Upheld, recommendations

Summary

C complained that the council unreasonably failed to follow relevant processes and procedures in managing and responding to bullying behaviour experienced by C's child (A). C also complained about the way the council handled their complaint.

In response to C's complaint, the council confirmed that the school had taken appropriate action in responding to incidents and had investigated C's complaint reasonably. C was dissatisfied with the council’s responses and brought their complaint to this office.

We found that the school had not consistently recorded incidents reported in pastoral and other recording systems. Therefore, it was not possible to determine with any certainty what actions the school took in response to concerns and the impact those actions were having both on A and any perpetrators of bullying behaviour. We also found that the council failed to reasonably investigate aspects of C’s complaint. Therefore, we upheld C's complaints.

Recommendations

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

• Ensure staff at the relevant school are following the council Anti-bullying Policy and are familiar with the requirements of SEEMIS recording, reporting and monitoring. Staff should understand the importance of keeping accurate records and chronologies of a pupil’s time in school.
• The council should audit the SEEMIS recording and pastoral record keeping in the relevant school to ensure that the school and its staff are meeting the requirements of relevant policies.

In relation to complaints handling, we recommended:

• Individuals investigating complaints should be aware of the complaints handling process together with the importance of assessing the quality of the evidence available, the impact this has on the ability to respond to a complaint and the learning and improvements which should be identified. We offer SPSO accredited Complaints Handling training. Details and registration forms for our online self-guided Good Complaints Handling course (Stage 1) and our online trainer-led Complaints Investigation Skills course (Stage 2) are available at https://www.spso.org.uk/training-courses.

Summary

C complained that the council failed to reasonably respond to reports of damp and mould in their property. C also complained about the council’s handling of their complaint.

The council said that they had commissioned an independent survey of the property. They also apologised for delaying with some repairs.

We found that C was responsible for helping to manage the levels of humidity and the temperature in their home by maintaining ventilation and ensuring a reasonable temperature. However, it was clear that there were a number of repairs which the council were responsible for, some of which were delayed and which have generally occurred over an extended period of time. On review, it appeared that they had only been progressed or completed as a result of C’s persistence. Therefore, we upheld this part of C's complaint.

In terms of complaint handling, we found that the council acknowledged and responded to C's complaint in a timely manner. However, we found that they failed to provide a full and informed response to a later complaint. On balance, we upheld this part of C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failings identified in this report. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/meaningful-apologies.
• The council should clarify for C the works which are still to be completed and provide a timeframe for completion of the repairs.

In relation to complaints handling, we recommended:

• Complaint investigations should be managed in accordance with the Model Complaints Handling Procedure https://www.spso.org.uk/the-model-complaints-handling-procedures. Complaint investigations should fully investigate the matters of complaint made and, where appropriate, timeous action should be taken to rectify matters.
• The council should have effective systems in place to ensure that repairs are completed timeously.

Summary

C complained about the care and treatment that they received from the board when under the care of orthopaedics (specialists in the treatment of diseases and injuries of the musculoskeletal system) for foot surgery.

We took independent advice from an orthopaedic adviser. We found that the bones of C’s toe had been reset in the wrong position and the fixation was unreasonable. We also found that C was unreasonably managed at their first post-operative review, noting that C’s x-rays were described as satisfactory which was not the case. The decision to watch and wait was also unreasonable, as by this point a good outcome from the surgery would not have been possible based on the x-rays. We considered that it was unreasonable for the board to discharge C from orthopaedics at the next review appointment when the problem remained unresolved.

There were aspect of C’s care and treatment which we found were reasonable, particularly in relation to the three further surgeries C received. However, we recognised that that these had only been necessary due to the failure which had occurred during the original surgery. On balance, we upheld this part of C’s complaint.

C also complained about the board’s handling of their complaint. We found that the board’s response contained factually inaccurate information, that there had been delays in complaint handling and that there had been a failure to update C during this time. We upheld this part of C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failings identified in this report. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

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

• Patients should receive reasonable surgical care. When an unexpected or unintended incident occurs, processes should be followed to ensure reporting and learning and improvement takes place. This should be in line with both statutory duties and in keeping with any additional internal processes relevant to the incident type.

In relation to complaints handling, we recommended:

• Complaint investigations should be managed in accordance with the Model Complaints Handling Procedure TheModel Complaints Handling Procedures | SPSO. Complaint investigations should fully investigate the matters of complaint made and identify actions for learning and improvement.

Summary

C complained that their GP practice failed to provide them with reasonable care and treatment. C attended the practice with loss of appetite, vomiting, concentrated urine, poor fluid intake, a temperature of 38.7 degrees, and a high heart rate.

C was prescribed antibiotics and given advice on what to do if their condition worsened. C’s condition deteriorated and they attended the practice again. C was referred for a chest x-ray and diagnosed with empyema (pockets of pus that have collected inside a body cavity). C’s condition was life-threatening and they remain impacted by it.

In their response to the complaint, the practice arranged an independent review of C's treatment by a respiratory consultant. They noted that C had a significant tachycardia (heart rate exceeding 100 beats per minute at rest). The practice said that this could have been discussed with the Acute Medical Unit at the time. However, it was likely that they would have advised to treat C at home rather than to admit them.

We took independent advice from a GP. We found that C’s presentation and clinical examination findings were suggestive of pneumonia at least, and indicated that they were at high risk of sepsis. We found that C should have been admitted to hospital rather than sent home with antibiotics. Therefore, we upheld C's complaint.

During the course of our investigation the practice confirmed further reflection and learning. We were satisfied that in doing so they had appropriately addressed the failings in C’s care.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for 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/meaningful-apologies.

Summary

C complained about the care and treatment given to their late sibling (A) by the board. A, who had a history of addiction issues and Chronic Obstructive Pulmonary Disease (COPD, a group of lung conditions that cause breathing difficulties), was admitted to A&E after overdosing on non-prescription drugs. A was treated for the overdose and was discharged to C’s care. A died the following day. C complained that the board inappropriately discharged A and that the treating doctor had failed to communicate adequately with them.

The board did not identify any failings in A’s care, but did apologise that A was discharged with a cannula in place. The board also apologised for communication failures with C. C remained unhappy and brought their complaint to us.

We took independent advice from a consultant in emergency medicine. We found that A was monitored for approximately 12 hours before discharge. This is the minimum period recommended by Toxbase (the primary clinical toxicology database of the National Poisons Information Service). However, we found that A would have required observation over and above this minimum period. This was because of A’s history of acute seizures, intoxication with opiate drugs and their complex medical history. In the circumstances, we found that it would have been reasonable for A to have remained as an in-patient to enable a greater period of medical observation. Therefore, we considered that the decision to discharge A was unreasonable. We upheld C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failings identified in this decision. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/meaningful-apologies.

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

• Internal reviews should include a thorough consideration of all of the relevant evidence including clinical records and there should be reflection on these in an open and transparent manner in order that lessons can be learned.
• Overdoses complicated with seizure activity and aspiration lower respiratory tract infection may require observation over and above the advice provided by Toxbase. Patients admitted with overdoses and who present with a history of seizure activity should be admitted for a minimum of 24 hours observation. Concerns raised by relative(s) of patients should be listened to by staff.

Summary

C complained about the obstetrics (specialists in pregnancy and childbirth) care and treatment that they received from the board during and after the delivery of their baby by planned caesarean section. C said that there was a delay in diagnosing retained products of conception (tissue that remains in the uterus after a pregnancy) which led to infection. C also said that they were kept nil by mouth (not allowed to consume food or drink by mouth) for over 30 hours as their surgery for evacuation of the retained products kept being delayed.

We took independent advice from a consultant obstetrician and gynaecologist. We found that some aspects of C’s care and treatment were reasonable. However, a doctor should have attended when C passed a large clot. There was also a misunderstanding between C and a doctor regarding how long they would be kept nil by mouth for before their evacuation procedure. We also found that the board failed to address C’s concerns about the conduct of a sonographer (specialist in the use of ultrasonic imaging devices) in their response to the complaint. Therefore, we upheld C's complaint

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failings identified. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

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

• Doctors should attend when advised that patients have passed large clots following c-section delivery and are too tender for fundal palpation.
• In cases such as this, a DATIX should be submitted by the board and the case reviewed by the hospital’s obstetric risk management team.

In relation to complaints handling, we recommended:

• In their stage 2 responses to complainants, the board should address all the issues raised and demonstrate that each element has been fully and fairly investigated, in accordance with NHS Model Complaints Handling Procedure. The board should also answer enquiries from this office in full.

Summary

C complained on behalf of their client (B) about the care and treatment given to B's late parent (A). A was admitted to hospital and discharged a few days later. A was readmitted the next day and died the following week. B had concerns around A's diagnosis and said that they should have been consulted given that they held Welfare Power of Attorney (Welfare POA). C also complained that the board's communication with B was unreasonable.

The board said that A was treated for infection with broad spectrum antibiotics. A was discharged after their first admission as it was deemed appropriate and clinically safe to do. The board said that during A’s second admission a lumbar puncture procedure was indicated. They acknowledged that an Adults with Incapacity (AWI) certificate was in place and that during that time, Welfare POA rights were in effect. However, the board said that when the AWI certificate was revoked, the Welfare POA did not maintain the ability to make decisions on the patient’s behalf.

In relation to communication, the board apologised that B found the manner of staff to be abrupt and explained that the situation was urgent.

We took independent advice from a consultant physician in medicine for the elderly. We found that A received appropriate care and treatment. Appropriate investigations were carried out and various diagnoses were considered during A’s treatment. However, the board did not seek appropriate informed consent from B for a medical procedure when the AWI certificate was in place which was unreasonable.

We found that the content of the communication recorded in the medical notes was reasonable. However, the tone of communication lacked sensitivity and respect of B and their role as the Welfare POA. Therefore, we upheld C's complaints.

Recommendations

What we asked the organisation to do in this case:

• Apologise to B for failing to appropriately discuss treatment plans and seek their consent as the power of attorney for an incapacitated patient, communicating with B in an inappropriate way, failing to address all of the concerns raised in their complaint response, and failing to provide full and detailed responses and explanations in their response to the complaint.The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/meaningful-apologies.

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

• Detailing planned treatments on patients with an AWI certificate in place should be done with the full involvement of the power of attorney holder (or equivalent). When an AWI certificate is in place, consent for procedures should be sought from the power of attorney holder (or equivalent) before procedures are carried out.
• When communicating with patients, their families, and/or their power of attorney holders, the board should ensure that the content of the communication is accurate, whilst also paying mind to the manner in which they are communicating. Care should be taken to communicate in a way that is sensitive to the circumstances, compassionate, and respectful.

In relation to complaints handling, we recommended:

• Complaints should be investigated and responded to in line with the NHS Model Complaints Handling Procedure. When specific issues have been raised, these should be fully investigated and a meaningful response provided including, where appropriate, an explanation of the board’s position and the reasons why action was taken, rather than simply stating the facts of the situation. When a complaint investigation indicates that an apology is appropriate these should, insofar as possible, be sincere and acknowledge the impact on the complainant whilst meeting the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/meaningful-apologies. We offer SPSO accredited Complaints Handling training. Details and registration forms for our online self-guided Good Complaints Handling course (Stage 1) and our online trainer-led Complaints Investigation Skills course (Stage 2) are available at https://www.spso.org.uk/training-courses.

Summary

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

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

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

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failure to adequately investigate the cause of their persistent cough. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

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

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

Summary

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

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

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

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failings identified. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

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

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

In relation to complaints handling, we recommended:

• Complaints should be handled in line with the relevant model complaint handling procedure. We offer SPSO accredited Complaints Handling training. Details and registration forms for our online self-guided Good Complaints Handling course (Stage 1) and our online trainer-led Complaints Investigation Skills course (Stage 2) are available at https://www.spso.org.uk/training-courses.

Summary

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

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

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

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the specific failings identified in respect of the complaint. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

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

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

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