Upheld, recommendations

Summary

Mrs C complained on behalf of her client (Mrs A) about the board's handling of assessments of Mrs A's child in relation to diagnosing autism spectrum disorder (ASD).

Mrs A first reported concerns about her child when they were about two years old, as she felt they had some developmental issues. When the child was between four and five years old, community paediatrics undertook two formal assessments for ASD, both of which concluded that the child did not have ASD (although showed some ASD traits). Mrs A was dissatisfied with these results and sought the opinion of a private psychologist, who also considered her child had some ASD traits, although did not fulfil all the diagnostic criteria for ASD. Over the next nine years, the child continued to have developmental problems and was in on-going contact with health professionals and social workers. The child was also referred on several occasions to the children's reporter, including for non-attendance at school and for lack of parental care. While Mrs A asked on a number of occasions for a further assessment of ASD, the board considered that this had already been ruled out, and did not agree to offer a second opinion.

When the child was ten, Mrs A's solicitor obtained an independent psychologist's opinion for the children's reporter hearing, which found that there had not been appropriate assessments of ASD to date. Mrs A then asked her GP for a second opinion from a different NHS board, and the GP arranged an admission to a hospital outside the board area. As a result of that admission, the child was diagnosed with ASD. In view of the different diagnosis, the board undertook a significant event review (SER). The board also planned to meet with the hospital team which had diagnosed ASD, to discuss the case, although this had not been done at the time of our investigation.

Mrs C complained about the board's failure to undertake appropriate assessments and their handling of Mrs A's complaint. After taking independent medical advice from an experienced psychiatrist, we upheld Mrs C's complaints. Our adviser said that, although the initial assessment for ASD was reasonable for the time, further assessments should have been done when the child continued to have problems over the next few years. The adviser also said that the board should have given Mrs A a second opinion when she asked for one. However, the adviser said that the SER conducted by the board in response to the complaint was reasonable. In relation to the complaints handling, we found that the board had delayed unreasonably in responding to Mrs A's complaint, as well as failing to keep her updated, or respond to her requests for updates on several occasions.

Recommendations

We recommended that the board:

• arrange a meeting with the other board's team that diagnosed ASD, to discuss the differences in diagnosis in this case (as planned during the SER process);
• issue a written apology to Mrs A for the failings our investigation found;
• bring the failings identified in our investigation to the attention of relevant complaints handling staff; and
• remind complaints handling staff of the need to update complainants regularly where the complaint exceeds 20 working days, and to ensure that the full response is issued without undue delay.

Summary

Ms C, who was a patient of the community mental health team, complained that she had been discharged from the service contrary to advice given to her by phone, which was that her case would remain open so that she could arrange support, as needed, related to her employment. The board said a work development officer told Ms C she would be discharged after a period of five weeks. We were unable to reconcile the two very different accounts of this conversation. We found no supporting evidence that the board had reasonably followed their operational procedures which said that discharges from the service were planned with the patient, with advice on staying well and appropriate contact numbers for support organisations clearly communicated. We also found no evidence that a written copy of the discharge summary had been sent to Ms C's GP as it should have been. We recommended that the board review the discharge process.

We found that two mistakes had been made in the response to Ms C's complaint. Firstly the person named as having spoken to Ms C whilst she was attended her appointment had not done so. The second error was a reference to Ms C's employment being temporary rather than probationary. In view of the communication errors we asked the board to apologise to Ms C.

Recommendations

We recommended that the board:

• ensure that patients, GPs and other agencies are being given clear information at the point of discharge in line with the stated operational policy; and
• apologise for failing to communicate effectively with Ms C in relation to her discharge and and for the inaccuracies identified within the response to her complaint.

Summary

Miss C was concerned about a large lump in her mouth, and arranged an emergency dental appointment, where she was given antibiotics and advised to see her regular dentist. By the time Miss C saw her regular dentist a few days later her face was quite swollen. Miss C was advised by her regular dentist to have root canal treatment (RCT) on the infected tooth, noting that Miss C had started this treatment a year earlier but had cancelled the appointment to complete the treatment and not made another.

The dentist administered an anaesthetic to start the treatment, but this did not take effect, so asked Miss C to return the next day. When Miss C returned, the dentist administered the anaesthetic and started RCT. However, by the next day Miss C's face was extremely swollen and she was in considerable pain. She attended another emergency appointment and was immediately referred to hospital, where the tooth was removed and the abscess drained.

Miss C complained to us about the care and treatment she received. In particular, Miss C was concerned that the dentist did not take an x-ray, or attempt to remove the tooth or drain the abscess in her mouth.

After taking independent dental advice, we upheld Miss C's complaints. We found that the dentist should have attempted to drain the abscess, or referred Miss C on if she was not comfortable attempting this. We also found that the dentist should have taken an x-ray before starting RCT. Finally, we found that the dentist's record-keeping was not of a reasonable standard, as there was no proper description of the diagnosis or treatment plan.

Recommendations

We recommended that the dentist:

• issue a written apology to Miss C, acknowledging the failings our investigation found; and
• reflect on the findings of our investigation, as part of their on-going professional development.

Summary

Miss C was concerned about a large lump in her mouth, and made an emergency appointment at a dental practice. The dentist who carried out the emergency appointment examined Miss C, prescribed antibiotics and advised her to see her regular dentist. Following further visits to different dentists, Miss C was diagnosed with an abscess in her mouth, and a few days later she was referred to hospital, where the tooth was removed and the abscess drained.

Miss C complained to us about the care and treatment she received. In particular, Miss C was concerned that the dentist who she saw during the emergency appointment did not take an x-ray, or attempt to remove the tooth or drain the abscess in her mouth. In response to our enquiries the dentist said that Miss C had been undergoing root canal treatment to her tooth about a year previously, but had cancelled the appointment to complete the treatment and not made another. The dentist explained that, at the time of her appointment, it was not clear whether this tooth was the cause of the problem, as Miss C had multiple treatment needs.

After taking independent dental advice, we upheld Miss C's complaint. We found that, while the abscess was probably not swollen enough at that stage to drain it, the dentist should have taken an x-ray to establish which tooth was the source of the infection.

Recommendations

We recommended that the dentist:

• issue a written apology to Miss C, acknowledging the failings our investigation found; and
• reflect on the findings of our investigation, as part of their on-going professional development.

Summary

Miss C complained to us about her dental practice's handling of a complaint she made. She said that the practice's response to her complaint was inadequate, as it failed to address all the questions she had asked, and did not include comments from two of the three dentists she had complained about.

After investigating the matter, we upheld Miss C's complaint. We found that the staff member who dealt with Miss C's complaint had only sought comments from one of the dentists involved, and the other two had been given no opportunity to comment. The staff member also failed to check the response, to ensure that it addressed all of the relevant points of the complaint. While the dentist who did respond answered Miss C's questions relevant to the care he provided, and apologised appropriately for some aspects of treatment, the lack of coordination meant that the overall response was poor.

We also found that the complaints handling policy used by the practice appeared to be out of date and did not meet the Scottish Government's requirements for managing complaints about health services. This meant that the practice had failed to meet relevant requirements, such as including information in their acknowledgement letter about the complaints handling process and Miss C's right to bring her complaint to us. The policy also had incorrect information on where to direct customers if they remained dissatisfied, as it said that complaints could be directed to the board (instead of us).

Recommendations

We recommended that the practice:

• issue a written apology to Miss C, acknowledging the failings our investigation found;
• review staff training needs, to ensure complaints are appropriately coordinated and responded to; and
• review their complaints procedure to ensure that it reflects the requirements of the Scottish Government's 'Can I Help You?' guidance.

Summary

Mr C, an advocate, complained on behalf of Mrs A about the care and treatment of her late husband (Mr A). Mr C raised concerns that the board failed to appropriately manage Mr A's skin condition and that, as a result, he developed pressure ulcers. He submitted a photograph demonstrating that Mr A had a pressure ulcer on the day he was discharged from hospital to a care home, complaining that he should not have been discharged with his skin in such condition.

We took independent advice from one of our nursing advisers. She was critical that a specific care plan for the management of Mr A's skin, which was identified as being at high risk of pressure ulcers, was not begun until his skin showed signs of deterioration. She told us that the photograph from the time of discharge showed a small yet established pressure ulcer. Whilst this would not have provided grounds for keeping Mr A in hospital, she highlighted that sufficient information on the care of his skin should have been passed to the care home to allow them to carry this on.

We concluded that the board had not consistently followed their pressure ulcer prevention policy and we upheld the complaint. We were concerned that, in responding to the complaint, the board maintained that Mr A's skin was intact at the time of discharge when the records did not demonstrate this clearly and the photographic evidence suggested otherwise. That said, we welcomed the comprehensive remedial actions the board had already taken further to the complaint. However, we recommended that they take additional action to ensure that sufficient information is passed on at the time of discharge. We also recommended that they apologise to Mrs A for the failings we identified.

Recommendations

We recommended that the board:

• remind staff of the importance of providing sufficient information on handover to ensure continuity of care; and
• apologise to Mrs A for the failings this investigation has identified.

Summary

Miss C complained to us that the time taken by the board to begin an assessment of her son for possible autistic spectrum disorder (ASD) was not reasonable.

Miss C told us that she had raised concerns about her son's development and behaviour with his nursery teacher and her health visitor, and, in particular, her concerns that her son may have ASD. Various referrals for her son to be assessed were then made to the board's community child health services. Miss C considered there was an unreasonable delay by the board in carrying out these assessments.

We took independent advice from our adviser, an experienced paediatrician who specialises in autism and communication disorders, who told us that the community paediatrician involved in assessing Miss C's son and the other professionals involved including speech and language therapy and occupational therapy had provided continued, frequent and supportive contact with Miss C. However, our adviser considered the wait Miss C had for her son's first developmental assessment, a period of ten months, was excessive. Furthermore, our adviser was of the view that it would have been appropriate to consider ASD as a potential diagnosis and to have referred Miss C's son immediately to the board's Autistic Spectrum Community Assessment (the ASCA pathway) at that time.

However, the ASCA pathway was not initiated for four months and, thereafter, Miss C waited another seven months for a diagnostic discussion about her son with the community paediatrician followed by a further lengthy wait for a specialist ASD assessment with the Fife Autism Spectrum Team (FAST), which the adviser considered was unreasonable, particularly in a pre-school child. The adviser also considered that, as a process, the ASCA pathway did not address sufficiently promptly the question of a diagnosis and did not appear sufficiently collaborative with Miss C and her partner as parents.

Although the adviser could not fault the community paediatrician's care of Miss C's son, he was of the view that a multi-disciplinary assessment at an earlier stage would have been helpful, possibly saved time and meant that Miss C and her family would have been better satisfied with the process and the outcome.

In light of the advice we received, we found there was unreasonable delay in the assessment of Miss C's son and, therefore, we upheld the complaint.

Recommendations

We recommended that the board:

• apologise to Miss C for the unreasonable delays identified in this investigation;
• provide evidence of the action taken to address waiting times for assessment and diagnosis for children and young people with suspected ASD; and
• ensure that the comments of our adviser, including the ASCA process, are shared with the relevant staff for consideration.

Summary

Early in 2013, Mr C was seen at Dumfries and Galloway Royal Infirmary as he had been experiencing throat discomfort. The consultant he saw said that no abnormality had been revealed and he discharged him with an assurance that all was well. However, Mr C's throat problems continued and, in July 2013, he found a lump on the side of his neck. His GP referred him urgently to hospital where, on examination, he was found to have throat cancer requiring urgent surgery. Mr C complained to the board who acknowledged that the consultant should have had greater suspicion about Mr C's symptoms and done a more extensive examination. These findings were discussed with the consultant but he remained of the view that it had been appropriate not to diagnose Mr C as having throat cancer.

Mr C complained to us. We investigated and took independent advice from a consultant surgeon who specialised in ear, nose and throat surgery. Our investigation confirmed the board's own findings about Mr C's complaint that the consultant did not show enough suspicion about his symptoms given current accepted risk factors; did not examine him appropriately; and that furthermore, as Mr C's symptoms were untypical of the diagnosis initially given, Mr C should not have been discharged without follow-up. Later, Mr C was not seen within an appropriate timescale as dictated by the urgent GP referral.

Mr C also complained about the board's delay in dealing with his complaints on this matter and we found that this had been the case and that he had not been kept fully updated. In light of this, we also upheld this complaint.

Recommendations

We recommended that the board:

• provide a formal apology for failures in care and treatment;
• ensure that the case is reviewed by the consultant as part of his next appraisal;
• discuss the case at the next Ear, Nose and Throat department's clinical governance meeting so that all members of staff are made aware of the circumstances and can learn from them;
• make a formal apology for the delay and lack of information; and
• consider current complaint response times and assure us that they meet the targets required in stated policy.

Summary

Mr C complained about the care and treatment provided to his late brother, Mr A (who had a significant mental health condition), when he was admitted to University Hospital Ayr with internal bleeding. Following treatment, Mr A was transferred to East Ayrshire Community Hospital with a view to discharging him home a few days later. However, when Mr A's support workers came to the hospital to take him home, they raised concerns about his condition and he was readmitted to University Hospital Ayr. Mr A had further internal bleeding and several weeks later a scan showed that he had had a stroke. He was later discharged to a nursing home, where he became severely disabled and in need of constant attention before his death some six months later.

Mr C complained that if it were not for Mr A's support workers querying his discharge, he would have been sent home and died. Mr C also believed that the result of the stroke would not have been as serious if Mr A had received adequate care and treatment sooner. Mr C was also unhappy with communication from a stroke consultant about the possibility of stem cell treatment, and the board's response to the complaint, saying it was not an accurate reflection of what happened.

We took independent advice from one of our medical advisers after which we upheld Mr C's complaint. Our investigation found that Mr A was clinically unstable when he was transferred to the community hospital, that healthcare professionals failed to check a blood test before the transfer, and that the stroke consultant's discussion with Mr C unreasonably raised his hopes for curative treatment. However, we found that healthcare professionals had diagnosed Mr A's stroke within a reasonable time. In relation to Mr C's complaint about the board's response to his complaint, we found shortcomings in the board's response and made a recommendation to the board about this.

Recommendations

We recommended that the board:

• inform us of how they intend to ensure the safety of transfers to community hospitals, particularly for vulnerable adults with severe mental health problems such as Mr A;
• provide a copy of the latest audit of the appropriateness of admissions to the community hospital;
• feedback the failings identified in relation to checking a blood test and communication about stem cell treatment to the relevant healthcare professionals;
• bring the failures identified to the attention of relevant complaints staff; and
• apologise to Mr C for the failings this investigation identified.

Summary

Mr C complained about the university's actions, after he had a period of ill health while studying there. He complained that they did not do enough to support him through a difficult time, and did not make reasonable adjustments to enable him to continue his studies. He said this led to him having to withdraw from the course.

We found that Mr C had had a number of absences, despite the expectation that he attend all elements of the course. We reviewed what the university expected of Mr C in order for him to continue to the next year of the course, and noted the meetings he had with staff and the support that he was offered in trying to overcome his situation.

We sought independent advice from an equality and diversity specialist, who noted that the university had referred Mr C to sources of support. However, she said that Mr C's department did not take reasonable steps to inform and assist him. They had not implemented the university's policies about equality of access and fees refunds. She took the view that had they done so Mr C might have been able to agree an approach with the university that would have enabled him to continue his studies. She also noted that they had not sought advice from occupational health before making a decision about Mr C's future studies.

We noted the difficulties for Mr C and the university in predicting how the year would progress, and in deciding what he could best do to overcome these challenges. However, we considered that the university could have done more to discuss the options with him, highlight their concerns, and review any alternative approaches available to him. We noted that an occupational health referral could have assisted with this, and we were critical of the lack of notes or minutes of meetings.

Mr C also complained about the number of people that he had to inform about his health issues, saying this breached his privacy. Our review of the university's policies and procedures identified who he was required to tell about his sickness absence. We noted that, on occasion, Mr C chose to share personal health information with staff when he was absent due to ill health, beyond the requirements of the university's procedures. However, we found that there was a lack of procedures in relation to situations other than reporting illness. We were critical of this, as it meant that information could have been shared with more people than was necessary.

Recommendations

We recommended that the university:

• apologise for their handling of Mr C's poor health in the academic session 2012-13, for the stress this has caused him, and the potential impact on his career;
• consider applying their refund policy to Mr C's fees for the academic session 2012-13;
• undertake a full review of the events that led to the curtailment of Mr C's studies, to identify what they could have done differently, and how their policies and practices could be improved in future;
• review their policies regarding the provision of support and adjustments for students, and consider consolidating them into one document, to ensure clarity for students and staff in relation to what support is available and how it is implemented;
• ensure staff are aware of the need to minute meetings with students, particularly where performance is in question, and that these minutes should be shared with the student;
• apologise to Mr C for their handling of his sensitive personal information; and
• review their policies relating to the provision and sharing of personal sensitive information, to ensure that they clearly indicate why such information is required and who needs to have access to it.