Upheld, recommendations

Summary

C complained that the practice failed to adequately investigate and/or diagnose the cause of their persistent cough. C was subsequently hospitalised and diagnosed with pneumonia while on holiday.

The practice did not uphold C’s complaint. They said that they had taken reasonable action in light of C’s presenting symptoms and that C’s cough had been reasonably treated. They said that C’s final examination was normal and not in keeping with a diagnosis of pneumonia and that, therefore, there was no missed diagnosis.

C remained unhappy and asked us to investigate. We took independent advice from a GP. We found that there had been a failure to adequately investigate the cause of C’s cough. In light of C’s presenting symptoms, a persistent cough and infection, we found that an in person appointment and an urgent referral for a chest x-ray should have been considered after their initial telephone presentation. We also considered that C should have been referred for an urgent chest x-ray following a second presentation, in accordance with the Scottish Referral Guidelines for Suspected Cancer. Therefore, we upheld C’s complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failure to adequately investigate the cause of their persistent cough. 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:

• Patient treatment should be considered in line with relevant guidance.

Summary

C complained about the medical care provided to their late parent (A) by the board when they were admitted to hospital. We took independent advice from a consultant in emergency medicine. We found that there should have been better communication between the medical, nursing, and other allied health professional staff in relation to bruising found on A. We found that medical staff failed to take note of the physiotherapy findings of bruising and to document the presence of any significant injury.

We also found that medical staff should have prescribed a second antibiotic at the time of A’s admission, that an assessment using arterial blood gas analysis should have been carried out before A’s transfer to the critical care unit and that the mental health team failed to assess A’s delirium, or prompt medical staff to consider this. Finally, we noted that the cause(s) of A’s death should have been recorded in more detail on the death certificate. Therefore, we upheld this part of C's complaint.

C also complained about the nursing care that the board provided to A. We took independent advice from a nurse. We found that nursing records, in particular, risk assessment and care planning documents, were not always completed to the required standard or frequency. We also found that A did not receive a reasonable standard of person centred care in relation to their fluid intake and nutritional support and there was poor and inadequate support provided to assist A with their personal hygiene. Nursing staff should also have identified earlier the bruising on A’s body and ensure A had timely access to their medications.Therefore, we upheld this part of C's 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:

• A patient’s cause of death should be accurately recorded.
• All relevant staff should be aware of the board’s responsibilities under the Adults with Incapacity (Scotland) Act 2000.
• All relevant medical staff should have read and understood the contents of the board's doctors handbook.
• Arterial blood gas analysis should be considered for 'any patient with a new oxygen requirement' and 'all critically ill patients'.
• Patients should receive their prescribed medication at the appropriate time.
• Patients should be appropriately examined and assessed and findings from the examination / assessment should be appropriately recorded and communicated.
• Patients should be appropriately examined and assessed. Relevant documentation should meet the standard required by the NMC The Code. All nursing staff involved in this case should be aware of their requirements to document to the standard required by the board and the NMC to ensure patient safety, person centred care and essential communication.

In relation to complaints handling, we recommended:

• Complaints should be handled in line with the relevant model complaint handling procedure. 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.

Summary

C complained that the council unreasonably failed to assess their housing application in accordance with their policies and procedures. C and their partner had two children and shared their bedroom with the youngest child. C submitted a request for rehousing. The council awarded C a priority band 2 (with 1 being the highest and 4 the lowest). C then submitted medical information regarding their mental health to support their application for rehousing. However, the council advised C that they did not meet the criteria for a band 1 priority and that their current award of band 2 was correct and in line with the allocation policy.

C submitted an appeal, along with a further supporting letter from their mental health nurse. The council responded stating C’s current band 2 status was deemed appropriate and in line with the established policy guidelines.

We found that the council’s position was not in line with the allocation policy. We were concerned by the council’s statement that band 2 was correct, that there would be no band 1 award on the basis of mental health and that they had been applying this reasoning consistently. Their policy states that Band 1 is awarded to those applicants whose home is causing significant problems due to a physical, medical, or mental health problem or disability. We also found that C did not receive timely responses from the council. Their responses were delayed and C had to chase several times for a response. Therefore, we upheld C’s complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the specific failings identified in respect of the 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:

• Housing applications should be assessed in line with the Allocation Policy.
• The council should ensure that correspondence is responded to within a reasonable amount of time and in line with published service standards.

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 client (B) that the care and treatment provided to B's relative (A) was unreasonable.  

In response to the complaint, the board acknowledged that there had been failings in the delivery of care throughout A’s hospital stay and explained that action had been taken in response to these failings.

We took independent advice from a nurse. We found areas of good practice. However, we found significant and serious failings in A’s care in relation to delirium, observations and vital monitoring, record-keeping and escalation processes. Therefore, we upheld C’s complaint. We recognise the learning implemented by the board which has led to significant learning and improvements to patient care and has addressed the failings identified in this case. 

During our investigation, we identified issues with the board’s handling of the complaint. We made a recommendation to the board to support improvement of their complaint handling.

We also provided feedback that the board should reflect on the advice we received that the score given on the serious adverse event review (SAER) report was not reflective of the failures identified in this case. We also noted that a SAER should be reviewed in a timely manner in partnership with the patient and/or their family/carers and that in this case, A's family should have received regular updates. 
 

Recommendations

In relation to complaints handling, we recommended:

• Complainants should be kept updated on their complaints in line with the Model Complaints Handling Procedure. 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.

Note - 30 May 2025

On 21 May 2025, an earlier version of this summary was published in place of the intended final version due to an administrative error. This has now been corrected. We apologise for any confusion this may have caused.

Summary

C complained about being de-registered from their dental practice. C also complained that the practice failed to handle their complaint reasonably. Due to a broken tooth, C phoned for an emergency appointment and was told they could attend the same day. However when C arrived, they were given a temporary substance to place over the tooth until an appointment the next day. When C later phoned the practice to explain their situation had worsened, they were told to wait until the following day. C emailed the practice to complain about the service they had received but returned the following day to have the tooth treated. A year later, C requested an emergency appointment but was told that they had been de-registered and would not be seen.

We found that there was only very limited evidence to show that the de-registration letter was ever sent and that there was a delay in doing so. We found that the lack of record keeping in this case has made it difficult to assess the practice’s complaint handling. This in itself is unreasonable, given the concerns C raised. Overall, we upheld both complaints.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the specific failings identified in respect of the 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:

• Patients should be notified of de-registration from the practice within a reasonable timeframe. Letters sent by post should be correctly addressed.

In relation to complaints handling, we recommended:

• All complaints should be handled in line with the NHS Model Complaints Handling Procedure (MCHP). In particular, where an early resolution response is provided, a full and accurate record of the decision reached and given to the person should be made. 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 on behalf of their parent (A) about the care and treatment they received from the board following neurosurgery (surgery performed on the nervous system, especially the brain and spinal cord). C complained that the board did not provide follow-up care to A and they were not referred to oncology (cancer specialists) for further treatment. C said that A required further surgery to treat recurrent disease a few years later as a result.

The board’s complaint response explained that an administrative error had occurred which had led to A not receiving follow-up care from neurosurgery or a referral to oncology. The administrative error had been managed via staff training to prevent it from happening again. In response to our enquiries the board confirmed that no internal review, such as a Serious Adverse Event Review (SAER), had taken place.

We took independent advice from a neurosurgery adviser. We found that it was unreasonable that A had not received the planned clinical follow-up after their surgery. It was also unreasonable that SAER or Duty of Candour guidance had not been followed in this case. As such, we upheld C’s complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to A for the failings identified in this report. 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 initiate statutory duties and processes for learning when it becomes known that a potential harm has occurred. Including, but not limited to, Duty of Candour and adverse event review processes.

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 to stop the anticoagulant (blood thinning) medication given to their late parent (A) and a lack of communication with the family around this decision. The practice instructed to stop the medication due to an unexplained bleed. Following this stoppage, A died from a stroke. A’s family contacted the practice to discuss their concerns about the medication but they were unable to speak to a clinician in a timely manner.

We took independent advice from a GP adviser. We found that there were clear indications for A to be on anticoagulant medication and that it was unreasonable that the medication was stopped without a replacement in place. The decision to stop the medication was not fully informed. We noted that the practice did not undertake timely blood tests or communicate with A’s family and the relevant specialists. We also found failings around the administration of blood tests.

The practice carried out a Significant Adverse Event Review (SAER), which we found was not in line with relevant national guidance. We upheld C’s complaint

Recommendations

What we asked the organisation to do in this case:

• Apologise to the family for the failings identified in this report. 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:

• Significant Adverse Event Reviews should be reflective and learning processes that ensure failings are identified and any appropriate learning and improvement taken forward. SAERs should be held in line with relevant guidance.
• Appropriate blood tests should be carried out in line with relevant guidance when anticoagulant medication is stopped or replaced. Test results should be appropriately actioned.
• Contacts to the practice from patients or their carers should be adequately assessed to ensure that they are appropriately escalated and, where necessary, there is discussion with the appropriate member of staff, including clinicians.
• Patients should be fully assessed prior to the stopping of anticoagulation medication with appropriate consideration given to the risks. Full information should be sought, including where appropriate communication with relevant specialists and the family members prior to any decision being reached. Where this information is received in the GP’s absence, arrangements should be in place for this to be picked up by another clinician.

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 parent (A) received during a hospital admission. C complained about the way episodes of agitation and aggression were managed by the board including in respect of administration of medicines; bruising to A during episodes of restraint and lack of dignity; a failure to manage their nutritional needs; and poor communication with A’s family.

The board’s response to C’s complaint advised that medication had been used to settle A when other measures had been unsuccessful. The board said that A’s weight loss had been recognised and a referral had been made to the dietician, however, they had been discharged from hospital before a review could take place. It was recognised that documentation including fluid and food intake charts were incomplete and steps would be taken to ensure improved compliance. The board considered there had been good communication with A’s family, however, they apologised for the lack of empathy reported by C, which staff would be asked to reflect on for future learning.

We took independent advice from a senior nurse adviser and a consultant geriatrician (specialist in medicine of the elderly). We found that there were aspects of A’s care which were reasonably managed particularly in relation to the way episodes of agitation and aggression had been managed on the ward. We found there were aspects of A’s care which were unreasonably managed particularly in relation to management of their nutritional needs, record keeping and communication.

On balance, we considered the board failed to provide a reasonable standard of care and treatment to A and we upheld C’s complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failings identified in this report. 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 ensure effective communication with family members, particularly in circumstances where Adults With Incapacity is in place.

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

A & B complained to the council about their handling of their claims procedure in relation to the Trams to Newhaven project. A and B were unhappy with the council’s response because they considered that the council failed to appropriately address and investigate their complaint and that relevant issues were not given due consideration.

A and B complained to the SPSO. After an initial review, we considered that the council had failed to engage with A and B to specify their complaint. We also considered that the council had opted to summarise what they regarded as the issues of complaint without obtaining A and B’s agreement to this. As the council had not fully addressed or clearly responded to all of A and B’s concerns, we directed that they should provide an additional response. The council provided A and B with an additional response and apologised to them for failing to adequately address their complaint.

A and B then complained to our office that the council failed to investigate their complaint in accordance with their complaints handling procedure (CHP). During our investigation the council acknowledged that A and B’s complaint was not fully responded to and was not handled in accordance with their CHP. We also considered that the council failed to act in line with their CHP when initially investigating and responding to A and B’s complaint. We upheld the complaint.

The council informed us of the learning that they identified from A and B’s complaint and their wider experience of the Trams to Newhaven project. We considered this to be an example of good practice.

Recommendations

What we asked the organisation to do in this case:

• Apologise to A and B 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.

In relation to complaints handling, we recommended:

• All complaints should be investigated and responded to in accordance with the council’s complaints handling procedure. 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 handling of two planning enforcement complaints which they had brought to the council in regards to Air Source Heat Pumps (ASHPs) installed at two neighbouring properties, which were affecting their enjoyment of their property due to the noise generated. C complained that the council had taken too long to determine that planning applications were required and that the council’s communication had been inconsistent and slow. C also complained that the time to determine the retrospective planning applications was too long.

The council admitted that their initial handling of the enforcement complaints was inconsistent and slow. They apologised, restructured the team and provided reminders as to when planning was required for ASHPs. As regards the determination of the planning applications, they advised that they were waiting for Noise Impact Assessments (NIAs) from the applicants which were never provided.

The applications were due to be determined by the Planning Committee in June 2024. However, just prior to this C commissioned their own NIA which needed to be robustly considered by Environmental Health Services. The applications were considered in February 2025.

We found that given the ASHPs were potentially impacting C’s amenity, due to noise, it took the council too long to investigate the planning enforcement complaints and to decide that planning applications were required. It also took them too long to determine the planning applications. We upheld the complaint on this basis.

Recommendations

What we asked the organisation to do in this case:

• Apologise for the time taken to determine the planning applications in respect of the neighbours ASHPs. 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 council should provide clear advice on the situations where express planning consent is required for ASHPs, and what information is required to support such applications.

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.