subsequently taken in response to these failings and made no recommendations.

Summary

Mr C complained that St Johns Hospital did not provide reasonable treatment to his late father (Mr A) during his hospital admission. During admission Mr A received an incorrect dose of paracetamol which the hospital recognised and responded to. The board determined that the medication error was not a contributory factor to Mr A's death.

We took independent advice from a consultant geriatrician (a doctor who specialises inmedicine of the elderly). We found while the general treatment provided to Mr A was reasonable, a significant error occurred, leading to Mr A receiving an overdose of paracetamol. Therefore, we upheld the complaint. Wenoted that the board have already taken action to address this failing so madeno further recommendations.

Summary

Ms C, an advocate, complained on behalf of her client (Ms A) about the standard of communication between clinicians and Ms A in relation to breast implant reconstruction. Ms A was concerned about the outcome of the procedure saying that her breasts were completely asymmetrical and the skin on top of her left breast was bunched up. Ms C said that Ms A had not been given realistic expectations about the results of the procedure.

We took independent advice from an adviser in plastic surgery. We found that there were shortcomings in record-keeping which meant it was not entirely clear what was discussed with Ms A or what information was provided. The evidence from the clinical notes indicated that the risks were outlined during at least one consultation, but there was a lack of documented evidence that Ms A was informed in a clear way that her breasts may not be symmetrical in size, shape and volume following the procedure. We upheld the complaint. However, we made no recommendations in light of the action already taken by the board to resolve the complaint.

Summary

Mr and Mrs C complained about the care and treatment their child (Child A) had received in Raigmore Hospital. Child A had asthma and was referred to the hospital by their GP because of breathing problems. They were admitted to the children's ward and was discharged on the following day. They were readmitted three days later and were then discharged later that day. Child A was readmitted again on the same day after a rapid deterioration in their symptoms. Their condition continued to deteriorate and the emergency team in the hospital took them to theatre. They were then transferred to the intensive therapy unit before being transferred back to the children's ward three days later.

Mr and Mrs C complained that staff had unreasonably considered that Child A had anxiety. We acknowledged that it can be difficult on occasions for both clinicians and patients to distinguish feelings of breathlessness due to asthma from those due to anxiety or a combination of both. We found that much of the care and treatment provided to Child A had been reasonable. It was reasonable to carry out spot-checks of their oxygen saturations, and their medication was also in keeping with standard asthma guidelines. However, on balance, the delay by medical staff in responding when nursing staff continued to raise concerns about Child A's condition had been unreasonable. The discharge letter was also inadequate, as it did not describe the clinical course accurately and did not give GPs and those subsequently involved in Child A's care a full picture of the issues. We upheld this complaint.

However, we did not make any recommendations, as the board had already apologised to Mr and Mrs C. They had also stressed to staff the importance of listening to patients and the importance of appropriate assessment of any child with breathing difficulties. The board also told us that in future, discharge letters would be verified by a consultant.