Upheld, recommendations

Summary

C complained that social work did not adequately safeguard their child (A) when they disclosed that they had been a victim of assault. C also complained that they were not informed of the incident. The council considered that appropriate support had been offered to A.

We took independent advice from a social work adviser. We reviewed the relevant case records and the council’s child protection procedures. We found that the council failed to meet their obligations and take the appropriate action in response to the disclosures made by A. We found that there was sufficient concern about A’s ability to maintain their wellbeing and that social work should have instigated their child protection procedures. We also found that there was insufficient recording within the case records of a clear plan and rationale to explain decision making. As such, we upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to meet their obligations and correctly apply their child protection procedures in response to the disclosure made by A. 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:

• Case records should include details of discussions held with relevant persons, rationale for any decision making, and evidence of risk assessments, where appropriate.
• Staff should be familiar with the requirements of the council’s child protection procedures and have a clear understanding of when an Inter-agency Referral Discussion should be held.

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 council’s handling of a planning application. C’s next door neighbour made a retrospective application for planning permission for the erection of a garden room/store and timber fencing to the boundary at the rear of the property. This followed an earlier enforcement enquiry in respect of the garden room structure being erected without the necessary permission in place.

C objected to the planning application through a solicitor on the basis that it constituted overdevelopment and would adversely impact neighbours’ residential amenity and did not contribute towards quality place making. Planning permission was granted with no conditions attached.

We took independent advice from a planning specialist. We were satisfied that the assessment of the impact of the fence was an issue of discretion and that carrying out site visits and allowing additional comments/objections to the planning application were matters of planning judgement. Whilst we found that the council did reach the right planning decision, we considered that there had been a lack of clarity and explanation and that the council’s calculations in relation to the coverage of rear curtilage in the Report of Handling were ambiguous and are not in line with the relevant guidance. On balance, we upheld the complaint.

Recommendations

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

• Case officers should be aware of how to measure curtilage areas and calculate the proportion proposed to be built upon. The calculation should be clearly set out and a record made.

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 health and social care partnership’s (HSCP) investigation of a medicine protocol breach identified at their relatives (A) care home in the week before A's death. A social worker investigated the breach in response to an Adult Support and Protection (ASP) notice raised by the care home, and determined that no further action was required. Separately, the Care Inspectorate had investigated other concerns raised by C about the care and treatment provided to A, including the medicine protocol breach. The Care Inspectorate’s investigation identified failings and made recommendations for improvement. In light of this, C contested the partnership’s position, indicating their view that the investigation was faulty, particularly noting the outcome of the Care Inspectorate’s investigation of the same matter.

C received a stage two complaint response letter from the partnership. We considered the response had not fully considered C’s concerns, therefore, we asked the partnership to provide a further response to C’s complaint. C remained dissatisfied with the partnership’s second response.

We took independent advice from a social work adviser. We found that the partnership had a duty to investigate the concerns raised in keeping with ASP legislation. We noted that this matter had been investigated by a single social worker. However, we found that the Care Inspectorate were better placed to investigate the matter in keeping with the Health and Social Care Standards, with the partnership’s role being to liaise with the Care Inspectorate and the care home regarding the outcome and recommendations. While the social worker’s report was in itself reasonable for an inquiry, we found that it was better suited to be used in collaboration with the other relevant agencies. We upheld the complaint.

We also upheld a complaint about complaint handling, noting that C had not been made aware that their concerns were being managed in line with the complaint handling procedure, that the matters to be investigated had not been confirmed at the start of the process and that the complaint responses did not fully address C’s concerns.

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:

• The partnership should reflect on this decision, particularly taking into account the professional judgement and the decision-making process applied in this case, in reference to the guidance and how this is interpreted in practice.

In relation to complaints handling, we recommended:

• The partnership should ensure complaints are correctly identified and processed in accordance with their complaints handling procedure. Responses to complaints should be clear and answer the points of concern raised.

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 ophthalmology treatment (the branch of medicine that deals with the anatomy, physiology and diseases of the eye) that they were provided by the board. They were referred by a consultant (Doctor 1) for a second opinion from a corneal specialist. C complained that they should have been seen by a consultant (Doctor 2) but were instead treated by a junior doctor (Doctor 3). Additionally, C complained about the treatment provided by Doctor 3 and the decision to discharge them from the ophthalmology service.

We took independent advice from a consultant in ophthalmology. We found that it was clear that Doctor 1 intended a specialist to examine C and that this did not happen. Although it may have been reasonable for C to have been seen by a junior doctor in clinic, there should have been clinical oversight by Doctor 2, with direct input to C’s management plan. We found that it would have been good practice for the outcome of the consultation to be reported back to Doctor 1, copying the letter to the GP and C. Instead, the outcome was only reported to C’s GP. We upheld this complaint. We also found that Doctor 3 should have tested C’s eye pressure before prescribing fluorometholone (a mild steroid). We upheld this aspect of C’s complaint. Finally, we also found it was unreasonable for the board to discharge C from their ophthalmology service, when Doctor 1 had agreed to follow-up in one year. We upheld this aspect of C’s complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failings our investigation has identified. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.
• When apologising to C, the board should address their treatment plan and communications in relation to their discharge.
• The board should offer C a further consultation with Doctor 1, given they had agreed to a follow-up consultation with C.

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

• Clinical staff ensure that they write back to the referring clinician, copying to the GP and patient.
• Eye pressure is tested, in accordance with good clinical practice, prior to FML being prescribed.
• Where a tertiary consultant to consultant referral is made, the consultant should be aware that the case is there for their specialist opinion and provide some direct input to their management plan.
• Where referrals are made for a second opinion, the patient is discharged back to the referring 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 that the practice had prescribed them with Hormone Replacement Therapy (HRT) for a period of approximately four months despite knowing that they were trying to conceive. C said that they had subsequently attended a fertility clinic and were advised by a specialist that HRT would have a negative impact on their fertility. The practice identified learning and improvement from C’s complaint. They apologised to C for the frustration and distress caused to them by their experience.

We took independent advice from a GP adviser. We found that it was unclear from the medical records if the prescription of HRT was fully discussed with C to ensure that they understood the implications on their fertility and general health. We found that it was unreasonable for the practice to have prescribed C with HRT in the absence of their clear informed decision. Therefore, we upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the prescription of HRT in the absence of their clear informed decision. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

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’s spouse (A) was provisionally diagnosed with torticollis (a condition in which the head becomes persistently turned to one side) by their GP resulting in a routine referral to orthopaedics (specialism in the treatment of diseases and injuries of the musculoskeletal system). A’s symptoms continued to worsen and their referral was upgraded to urgent. A had a telephone call with an orthopaedic consultant and an MRI scan was organised. The pain continued to intensify despite strong medication. A presented to the out-of-hours service and also to A&E with worsening pain in their neck. A was referred to the hospital by their GP and advised that they were terminally ill with bladder cancer which had spread to the spine. A later died.

C complained to the board with concerns about A’s initial referral to orthopaedics not being treated as urgent, for the delay for an MRI scan, for orthopaedics not being consulted by A&E and further testing not being arranged. C additionally complained about the lack of process for a patient to be moved up the list of clinical priority when presenting to A&E. The board’s response indicated that no red flags were raised in the initial referral, that the orthopaedic consultant organised an MRI scan after speaking with A and that the out-of-hours assessments did not identify immediate orthopaedic review was required. The response also noted that A&E noted a plan was in place for further investigation, that there was no emergency issue which required immediate referral and that the GP was best placed to expedite further care with the orthopaedic team.

We took independent advice from a trauma and orthopaedic consultant, a GP and a consultant in emergency medicine. We found that it was reasonable for orthopaedics to treat the original referral as routine, but it was unreasonable that there is no evidence of a clinical summary of the orthopaedic consultation, and thereby no evidence that red flags were explored. We upheld this aspect of the complaint. We found that it was unreasonable that a more detailed history and clinical examination was not undertaken at the out-of-hours consultations, especially of red flags. We upheld this aspect of the complaint. We found that it was reasonable that A&E did not refer A urgently to another speciality or arrange further investigation or immediate assessment. We did not uphold this element of the complaint.

We also found that the board failed to identify that a Significant Adverse Event Review should have been carried out and that their complaint response did not clarify that it was a joint response with a second board, resulting in a lack of clarity and transparency.

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:

• Orthopaedic telephone consultations should be recorded, including evidence that any possible red flag symptoms have been explored and considered.
• Patients should be examined thoroughly and a clear history should be taken which considers the presence or absence of red flag symptoms.
• When a relevant adverse event occurs, the board should promptly carry out an SAER to investigate the cause and identify any potential learning.

In relation to complaints handling, we recommended:

• Relevant staff should be aware of the requirements of the complaints handling procedures, particularly with respect to dealing with complaints which span more than one NHS board.

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 the partnership did not provide reasonable care and treatment to their parent (A). A was admitted to hospital on three occasions during one month following falls. After their third admission, A was discharged to C’s home due to the COVID-19 pandemic. A week later, A was admitted to another hospital and was diagnosed with a lumbar (spinal) fracture and incomplete spinal cord damage. C raised a number of complaints with the partnership about the care and treatment A received and about their discharge.

The partnership did not indicate any concerns about A’s care and treatment or discharge but noted that discharge planning had been disrupted due to the COVID-19 pandemic. The partnership also undertook a Significant Adverse Event Review (SAER).

We took independent advice from an appropriately qualified adviser. We found that the partnership did not reasonably document communication, from physiotherapy staff to medical staff, of the observation of changes in A’s condition. Therefore, we upheld this part of C’s complaint.

In relation to A’s discharge, we found no clear evidence that the concerns expressed by the physiotherapist about deterioration were assessed before the decision to discharge A was made. Therefore, we considered A was unreasonably discharged and upheld this part of C’s complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to A’s family that partnership staff did not reasonably document communication, from physiotherapy staff to medical staff, of the observation of increased leg weakness in A, that concerns expressed by physiotherapy staff about deterioration in A were not assessed before the decision to discharge A was taken and that the findings of the SAER were not shared with A and their family. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets. Enquire whether A’s family wish to meet with the hospital manager and lead nurse and, if so, arrange and hold that meeting.

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

• Communications related to changes in patient care or decisions are reasonably documented.
• Decisions to discharge always take into account the circumstances of the patient at the time, and that if any change in a patient’s condition could affect the decision to discharge them, this must be considered at the time.

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 their parent (A) during an admission to hospital. At the time of admission, A was taking medication for atrial fibrillation (a heart condition affecting the rhythm and rate of the heart). The medication included a blood-thinner to reduce the risk of blood clots. While A’s condition was being assessed, a decision was made to withhold this medication. A developed pain and discolouration in their leg and was unable to weight bear. C complained that there was a delay of 12 hours before medical staff acted upon this. A required a transfer to another hospital by ambulance, where they underwent emergency surgery for clots in the leg. A has been left with deep incisions in the lower leg and their mobility has been significantly reduced.

The board discussed the case at a Morbidity and Mortality meeting, and following review of the circumstances did not think that there was anything from a system perspective that should be changed.

We took independent advice from a consultant physician and geriatrician (specialist in medicine of the elderly). We found failings in record keeping and examination. We found that the board ought to have been alert to the risk of A developing blood clots after the blood-thinning medication was withheld, and should have acted more promptly when A started to deteriorate. We considered that A suffered pain for a longer period because their deterioration was not recognised in a timely manner. Their situation might not have been so serious had their condition been recognised sooner. We also found that the board did not carry out a suitably rigorous analysis of what happened, including review by staff who were not involved in A’s care. The board’s review failed to identify appropriate learning. Therefore, we upheld C’s complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C and their family for the failings our investigation has 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:

• Before reaching a decision to stop anticoagulant medication in patients with atrial fibrillation, full consideration should be given to the risks and benefits of doing so. Clear records of patient care should be maintained, with all patient examinations documented. Deterioration in patients should be escalated appropriately including clinical examination where merited. Staff are confident in identifying adverse events and conducting appropriate reviews.

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 ear, nose and throat surgery (ENT) that they received from the board. C was referred for surgery for biopsy of a nasal ulcer that would not heal, and for treatment of a nasal drip. C complained that the biopsy had not been taken as expected, which they were not aware of until making a complaint. C also complained that they had been left worse off due to a perforation being caused during the procedure. This has caused them to have an audible whistling sound when they breathe. C said that, while the risk of perforation had been mentioned at the outpatient appointment, they were led to believe it was not something they had to worry about. Furthermore, they were not told that if it happened, it wouldn’t heal naturally, and surgery to fix it often fails.

The board explained that the biopsy had not been taken as the ulcer had healed by the time C attended for surgery. The board apologised for the perforation. They noted that the surgeon was not aware of one occurring before in their career but had since changed their practice to ensure it was discussed when obtaining consent.

We took independent advice from an ENT adviser. We found that C had not been reasonably consented for surgery at the outpatient clinic or on the day of surgery. We noted that the documentation did not support the reported discussions which took place about the surgery or the associated risks, or the implications should C have decided not to proceed with the procedure. We also found that the written information provided to C was unreasonable. The patient information leaflet did not provide information about the short and/or long-term implications of a perforation or that it may occur after the surgery has taken place. It did not note that it was unlikely to heal on its own, that surgery to correct it may not be an option or, if attempted, successful.

We considered that C had received reasonable post-operative care and follow-up from the board. It was reasonable to plan to see them back at 3 – 6 months, and for this to be expedited at the point of C reporting their concerns about the whistling noise that had developed. On balance, we upheld C’s complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failures identified in relation to the consent process for surgery. 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 reasonably consented for surgery and this should be documented in the patient’s medical record and on the consent form for the planned procedure.
• Patients undergoing septoplasty surgery should be given appropriate verbal and written information about the procedure. Risks and complications should be fully explained to allow patients to make an informed decision.

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 parent (A) received whilst in hospital following a stroke. C said that the board failed to provide appropriate nutrition for A when they lost the ability to swallow. A required a percutaneous endoscopic gastrostomy (PEG) feeding tube to be fitted (a tube passed into the stomach through the abdomen to provide a means of feeding). However, there were delays with this and A died shortly after the procedure was carried out. C was concerned that other types of feeding were not considered by the board and that staff were not appropriately qualified to deliver alternative feeding.

The board said as soon as it became apparent that a PEG feeding tube would be appropriate, a referral was made to have this done. A dietician identified another method of feeding called TPN (a type of nutritional fluid administered to a patient intravenously) however, ward staff were concerned that they were not trained on how to deliver this method of feeding. As such, a decision was taken to expedite the referral to have the PEG tube fitted instead.

Before surgery could take place, A had to be tested for COVID-19. The results of the test were not back in time for surgery to be carried out on the day it was initially scheduled. The board apologised for the delay that this caused.

We took independent clinical advice from a consultant geriatrician (specialist in medicine of the elderly). We found that the clinical decisions made in the management of A’s nutrition were reasonable. TPN feeding is not typically used in cases like this one. The standard of care was in keeping with guidance and was of reasonable quality. However, the delay in receiving the results of the COVID-19 test, and the failure to expedite this, was unreasonable. This led to the delay in treatment. On balance, we upheld C’s complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the delay in receiving the results of the COVID-19 test that led to a delay in A having a PEG tube fitted. 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:

• Obtaining the results of tests required before surgery should not be delayed. In cases where surgery is urgent, tests should be expedited where required to ensure that they are received timeously in order to avoid delays in the patient receiving surgery. When delays are experienced, the reasons for this should be noted in the medical records.

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.