Upheld, recommendations

Summary

Mrs C complained that the council failed to comply with their bullying policy. Mrs C had raised issues with the council in relation to her daughter (Miss A) being bullied at school. The council explained that they had not initially treated the issues raised by Mrs C as bullying. They provided logs detailing concern by Mrs C that Miss A was being bullied and outlined the action taken by the school.

Mrs C was also concerned that Miss A was not given a suitable room on a school trip in light of problems with bullying and that the council had not looked into why her daughter had slept outside her room. In their response, the council provided a copy of the risk assessment that detailed that spot-checks would be carried out. However, there was no record detailing these checks. Although the council apologised to Mrs C that the information she provided prior to the trip had not been passed on to staff, we were concerned that there was no record of conversations with staff members. We therefore upheld these elements of Mrs C's complaint.

Mrs C also complained that the school did not provide accurate information on whether the school operated a buddy system. The council acknowledged and apologised for this and we therefore upheld Mrs C's complaint.

Mrs C said that the council failed to keep reasonable care records. The council said they were satisfied that Miss A's notes contained sufficient information. However, we found in particular that they did not include a record of a pre-arranged meeting. We therefore upheld Mrs C's complaint.

Mrs C also complained that staff at Miss A's school had inappropriate conversations with Miss A. While we were satisfied with the way the council had acknowledged the concerns Mrs C raised with them in this regard and had apologised, on balance we upheld Mrs C's complaint.

Finally, Mrs C complained that the council did not handle her complaint or communicate with her reasonably. The council said that it was difficult to communicate reasonably as Mrs C had raised her complaints with a number of people. They said they would offer Mrs C an additional apology in relation to this. The council also accepted that there had been a delay outwith their own timescales in responding to Mrs C's complaint. In light of this, we upheld this aspect of Mrs C's complaint.

Recommendations

We recommended that the council:

• consider their procedures for organising school trips to ensure all relevant information is recorded and taken into consideration when organising a school trip;
• consider, in view of the issues raised in this complaint, whether there is a need for a formal record of the checks carried out on pupils during bed times;
• ensure that relevant staff are fully aware of all the strategies, including the buddy system, that are available to assist pupils experiencing difficulties; and
• consider the benefits of retaining a brief record or note of meetings with parents, in particular when these are pre-arranged.

Summary

Mr and Ms C, who work for a law clinic, complained on behalf of Miss B about the care provided to Miss B's mother (Mrs A) and the charges for this care, including that there was a long delay in notifying Mrs A's family about the amount of accumulating arrears. Miss B said they had been unaware as a family that the transport taking Mrs A to day care was a chargeable service. She said that by the time the family became aware of the charges, Mrs A had used the service for around a year. When they became aware that the transport service was chargeable, they cancelled it.

Miss B's complaints about delay and the lack of transparency were both upheld by the council. Miss B wanted to take these complaints along with the other issues she had raised to a complaints review committee (CRC), an independent body and the final stage of the council's social work complaints procedure. The CRC declined to deal with the complaints that had already been upheld by the council, saying they considered them to be resolved.

We found it was unreasonable for the council to decline to deal with upheld complaints at CRCs. We found that it was for the complainant to decide whether, or to what extent, individual complaints had been addressed or resolved. We therefore upheld the complaint.

Recommendations

We recommended that the council:

• arrange a CRC to hear evidence relating to the upheld complaints.

Summary

Mr C complained about the council following an investigation they carried out into fly tipping near a property owned by a trust he was responsible for. He advised that he had recently instructed roof repairs to the property, which he told us had been completed and the waste properly disposed of in a skip procured by his roofing contractor. However, shortly after this, some roofing material was illegally left on council-owned land, near where the skip had been.

Mr C advised that he contacted the council officer responsible for the investigation after a note was posted into the property in question. He said that the council officer immediately accused him of dumping the materials in question and refused to accept his attempts to refute the allegations, threatening to serve a fixed penalty notice if he did not arrange for the material to be immediately removed.

On investigation, we found that the council officer had failed to carry out the investigation in line with council policies and procedures, which stated that enforcement action should only be taken if the council were in possession of two signed witness statements or conclusive evidence found within the dumped waste. From the evidence we saw, the council officer had acted on one informal report from a neighbour in the area, and that this report did not place the blame directly onto Mr C, but on the contractor who attended to collect the skip.

We also considered that Mr C had presented clear arguments to support his innocence, including offering photographic evidence and a copy of a signed contract confirming that the roofing contractor was responsible for disposing of all waste generated by the repairs. According to the council's policies, their officer should have then contacted the contractor to discuss the matter further. Instead, he repeatedly threatened Mr C with a fixed penalty notice until Mr C arranged for the waste to be removed.

Further to this, we were critical that the council had failed to identify these errors, both when investigating Mr C's complaint to them and in response to our enquiries. We upheld Mr C's complaint.

Recommendations

We recommended that the council:

• apologise to Mr C for the failings identified;
• discuss these findings with the council officer in question to identify the root cause of the failings identified and take suitable steps to address this;
• explain why these failings were not identified as part of their own investigation; and
• carry out a thorough audit of similar investigations to ensure the proper procedures are being followed.

Summary

Ms C complained about the council regarding toileting equipment for her disabled child at the two schools the child attended. She told us that she found there had been no suitable toilet chair in place at either school for some time. She said that she then requested appropriate equipment was put in place but that this took a number of months.

We found that it was not reasonable for the council to have failed to ensure appropriate equipment was in place until Ms C brought it to their attention. We also found that there were avoidable delays following Ms C's request. In particular, there was a delay of six weeks due to planned leave for a single member of staff. We considered that the council should have taken steps to ensure appropriate cover was in place given the nature and length of the leave.

We also found that the council had failed to deliver accessories required to install the equipment in one of the schools. After this was identified by an occupational therapist there was a delay of around three months before these were provided. The council failed to provide an explanation for this error or subsequent delays.

During our investigation, we also found that the council had failed to record a number of discussions held with Ms C that related to the care arrangements of her child.

Recommendations

We recommended that the council:

• apologise to Ms C and her child for the failings identified;
• provide us with an explanation for the delays in delivering the missing accessories; and
• review the process for recording review meetings and discussions with parents, to ensure all decisions reached are accurately recorded.

Summary

Miss C complained about the care received by her brother (Mr A) at the Royal Infirmary of Edinburgh following a suspected drug overdose. During his admission, Mr A was drowsy and had slurred speech. Mr A was moved to the acute medical unit and received treatment for a chest infection. He also had a scan to check for a blood clot on the lung. No blood clot was found and Mr A was to be discharged. On the morning of his discharge, he experienced a cardiac arrest and died.

We took independent nursing and medical advice. The nursing adviser was satisfied that nursing staff had noted Mr A's condition but raised concerns that Mr A's oxygen saturation (the relative measure of the amount of oxygen in the blood) was abnormally low during the admission. Whilst nursing staff had noted this, they had not informed medical staff.

The medical adviser considered that Mr A had received appropriate care and treatment for the first two days of his admission, but that Mr A's low oxygen saturation should have resulted in a medical review on the evening before discharge. They noted that a possible explanation for the omission of a review was that staff considered his oxygen levels to be low as a result of drug use, rather than his chest infection. The medical adviser noted that staff could have considered administering a medication which temporarily reverses the sedative effects of drugs to help them determine the reason for low oxygen levels. The adviser could not say whether better care at this time would have prevented Mr A's death. However, they considered that the treatment provided to Mr A was unreasonable. We upheld this aspect of Miss C's complaint.

Miss C also complained that staff had failed to respond reasonably to concerns raised by Mr A's family. The medical adviser noted that Miss C had spoken to a doctor on the evening before the planned discharge. The adviser was critical that the doctor had informed Miss C that Mr A was well enough for discharge, when the evidence available at that time did not support this. They considered that there was evidence that staff had shown a lack of appreciation for the family's concerns, and we therefore upheld this aspect of the complaint.

Miss C also complained about the board's handling of her complaint. We noted that the board had met with Miss C and Mr A's family and had also taken steps to investigate the concerns raised by Miss C. We were critical that the board delayed interviewing staff regarding Miss C's complaints and that the board did not update Miss C about the delay in arranging a second meeting. While we noted that the board had responded in writing to aspects of Miss C's complaints, we were critical that they did not conclude their investigation with a definitive final response or inform Miss C in writing of what to do were she not happy with their response. We also noted that Miss C had not received a copy of a substance misuse leaflet that the board had agreed to provide. We upheld this aspect of Miss C's complaint.

Miss C also complained that Mr A's medical records inaccurately stated that his family had given him drugs. We found that the discharge letter did not explicitly state this, but that staff did have concerns that Mr A's family had brought him drugs. The medical adviser noted that there was no suggestion in the letter that any additional drugs caused Mr A harm, and no indication that the letter was directly critical of the family. However, they found that the letter contained a statement that was not supported by the clinical notes and that there was no clear evidence in the records of specific additional drug use, or evidence of involvement of the family related to the drug use. The adviser considered that the statement was unreasonable. We therefore upheld this complaint.

Recommendations

We recommended that the board:

• feed back the comments of the advisers to medical and nursing staff in the acute medical unit;
• issue a written apology to Mr A's family for the failings in nursing and medical care identified by the advisers;
• provide evidence that the learning from this complaint has been implemented;
• issue a written apology to Mr A's family for failing to respond reasonably to the concerns that were raised;
• issue a written apology to Miss C for the complaints handling failings identified in this investigation;
• feed back to staff the importance of interviewing staff within good time of events, of concluding a complaint investigation with a written report and of updating complainants with the progress of the investigation where delays occur;
• provide Miss C with a copy of the substance misuse leaflet and details of the steps taken to improve communication;
• feed back the comments of the adviser to the member of staff who wrote the discharge letter;
• make an addendum to the records, which notes that the statement about the family in the letter was not reflected in the clinical notes, and send a copy of this addendum to Practitioner Services to be filed with Mr A's GP records; and
• issue a written apology to Mr A's family for the inaccurate statement in the records.

Summary

Mrs C attended Raigmore Hospital with an injury to her ankle. She complained about the care and treatment provided, in particular that there was an unreasonable delay in providing her with orthopaedic treatment.

During our investigation we took independent advice from a consultant radiologist and a consultant trauma and orthopaedic surgeon.

The consultant radiologist considered that an abnormality on Mrs C's first x-ray was missed, and as a result there was a delay in being referred to an orthopaedic surgeon and in a diagnosis being made. In addition, the consultant radiologist considered that the abnormality was also missed on an x-ray taken 15 months later and that had this been noticed, Mrs C may have been referred for imaging earlier than she was.

We found that there were no long-term orthopaedic consequences for Mrs C's ankle as a result of the delays. However, we were concerned that the delays added to Mrs C's distress and that she had continued to suffer pain and discomfort when this could possibly have been avoided.

We considered that a delay between Mrs C being placed on the waiting list for an orthopaedic appointment and being advised four months later that she would not be offered an appointment within the target timescale was unreasonable.

We also found that the delay between Mrs C attending hospital for her injury and being seen in an orthopaedic clinic was unreasonable. However, we noted that action was being taken by the board to address the delays. We upheld Mrs C's complaint.

Recommendations

We recommended that the board:

• apologise for the failure to report and act on the abnormality shown in
• x-rays of Mrs C's ankle and for the prolonged waiting time between being referred to orthopaedic services and receiving an orthopaedic appointment;
• consider the adviser's comments on the failure to observe the radiological abnormalities in this case and identify any action which could be taken to minimise the occurrence of such errors;
• ensure patients are advised in a timely manner that they may not be seen within waiting-time targets; and
• provide us with evidence that the action taken to reduce waiting times is having the desired effect.

Summary

Mrs C complained that there was an unreasonable delay by the board in diagnosing her breast cancer.

We took independent advice from a consultant clinical oncologist, who said that there had been an unreasonable delay in diagnosing and treating Mrs C's breast cancer. We also found that it was not possible to know what the outcome would have been had Mrs C been diagnosed with earlier with breast cancer.

The board accepted that they had failed to meet the 12-week guarantee time for referrals and outlined the action they had taken to minimise delays to appointments and subsequent treatment, including managing out-patient referrals. We upheld Mrs C's complaint.

Recommendations

We recommended that the board:

• provide an update on the review being carried out of the management of out-patient referrals.

Summary

Mr C, who works for an advocacy service, complained on behalf of Mrs B. Mrs B's husband, Mr A, was a patient at the medical practice. He initially attended with left-sided chest pain that he reported had been present on and off for months. An x-ray was arranged but this was normal. He went on to report neck pain and urinary symptoms. Mr A was later diagnosed with lung cancer which had spread to the vertebrae in his neck. His urinary symptoms were found to be unconnected to this diagnosis.

Mrs B was concerned that the practice had not provided an appropriate level of care to Mr A. She said that his condition could have been diagnosed earlier and made particular reference to a scan which she felt should have been arranged.

After taking independent advice from a GP, we found that Mr A had not been provided with appropriate medical treatment. While we found that a scan could not have been arranged for Mr A by the practice, he should have been referred to the local NHS board's respiratory team after he reported chest pain being present on and off for months, even though the x-ray was normal. The adviser highlighted that this action was supported by the Scottish Referral Guidelines for Suspected Cancer. We found that the other aspects of Mr A's care were reasonable.

Recommendations

We recommended that the practice:

• apologise to Mrs B for the lack of respiratory referral;
• ensure that all relevant staff are familiar with the Scottish Referral Guidelines for Suspected Cancer; and
• ensure this case is discussed at the next appraisal of the doctor who saw Mr A at the relevant consultation.

Summary

Mrs C complained about the care and treatment she received in relation to her labour at Forth Valley Royal Hospital. Mrs C had a long and difficult labour, and her baby was born with the use of forceps. An episiotomy (a surgical cut of the area between the vagina and anus) was performed and Mrs C suffered a fourth degree tear (a severe tear in the vaginal tissue), which was repaired that day. A few months later, Mrs C was diagnosed with a recto-vaginal fistula (an abnormal connection between the rectum and the vagina) and disrupted anal sphincter (muscle that surrounds the anus), for which she underwent several unsuccessful operations. Nine months later, Mrs C was referred to a specialist at Glasgow Royal Infirmary, who decided that a colostomy bag (a pouch placed over one end of an intestine) was required to allow healing before further procedures to repair the fistula.

We took independent obstetrics and gynaecology advice and surgical advice. In relation to Mrs C's complaint about the standard of obstetric care and treatment provided, we found that the fourth degree tear was properly identified and repaired within a reasonable time, but that the board failed unreasonably to arrange an obstetric review before discharge from Mrs C's first admission to hospital (which also had an adverse effect on communication) and that there was confusion about postnatal appointments and delays.

Regarding the standard of surgical care and treatment provided, while we were satisfied that medical staff managed the fistula in a reasonable way, we found that they failed unreasonably to obtain consent for one of Mrs C's operations. Finally, we were critical that the board failed to respond formally to the surgical aspect of Mrs C's complaint.

Recommendations

We recommended that the board:

• ensure that consent is obtained and documented in line with the relevant guidelines;
• raise the failings this investigation identified with the relevant staff;
• inform us of the actions taken to address the complaints handling failings this investigation identified; and
• apologise for the failings this investigation identified.

Summary

Mrs C, an advocacy and advice worker, complained on behalf of Mr and Mrs A regarding a child protection referral which was raised by a children's physiotherapist in relation to their daughter (Miss B). The physiotherapist raised concerns in the referral that Mr and Mrs A were fabricating injury and illness in Miss B and were refusing to engage with physiotherapy. This was not taken forward by social services as Miss B was subsequently diagnosed with a genetic condition.

We took independent clinical advice from a senior nurse director, who noted that those raising child protection concerns have a duty to be as sure of their grounds for suspicion as is practicable. It was noted that Miss B had indeed sustained an injury but that there appeared to have been a misunderstanding as to the nature of this. It was also noted that while a formal diagnosis of Miss B's illness had not yet been received, there was evidence that she was undergoing genetic testing at the time. The adviser considered that, in both instances, the physiotherapist could reasonably have attempted to clarify matters by speaking to Mr and Mrs A and medical staff.

There were conflicting accounts as to whether Mr and Mrs A were refusing to engage with all physiotherapy, or just the physiotherapist in question. However, it was clear that relations between Mr and Mrs A and the physiotherapist were already difficult and the adviser considered that the board might reasonably have taken earlier steps to offer Miss B the opportunity to see a different therapist. The adviser also noted that the physiotherapist did not inform Mr and Mrs A about the referral, despite there being no record of any decision having been taken that this would not have been in Miss B's best interests. We therefore concluded that the physiotherapist did not act in line with the board's child protection procedures. We therefore upheld this complaint.

Mrs C also complained about a delay in providing Mr and Mrs A with copies of their children's medical records when they requested access to these. We noted that there had been a lengthy delay which the board had acknowledged and apologised for. However, while the board had undertaken to review their process to avoid a similar future delay, we noted that no action appeared to have been taken in this regard until after we sent an enquiry to them. We were critical that the board had not progressed action they had promised to take in response to a complaint. We therefore upheld this complaint.

Recommendations

We recommended that the board:

• apologise to Mr and Mrs A for the failings this investigation has identified;
• inform us of the steps they have taken to ensure that staff adhere to their child protection procedures, particularly in relation to the involvement of parents/carers;
• take steps to ensure that staff are aware of the importance of taking any action reasonably available to them to clarify the validity of any child protection concerns they have;
• apologise to Mr and Mrs A for the delay in taking forward the promised action to look at their process for responding to requests for access to medical records; and
• inform Mr and Mrs A of the outcome of their policy review and, particularly, any process changes that have been made to prevent a recurrence of the problems they experienced obtaining access to their children's medical records.