Upheld, recommendations

Summary

C complained that Social Security Scotland (SSS) unreasonably delayed in changing responsibility for Child Disability Payment (CDP) when C reported that their child (A) was living with them. C and A's other parent (B) were living apart and A had previously been living with B. However, A moved out of Scotland to live with C.

C complained that when this change in circumstances was reported, payments of CDP had initially been suspended pending transfer to C, however, the suspension was subsequently removed and all outstanding payments due before the account was closed continued to be made to B. C complained that B did not make this income available resulting in C and A being negatively impacted financially.

SSS agreed that there had been delays in processing the transfer, pending new guidance and processes being put in place. SSS also stated that the transfer of payments to C should have been actioned before the process for ending CDP payments was completed. Nevertheless, SSS stated that their statutory duty was to make payments for A, which they fulfilled, and that any dispute over how the CDP payments were distributed between the two parents was a civil matter. Additionally, they considered that there was no evidence that A was not benefiting from the payments during this time.

We found that B had confirmed their agreement for the change in responsibility and that payments to B had initially been suspended only for the suspension to be subsequently removed with no reasoning recorded. We found that there were delays due to lack of formal SSS guidance being in place. Additionally, it was evident that conflicting information and communication received from C and B should have raised concerns about whether A was benefiting from the benefits income intended for them, and there were missed opportunities to give clear advice to both C and B. Additionally, SSS had acknowledged that they should have processed the change in responsibility before processing A’s move out of Scotland.

Given these failings, we upheld C’s complaint. We recommended, under SPSO’s redress policy, that SSS should make a payment to C for the amount of CDP due from the point at which the account had initially been suspended until the account was closed.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failings in relation to changing responsibility for Child Disability Payment when C reported that A was living with them. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/meaningful-apologies.
• Provide an ex-gratia payment to C equivalent to the amount of Child Disability Payment that A was entitled to, from the point at which theaccount had initially been suspended until the account was closed.

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

• SSS should ensure that appropriate consideration is given to whether evidence has been provided to suggest that payments of benefits are not being used for their intended purpose, and to whether financial abuse may be taking place. In cases where such information is received, consideration should be given to suspending payments, in line with the relevant guidance and legislation.

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 events at their child (A)'s school, in relation to suspected candidate malpractice and subsequent investigations into the school’s handling of the matters.

C queried whether the council followed the correct process when C raised their concerns, as C was of the view the council should have followed the Scottish Qualifications Authority (SQA)’s Centre Malpractice Procedure, rather than the complaint procedure.

C also raised concern that the investigating officer had shown bias in the process, that the child friendly complaint process had not been followed, and that the Stage 2 complaint response downplayed or omitted serious breaches, contained inaccuracies and misrepresentations, and directly contradicted the SQA’s findings.

We found that while it was reasonable for the council to use the complaint handling process as opposed to the SQA’s centre malpractice process, they appeared to be uncertain about the correct procedures. We also found that the council failed to address legitimate concerns about bias in the appointment of the investigating officer or respond to these issues.

We found that the council failed to follow child friendly complaint handling procedures, as they did not seek consent and views from the young person at the appropriate stage, and did not clearly consider and take into account the young person’s views when making their decision. Finally, we found that there were incompatibilities in outcome of the council’s investigation. We upheld the complaint.

The council had begun to take action to address these failings including developing a Malpractice Policy, building steps into their processes to ensure the views of young people are included in investigations, and committing to refresher complaint handling training, so we asked for evidence of these actions.

Recommendations

What we asked the organisation to do in this case:

• Apologise to A and C for the failure to reasonably investigate and respond to the complaint. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/meaningful-apologies.

In relation to complaints handling, we recommended:

• Where concerns about impartiality are raised, these should be appropriately acknowledged and addressed. We offer SPSO accredited Complaints Handling training. Details and registration forms for our online self-guided Good Complaints Handling course (Stage 1) and our online trainer-led Complaints Investigation Skills course (Stage 2) are available at https://www.spso.org.uk/training-courses.

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 their parent (A) suffered a fall while in hospital. C was concerned that bedrails and falls risk assessments were not appropriately completed prior to A suffering the fall. The board said in their complaint response that both bedrails and falls risk assessments had been carried out appropriately.

We took independent advice from a registered nurse. We found that, from the evidence available to us, the falls and bedrail risk assessments carried out prior to A’s fall were limited and did not inform a comprehensive care plan. The board’s Policy for the Prevention and Management of Adult Inpatients Falling in Hospital Settings did not appear to have been followed. We upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failure to carry out appropriate risk assessments and care planning prior to A’s fall. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/meaningful-apologies.

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

• Falls and bedrails assessments should be completed, in full, within 24 hours of admission and reviewed regularly.

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 them by the board when they were admitted to hospitalwith chest pain and respiratory issues. C also complained that the board’s complaint response failed to respond reasonably to C’s concerns.

We took independent advice from a respiratory adviser. We found that it was unreasonable that the board had not performed a pleural aspiration (a procedure to remove fluidfrom the space around the lungs) and had not inserted a chest drain on the day that C’s condition deteriorated in hospital. We upheld this complaint.

We also found that the board’s response to the complaint was unreasonable given that they failed to identify failings in C’s care and treatment in their complaint investigation and failed to carry out a significant adverse event review (SAER). We upheld this complaint, however, we recognised that the board had accepted and apologised for failings.

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/meaningful-apologies.

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

• Patients should receive the necessary care to detect and address the progression in pleural infection, during the normal weekend respiratory cover period. All staff should follow relevant policies and a chest x-ray should be performed after a chest drain insertion.
• Complaints should be investigated and responded to in accordance with the board’s complaint handling procedure and the NHS Model Complaints Handling Procedure. The board should fully investigate and address the key issues raised, identify and action appropriate learning and apologise where issues have been identified. We offer SPSO accredited Complaints Handling training. Details and registration forms for our online self-guided Good Complaints Handling course (Stage 1) and our online trainer-led Complaints Investigation Skills course (Stage 2) are available at https://www.spso.org.uk/training-courses.
• The board should undertake SAERs in line with relevant guidance.

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 decision of the practice to remove them from their list and about the way that the practice handled their complaint. C had a consultation with a GP at the practice. A few days later C was removed from the practice list.

Practices are entitled to remove patients from their lists in certain circumstances. That said, for a removal to be reasonable, the practice need to be able to demonstrate that they have acted in a way that is consistent with The National Health Service (General Medical Services Contracts) (Scotland) Regulations 2018 (the 2018 Regulations) and General Medical Council guidance to ending a professional relationship with a patient.

Regarding C’s removal from the practice, we found that the practice did not act in accordance with the 2018 Regulations and the GMC’s guidance. The practice did not provide any contemporaneous written records setting out the reason why no warning was given in this case and the circumstances of the removal. They also did not provide records of the justification for removing C from the practice list for expressing dissatisfaction about the care and treatment provided and the grounds for it not being considered appropriate to provide C with a more specific reason for the removal.

Regarding the handling of C’s complaint, we found that the practice failed to fully investigate and respond to the points of complaint being raised in accordance with the practice’s complaint handling procedure and the NHS Model Complaints Handling Procedure. They also failed to provide C with a copy of the practice’s Public Facing Complaints Handling Procedure. We upheld C's complaints.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for not acting in accordance with The National Health Service (General Medical Services Contracts) (Scotland) Regulations 2018 and the GMC’s guidance, for not responding to the points of complaint that C raised and not providing C with a copy of the Practice’s Public Facing Complaints Handling Procedure. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/meaningful-apologies.

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

• Schedule 6, Part 2 of The National Health Service (General Medical Services Contracts) (Scotland) Regulations 2018 and the relevant GMC guidance should be followed when considering removing patients from the practice list.

In relation to complaints handling, we recommended:

• Complaints should be investigated and responded to in accordance with the practice’s complaint handling procedure and the NHS Model Complaints Handling Procedure. Complaints investigators should fully investigate and address the key issues raised, identify and action appropriate learning and apologise where issues have been identified. The practice should co-operate with the SPSO when we are investigating a complaint in line with the relevant legislation such as the National Health Service (General Medical Services) (Scotland) Regulations 2018 and the Scottish Public Services Ombudsman Act 2002. We offer SPSO accredited Complaints Handling training. Details and registration forms for our online self-guided Good Complaints Handling course (Stage 1) and our online trainer-led Complaints Investigation Skills course (Stage 2) are available at https://www.spso.org.uk/training-courses.

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 standard of medical care provided by the board during two attendances at A&E with severe abdominal issues. C was discharged home on both occasions, and shortly after the second discharge, the results of a magnetic resonance scan (MRI) indicated that they had significant abnormalities of the bowel. C was then admitted to hospital for treatment of inflammatory bowel disease.

We took independent advice from consultants in emergency medicine and general medicine. We found that the standard of medical care provided was not reasonable in that recordkeeping and communication was poor, C was misdiagnosed with constipation at the second visit, there was a failure to act on the results of the MRI scan and discuss C’s care with the relevant specialists at the second visit, and there was a delay in treating C and admitting them to hospital. We upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failings identified in this investigation in relation to the standard of medical care and treatment. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/meaningful-apologies.

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

• Patients’ records should be completed to a reasonable standard and in line with the relevant professional standards. Patients with abnormal test results should be acted on fully and within a reasonable time. Patients with a complex medical history and repeated presentation should have a full differential diagnosis list and all relevant specialists should be consulted with.

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 nursing staff to their late sibling (A), who was admitted to hospital with a chest infection. A was discharged with injuries and delirium, which C believed was due to a fall they had shortly after admission. A was a wheelchair user and especially vulnerable to falls because of their bone condition (osteoporosis). C said that a full assessment of A’s risk of falling was not carried out and that the fall caused A to deteriorate, and led to their death three months later.

We took independent advice from a registered nurse adviser. We found that the standard of nursing care provided was not reasonable in that a falls risk assessment was not carried out fully and accurately, documentation and record keeping did not meet the required standards, communication needs were not met and full learning and improvement was not achieved because a significant adverse event review was not carried out. We upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failings identified in this investigation in relation to the standard of nursing care and treatment and complaint handling. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/meaningful-apologies.

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

• Patients who are at risk of falling should have a full falls risk assessment and all appropriate interventions to reduce the risks as much as possible. Families/carers should be informed of a patient’s fall within a reasonable time. Documentation and recordkeeping should meet the required standards. Adverse event reviews should be carried out in line with the relevant framework.

In relation to complaints handling, we recommended:

• Complaints should be investigated fairly and fully and in line with the requirements of the NHS model complaints handling procedures. Complaint responses should be accurate, complete and address all the points raised in line with the NHS model complaints handling procedure. We offer SPSO accreditedComplaints Handling training. Details and registration forms for our onlineself-guided Good Complaints Handling course (Stage 1) and our onlinetrainer-led Complaints Investigation Skills course (Stage 2) are available athttps://www.spso.org.uk/training-courses.

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 their late partner (A) received from the board’s gynaecology and oncology services at Glasgow Royal Infirmary. A was admitted to hospital, diagnosed with liver cancer, given two months to live and died. C also complained about the board’s handling of their complaint.

We took independent advice from a consultant gynaecologist and a consultant oncologist. We found that there appeared to be no evidence that A had any follow-up appointments with the board until 1 year and 11 months after completion of their cancer treatment, contrary to the west of Scotland cancer network guidelines. We noted that the board had acknowledged that A had a long wait for their gynaecology follow-up appointments, their cancelled appointments were not reappointed within a month, and they had to chase for appointments. We noted that the board had apologised for these failings and indicated that they were taking remedial action to address this. Given the board’s failure to follow the guidelines and their repeated cancellation of A’s gynaecology appointments, on balance, we upheld the complaint.

C also said that the board’s response to their complaint did not give them any option to ask for clarification or to challenge the response. We found that the board failed to follow the NHS Model Complaints Handling Procedure and advise C that a named member of staff was available to clarify any aspect of the response. We, therefore, upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

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

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

• The board should follow the WOSCAN CMG’s recommendations on follow up appointments for patients with endometrial cancer.

In relation to complaints handling, we recommended:

• In their complaint responses, the board should advise complainants that a named member of staff is available to clarify any aspect of the response. We offer SPSO accredited Complaints Handling training. Details and registration forms for our online self-guided Good Complaints Handling course (Stage 1) and our online trainer-led Complaints Investigation Skills course (Stage 2) are available at https://www.spso.org.uk/training-courses.

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 in A&E, and the subsequent handling of their complaint by the board. C initially attended the A&E with vomiting, diarrhoea and abdominal pain. Although C and their partner raised the possibility of appendicitis, this was dismissed. C was diagnosed with gastroenteritis and discharged without a full abdominal examination or review by a senior clinician. The following day C’s condition deteriorated, and C was found to have a ruptured appendix and septic shock, requiring emergency surgery, ventilation, and a prolonged hospital stay.

We took independent advice from an Advanced Nurse Practitioner. We found that the care and treatment that C received was unreasonable because a thorough abdominal examination was not carried out by a senior decision maker and documented to exclude appendicitis as a differential diagnosis, prior to discharging C. It was also unreasonable that the board did not initiate an Adverse Event Review at an earlier stage. We upheld C’s complaint.

Regarding complaint handling, we found that the board failed to provide a response addressing all issues raised and did not give C a revised timescale for their delayed response, contrary to the NHS Model Complaints Handling Procedure. We upheld C’s complaint about the board’s complaint handling.

Recommendations

What we asked the organisation to do in this case:

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

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

• When a relevant adverse event occurs, the board should promptly carry out an Adverse Event Review to investigate the cause and identify any potential learning.

In relation to complaints handling, we recommended:

• Complaints should be investigated and responded to in accordance with the board’s complaint handling procedure and the NHS Model Complaints Handling Procedure. Complaints investigators should fully investigate and address the key issues raised. We offer SPSO accredited Complaints Handling training. Details and registration forms for our online self-guided Good Complaints Handling course (Stage 1) and our online trainer-led Complaints Investigation Skills course (Stage 2) are available at https://www.spso.org.uk/training-courses.

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 in relation to a cancerous lesion (squamous cell carcinoma, SCC) on their middle finger. C received cryotherapy for eight months but at the end of the treatment, the lesion was worse. C said that they should have been reviewed by a consultant sooner when it became apparent the treatment was unsuccessful and they would have chosen surgery at the outset if they had been told of alternative treatment options. As a result of the failings, C said that they developed a more serious lesion.

We took independent advice from a consultant in dermatology. We found that the standard of medical care provided was not reasonable in that the uncertainty of diagnosis was not communicated to C and treatment options were not fully considered and discussed. Additionally, cryotherapy treatment was continued without consultant review for an extended period and the GP’s re-referral of C was downgraded to ‘routine’. We upheld 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/meaningful-apologies.

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

• There should be careful discussion of options in the light of equivocal histology reports. This is typically a multidisciplinary team meeting (MDT). Diagnostic uncertainty or limitations should be shared with patients as part of a full discussion of treatment options.
• It is good practice for images to be incorporated into the patient record in the patient lesion pathway.
• There should be closer supervision of the nurse-led cryotherapy service.

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.