Upheld, recommendations

Summary

C complained that the council failed to respond appropriately to concerns they raised about their child (A) who had cancer. C was separated from A's other parent (B) and, at the time A became ill, both C and B shared A's care on an equal basis and had Parental Responsibilities and Rights in relation to A. C was concerned about aspects of A's care and quality of life during their illness. C raised concerns that B repeatedly acted against medical advice, and acted aggressively and was abusive to C and C's partner while A was present. C complained about the way social workers and A's Named Person (a central point of contact if a child, young person or their parent(s) want information or advice) dealt with their concerns. C complained that during A's illness council staff acted unprofessionally and did not take their repeated requests for help seriously.

We took independent advice from a social worker. We found that the council should have more fully investigated the concerns C raised about A's welfare. In particular, they should have made contact with a relevant health professional involved in A's care to clarify whether they shared C's concerns. The council had a statutory duty to make enquiries in connection with A's welfare, to satisfy themselves that A was not at risk. We found that the council failed to meet their statutory obligations in this regard. Therefore, we upheld this part of C's complaint.

C complained about the council's complaint handling. We recognised this was a difficult and complex complaint for the council to investigate, but we were critical of a number of aspects of the complaint handling. We recognised that the complaint investigation spanned some of the COVID-19-related lockdowns, when services were adversely impacted. However, we found that the council not only failed to meet the relevant timescales in accordance with their complaints handling procedure, they also failed to keep C updated regarding progress. We were critical of the complaint being passed back to the team manager to finalise the response when the senior manager investigating the complaint retired; the team manager was not sufficiently senior to deal with the complaint and they were cited in the complaint themselves. We also found that there was a lack of depth in the investigation. We considered the complaint handling was unreasonable and 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 in our investigation. The apology should recognise the impact of these failings on C, C's wider family, and on 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:

• Council staff are clear about their obligations and act within the relevant statutory framework. Parents with parental responsibilities and rights are treated equally by council staff. In particular, where parents present differing accounts of significant events which cannot be reconciled, relevant independent third parties should be contacted for verification, both parents should be involved in planning for meetings such as TATC, the child's views should be sought in relation to matters affecting them.
• The council should consider putting in place a system for auditing records of child protection concerns reported to a school or noted by a school.

In relation to complaints handling, we recommended:

• Complaints are investigated in line with the Model Complaints Handling Procedure. Complainants are kept updated regularly. Complex stage 2 complaints are investigated by a senior manager. Complaints should not be investigated by staff cited within the complaint.

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 provided to their elderly parent (A). A had to remain in bed to allow several pressure sores to be treated. To assist with moving A out of bed and changing A's position, a manual handling assessment was requested. C felt that there was an unreasonable delay in conducting this assessment and that when it was carried out, the equipment was provided too slowly and was not fit for purpose.

The partnership responded to C but denied acting unreasonably, or that there had been an undue delay. C responded to this challenging the accuracy of the partnership's response. The partnership issued a second response which acknowledged the first response had been inaccurate. However, they maintained that staff had acted reasonably, and that A had not been put at risk by the handling equipment used to move them.

We found that there had been a delay in providing a manual handling assessment caused by the referral not being initially received, which was compounded by staff absence on leave. However the partnership were able to demonstrate they had already addressed this through the recruitment of additional staff. We also found that the partnership's procedures required them to review the suitability of manual handling equipment after it was delivered to the patient, as well as ensure care staff were competent at using the equipment properly. This was not done, and we found it was unreasonable for the partnership not to have followed their own procedures. We also found that it was unreasonable for the partnership to have issued a stage 2 complaint response which was inaccurate, as their follow-up response acknowledged that it had not reflected the partnership's electronic records accurately. Therefore, we upheld C's complaints.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for 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.

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 they received from the board in relation to an incident of extravasation (the leakage into surrounding tissue of medication administered intravenously) of chemotherapy into their arm. C told us that following the incident, their arm became painful and swollen and that they were left with loss of function in their hand and arm, despite being referred to the board's orthopaedic, plastic surgery and physiotherapy departments for further treatment. C considered that the aftercare they had received had been unreasonable and that there had been a lack of diagnosis in relation to the injury to their arm. C also complained about the attitude of nursing staff after the incident, which they felt lacked compassion.

The board told us that extravasation is a known risk of chemotherapy treatment but that once the extravasation was noticed, chemotherapy treatment was stopped immediately and that attempts were made to aspirate the fluid from C's arm. The board also noted that C was reviewed by an on-call plastic surgeon, all in accordance with their extravasation policy. The board acknowledged that, while C was subsequently seen by specialist in orthopaedics and physiotherapy, their recovery appeared to be slower than would normally be expected and that the long term implications were unclear.

We took independent advice from an oncologist and a nurse. We found that the board's response to the extravasation incident, both immediately and in the months that followed, was in keeping with their extravasation policy and established good practice. However, on review of the available documentation, there was no evidence to show that nursing staff had completed the necessary hourly checks of C's peripheral vascular cannula (through which the chemotherapy was administered) or that the extravasation incident had been discovered as a result of monitoring by nursing staff. This was unreasonable and contrary to professional nursing standards in relation to record-keeping. For this specific reason, we upheld C's complaint. However, there was no evidence within C's clinical records to confirm that the attitude of nursing staff had been poor.

We also found failings in the board's handling of C's complaint and made recommendations under our powers to monitor and promote best practice in relation to complaints handling.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the complaint handling failings identified in this decision. 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:

• All relevant staff should be trained in and be aware of the relevant guidance in relation to PVC insertion, monitoring, maintenance and removal; and the completion of the relevant PVC monitoring documentation (this should include reference to the NMC Code Section 10). There should be a reliable method of ensuring that a PVC chart/aide memoire/policy/guideline is included in each patient's record as required. Relevant documentation should where appropriate be marked “N/A” if the sections are not required, so it is apparent that they have not just been missed.

In relation to complaints handling, we recommended:

• The board should comply with their complaint handling guidance when investigating and responding to complaints.

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 practice's care and treatment of their parent (A) who died as a result of sepsis several days after being admitted to hospital. According to the death certificate, one of the underlying causes of A's death from sepsis was an infected grade four sacral ulcer (an injury that breaks down the skin and underlying tissue, grade 4 is the most severe type) that had been there for several months.

C complained that in the period preceding admission to hospital, GPs from the practice never assessed A's sacral ulcer, despite C's requests for them to do so. C complained about a house visit consultation carried out by a GP (GP1) when the family suspected A may have sepsis. They complained about GP1's decision to prescribe oral antibiotics even though A was known to have swallowing problems. C also complained about the GP's refusal to assess the ulcer visually and their decision not to arrange admission to hospital. C also complained about a telephone consultation a few days later, in which a GP (GP 2) declined to carry out a house visit and arranged admission to hospital on a non-urgent basis.

We took independent advice from a GP. We accepted GP1's clinical assessment that oral antibiotics were appropriate. However, we were critical of GP1's failure to record observations during the house visit, noting that in the absence of these records it was not possible to establish the basis on which GP1 concluded A did not have sepsis. We found it unreasonable that GP2 declined to carry out a house visit or arrange urgent admission to hospital, even though this may not have changed the ultimate outcome for A. We found there were omissions in the records in relation to anticipatory care/palliative care planning. There was also a lack of recorded discussions with A's family. Taking all of this into account we upheld C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to A's family in writing for each of the failings identified in our investigation. 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:

• GPs should take and record observations where appropriate. GPs should review a grade 4 ulcer if requested to do so, with District Nursing support as required. GPs should carefully consider house visit requests where concerns about sepsis are raised. GPs should ensure record-keeping meets a reasonable standard. Where appropriate, anticipatory care plans/palliative care plans should be in place, documented and discussed with relevant parties. GPs should ensure patient records contain summaries of discussions with key family members and other health care staff.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

Summary

C complained that their spouse (A) was not properly assessed by Scottish Ambulance Service (SAS) paramedics and should have been conveyed to hospital, as they had a high temperature, was struggling to breathe, had a fever, a cough and a NEWS2 score of 5 (the system used to identify acutely ill patients). C felt paramedics dismissed A's high temperature due to the temperature in the room and that A should have been given oxygen. C also complained about SAS's handling of their complaint. SAS considered the assessment by paramedics was reasonable.

We took independent clinical advice from a paramedic. We found that while it was reasonable that paramedics did not administer oxygen, the paramedics did not follow the advice provided in the SAS Clinical Guidance for COVID-19 v5.0 guidelines, as A met the criteria for a referral to the Covid Hub and this was not considered by paramedics. We found paramedics did not appear to have considered or acted on warning signs for sepsis and there was no documented rationale for the decision to downgrade the NEWS2 score. We also found that the initial investigation and complaint response was lacking in detail and explanation.

As such, we upheld C's complaints.

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.

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

• Patients presenting symptoms should be appropriately assessed, taking into account relevant SAS guidance. The presence of warning flags for sepsis, including NEWS2 scoring, should be appropriately assessed and acted on taking into account relevant guidance. If a decision is made not to act on warning flags or NEWS2 scoring in accordance with relevant guidance the reasoning for this should be recorded in the clinical documentation.

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 late parent (A) was referred by their GP to the board's ear, nose and throat (ENT) department on urgent suspicion of cancer. A's referral was originally vetted and agreed as urgent. In response to the COVID-19 pandemic, significant operational changes were made by the board resulting in A's referral being re-vetted and downgraded to routine the following month. Due to worsening of their symptoms, A contacted the board and it was agreed that A required further investigation by barium swallow (a test to look at the outline of any part of the digestive system). However, as an aerosol generating procedure, these procedures had been suspended by the board and A did not undergo the test until six month's after their initial GP referral. Following the barium swallow and further investigations, A was diagnosed with oesophageal cancer.

C complained that the care and treatment provided by the board to A had been unreasonable, noting the delays in investigating A's primary symptom of dysphagia (interference with the swallowing mechanism). C also considered A's age had negatively impacted the decision-making in respect of the investigations and treatment options they were offered, and they advised that A had not known until a month after their barium swallow that cancer had even been considered as the likely cause of their symptoms.

We took independent advice from a consultant ENT surgeon. We found that the referral to ENT should not have been downgraded to routine when it was re-vetted given A's symptom of dysphagia. On being seen at the ENT clinic, it was reasonable to refer A for a barium swallow at this stage but only if it had been done urgently. In A's case, the time between the request being made and their appointment was four months, which we considered was unreasonable in light of oesophageal cancer being recorded as a possible differential diagnosis on the referral form. We did not find that A's age had negatively affected the treatment options available to them. On the matter of when A became aware of their diagnosis or knowing that they were being investigated for cancer, we could not find any evidence to reasonably determine what was known or understood by A about the cause of their symptoms at the time. On balance, we upheld C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the delays in investigating and treating A's symptoms. 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:

• Evidence that the findings of this investigation have been fed back to relevant clinical staff in a supportive way for reflection and learning, and to inform future decision making regarding vetting processes.
• Patients referred with urgent suspicion of cancer symptoms should be appropriately assessed, taking into account relevant guidance.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

Summary

C complained that the board failed to adequately investigate and/or treat their late spouse (A)'s condition by failing to follow up their appointment at a gynaecological clinic.

A experienced abdominal pain and heavy menstrual bleeding. A's GP referred them to a gynaecology clinic. A attended the clinic and was referred for a scan. A was then discharged back into the care of their GP. A year later, A's GP referred them to gynaecology under a suspicion of cancer. A was subsequently diagnosed with endometrial cancer (a type of cancer that begins in the uterus). A was given various cancer treatments but later died.

C complained to the board about A's care and treatment. The board acknowledged that A's care was not to the standard it should have been. They accepted that the gynaecology clinic had failed to follow local treatment guidance in A's case. They apologised for this. C remained unhappy and asked us to investigate. C was concerned that the board had failed to adequately explain events.

We took independent advice from a gynaecologist. We found that the board had failed to follow their local clinical guidance in A's case. We welcomed the board's acknowledgement of this failing and their apology. However, given the significance of the failings identified we made additional recommendations for action by the board.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failure to follow the relevant clinical guidelines in A's case. 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:

• Where local guidance varies from national guidance there should be appropriate review to ensure the variation has been adequately documented and controlled and diagnostic criteria and terminology is clear and appropriate. In undertaking the review we would encourage the board to consider our comments on the simplification of the local guidance and structure of its flowchart.
• Patients with heavy menstrual bleeding should receive appropriate care and treatment in line with the relevant clinical guidance.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

Summary

C asked a doctor at the practice to complete a DVLA medical examination. The doctor advised C that they did not have capacity to assist C and directed them to a private firm who could help.

C made a complaint to the practice about the decision and availability of doctors at the practice. In their response, the practice asked C to apologise for insulting staff or they would be removed from the practice. C was subsequently removed from the practice list. C made a further complaint to the practice regarding the decision to remove them from the practice list. The practice responded to the complaint, explaining the rationale for removing C. C was dissatisfied with the responses provided by the practice to their complaints.

We found that, whilst C's complaint was likely to have been difficult for staff to learn about, the practice's response was poor. Demanding C apologise was not an appropriate manner in which to try and establish an understanding or re-build trust between a complainant and members of staff. Therefore, we upheld this part of C's complaint.

We also found that it was not reasonable for the practice to have treated C's complaint as having caused an irretrievable breakdown of the relationship between C and the practice. The practice did not follow the appropriate process should they have wished to warn C about the appropriateness of the complaint. Therefore, we found it was unreasonable for the practice to remove C from the practice list and upheld this part of C's complaint.

The practice apologised to C.  While we acknowledge that an apology was given, that apology did not, in our view, meet the SPSO guidelines on apology, as was required by our recommendation.  In this respect it only partially met the recommendation.

Our office tried to engage constructively with the practice over a considerable period of time about giving a further apology, recognising that the original circumstances giving rise to the complaint, were rooted in an already difficult relationship with the C. The practice did not issue any further apology to C. The Ombudsman considered the extent to which it would be in C’s and in the public’s interest to escalate the matter and apply her statutory powers as set out in our Support and Intervention Policy. Having had regard to the length of time which had passed, the fact there had been partial compliance, and changes there had been at the practice in the meantime, the Ombudsman determined that a further apology, even were it to be issued by the practice, would no longer be meaningful, so would not be in either the C’s, or the public’s, interests to pursue.

The Ombudsman has communicated with the practice to communicate her disappointment about the practice’s failure to engage meaningfully with her office and their poor attitude, and to confirm additional steps her office will take when considering complaints received about the practice in the future

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to focus their response on the issue of C's complaint and in responding in an inappropriate manner. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.
• Apologise to C for the failures identified and the decision to remove them from the practice list. 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:

• Complaint responses focus on issues of complaint raised by complainants. Staff should be familiar with the practice's complaints handling procedure and reflect on appropriate approaches to communicating with service users, highlighting communication it deems to be offensive or inappropriate and how to resolve complaints in an effective manner.
• Staff should be familiar with the practice's complaints handling procedure and reflect on appropriate approaches to communicating with service users and how to resolve complaints.

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.

This decision was originally published on 16 August 2023. On the 24 July 2024, we added the following information: 

"The practice apologised to C.  While we acknowledge that an apology was given, that apology did not, in our view, meet the SPSO guidelines on apology, as was required by our recommendation.  In this respect it only partially met the recommendation.

Our office tried to engage constructively with the practice over a considerable period of time about giving a further apology, recognising that the original circumstances giving rise to the complaint, were rooted in an already difficult relationship with the C. The practice did not issue any further apology to C. The Ombudsman considered the extent to which it would be in C’s and in the public’s interest to escalate the matter and apply her statutory powers as set out in our Support and Intervention Policy. Having had regard to the length of time which had passed, the fact there had been partial compliance, and changes there had been at the practice in the meantime, the Ombudsman determined that a further apology, even were it to be issued by the practice, would no longer be meaningful, so would not be in either the C’s, or the public’s, interests to pursue.

The Ombudsman has communicated with the practice to communicate her disappointment about the practice’s failure to engage meaningfully with her office and their poor attitude, and to confirm additional steps her office will take when considering complaints received about the practice in the future."

Summary

C complained about the care and treatment provided to their relative (A) by the practice.

A attended the practice frequently within a year and was later diagnosed with an aggressive form of cancer. A died shortly after. C believed that A's concerns were not properly taken into account when they attended the practice and that A should have been referred sooner for investigations. The practice provided a detailed reply to C, stating their view that A's concerns had been investigated appropriately, and that there had been no indication for a cancer referral.

We took independent advice from a GP. We found that there was no reason to suspect cancer as a possible cause of A's symptoms. However, as symptoms persisted, an urgent cancer referral should have been considered. We found that it was highly unlikely, given the aggressive nature of A's cancer, that the delay in A's diagnosis had any impact on the outcome of A's disease. Although A's initial treatment was reasonable, we found that there were failings in care in that the practice should have made an urgent referral for A sooner. We therefore upheld this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C, and A's immediate family, for the failure to make a referral for A in line with the Scottish Government guidelines. 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 practice should be familiar with the Scottish Suspected Cancer Referral Guidelines and refer patients for specialist assessment in accordance with the guidelines.

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 late parent (A) by the board. A had dementia and was experiencing worsening delirium following a urinary tract infection. A was admitted to hospital by an out-of-hours doctor who visited A at home. C's sibling accompanied A in the ambulance but was told that they were unable to stay with A in hospital due to COVID-19 visiting restrictions. A was transferred to a side ward and later that evening, fell from the bed. A had a head laceration and complained of right hip pain. A head CT and hip x-ray were undertaken which confirmed a right hip fracture. A was transferred to an orthopaedic ward (specialists in the treatment of diseases and injuries of the musculoskeletal system) but it was decided A would not survive an operation due to the fall and hip fracture trauma. A died a few days later.

We took independent advice from a consultant geriatrician (a specialist in the care of older adults) and a senior nurse in falls prevention.

We found that a reasonable level of information from A's family was recorded and taken into account by medical staff, that the assessment of A's delirium was reasonable and that it is common practice for a doctor to try and speak directly with a patient with significant dementia or delirium to allow them to assess the individual's capacity. We also found that it was reasonable to transfer A to a side room, that the action taken by medical staff following the fall was reasonable, as was the communication with the family. Furthermore, that the pain relief was reasonable and was a priority of staff who saw A.

However, we found that there were a number of failings in the nursing care and treatment provided to A. We found that it was unreasonable that no family members were allowed to stay with A, that there was a lack of information documented in the nursing records and a lack of completed paperwork in relation to assessments that should have been carried out on A. Whilst nursing staff's immediate attendance and commencement of the post fall assessment and escalation tool was reasonable, we also found that there was a delay in contacting the family and failure to use a straight lift. Therefore, we upheld this part of C's complaint.

C also complained that the board failed to carry out a reasonable investigation into A's fall in hospital. We found that a serious adverse event review (SAER) should have been carried out instead of a local adverse event review (LAER). 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 specific failings identified in respect of the complaint. The apology should meet the standards set out in the SPSO guidelines on apology.

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

• Family members should be communicated with in a timely manner, particularly after a patient has fallen whilst in hospital, and the detail of conversations should be recorded. Relevant staff should be aware of the requirements for the assessment for potential fracture, safe manual handling for possible fracture including using flat lift equipment.
• Patients' nursing care should be clearly and accurately recorded including any conversations with family members. Entries should be legible, signed and dated.
• Adverse events should be reviewed and reported in line with relevant guidance and in a way that fully reflects the patient journey and outcome with appropriate regard to learning and improvement and communication with the family throughout the process.
• Assessments such as mobility; bedrail and TIME assessments should be completed appropriately and consistently and recorded in the nursing records.
• Relevant staff should be aware of changes to guidance.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.