Upheld, recommendations

Summary

C complained on behalf of their sibling (A) about the cancer care and treatment that A received and the handling of C’s subsequent complaint about this.

We took independent advice from a consultant urological surgeon (specialist in the male and female urinary tract, and the male reproductive organs) and a consultant oncologist (specialist in cancer).

We found that there was a delay in arranging an MRI scan and a ureteroscopy (a procedure that uses a thin telescope with a camera on the end to look inside the ureters and kidneys) for A. We also found that it was unreasonable that A had to involve their GP to prompt urology treatment and that there was no evidence that A’s scan results were revealed or discussed with them.

We found that the board’s investigation of the failings were inadequate. The board should have carried out a local significant adverse event review and there appeared to have been no process changes to prevent similar failings in future. The board also failed to keep C updated on the reason for the delay in issuing their complaint response. We upheld C's complaints. However, we considered that it is unlikely that earlier treatment would have changed A's prognosis.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C and A for failing to advise C that a named member of staff was available to clarify any aspect of the complaint response. 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:

• Staff should discuss scan results with patients and record this in the patient’s records.
• The board should ensure that where events meet the definition of a Category 1 adverse event (events that may have contributed to or resulted in permanent harm), as set out by Healthcare Improvement Scotland, they carry out a local SAER.
• The board should have systems in place which adhere to the Royal College of Radiologists recommendations on cancer imaging alerts and a robust system for booking procedures in theatre that does not rely on email.

In relation to complaints handling, we recommended:

• The board should keep complainants updated on the reason for any delay in issuing their complaint response and when the response is issued, advise complainants that a named member of staff is available to clarify any aspect of the complaint response. [In response to a draft copy of this decision notice that was issued to both parties, the board indicated that since this complaint, they had implemented a new complaint system that provided a facility to monitor when holding letters were due.]

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). A suffered a heart attack and was treated with increased levels of digoxin (heart medication) in hospital. Over a two-week period A became increasingly paranoid and agitated and needed to be medicated. A was then transferred to a nursing home.

A’s digoxin levels were found to be very high and this medication was reduced. C believed that A was suffering from digoxin toxicity. C felt that A’s digoxin levels were not properly monitored or controlled and that A's outcome might have been different with better monitoring.

We took independent advice from a consultant geriatrician (specialist in medicine of the elderly). We found that A’s digoxin was not appropriately monitored. However, it is difficult to assess whether A was suffering from digoxin toxicity. The board acknowledged this failing and provided information on the action taken by individual staff members as well as the board as an organisation to reflect on A’s experience and improve the delivery of care and treatment in the future. We upheld C's complaint and made recommendations to ensure these changes were taken forward.

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 https://www.spso.org.uk/meaningful-apologies.

In relation to complaints handling, we recommended:

• Complaints should be investigated fairly and fully and in line with the requirements of the NHS Scotland Complaints Handling Procedure. Complaint responses should be accurate, complete and address all the points raised in line with the NHS Scotland Complaints 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.

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 their late spouse (A) received for a bowel perforation. A died in hospital following a cardiac arrest. C complained that the conservative, non-surgical approach taken to A’s treatment led to a deterioration in their condition, leaving them unfit for surgery.

C also complained about the standard of A’s medical records, which made it unclear whether clinical advice and treatments had been followed.

Furthermore, C complained that the board’s complaint response contradicted information given at the time, particularly regarding the healing of the abdominal leak and plans for discharge. Instead, the board’s response stated that the treatment had failed, A’s condition was non-survivable, and the leak persisted. Given this, C questioned the board’s decision to attempt cardiopulmonary resuscitation and the lack of palliative care for A.

We took independent advice from a consultant surgeon. We found that there were aspects of A’s care which were reasonably managed including timely administration of intravenous antibiotics and a CT scan on admission. However, we found that there was a lack of urgency and clarity following the CT scan, and an absence of documented clinical reasoning such as treatment purpose, an escalation plan, and consideration of palliative care. High dependency care was not provided early despite signs of deterioration.

Communication with A and C was inadequate, with no documented discussions about the severity of A’s condition or care decisions. We also found failings in fluid resuscitation and monitoring, with delayed reviews of A’s response to treatment. 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 report. 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:

• Patients should receive reasonable surgical care at a level appropriate to their condition. In particular, patients should receive timely assessment and have a clear management plan in place. This should include appropriate monitoring, planned follow-up reviews, and repeat tests and investigations to assess the response to treatment. Fluid resuscitation should be adequate and fluid balance carefully monitored. Medical records should be comprehensive and completed in line with local and professional standards. Communication with a patient and their family about their care and treatment should be timely and transparent.

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’s mental health services did not communicate information regarding C's adult child (A) reasonably. A, who had experienced various mental health issues, was taken to hospital after taking an unknown quantity of tablets. C and another family member were concerned about A's mental health. A did not wish to remain in the hospital and clinicians assessed that A had capacity to make this decision. A few days later, A agreed to go to the hospital for a mental health assessment. The board referred A to the community mental health team (CMHT) and did not admit them to hospital. A few weeks later, A took their own life.

C complained about the board's actions in the lead up to A's death. The board’s complaint response indicated that they had no concerns about the actions taken in relation to A's care. A significant adverse event review (SAER) concluded that communication between agencies (including within the board) could have been improved and an action plan based on the SAER recommendations was developed. The board acknowledged that A had died while in their care and apologised for this. C remained dissatisfied and raised their complaints with SPSO.

We took independent advice from a consultant psychiatrist. We found that, as the SAER concluded, there were failures in communication involving the mental health team, including failures to update risk assessments, failures to use the electronic case notes system and inconsistency in referral criteria across CMHTs. We concluded that the board did not take a partnership approach when communicating with Ass family and did not adequately take into account their concerns when assessing risk. Therefore, we upheld C's complaint.

During our consideration of the complaint, we gave the board the opportunity to comment on the adviser's views on the SAER Action Plan. The board reviewed and rewrote the SAER Action Plan and the proposed actions now relate directly to the recommendations in the report. However, we also noted that the board do not have the resources to undertake the proposed actions due to funding decisions. We noted that the revised SAER Action Plan could have included alternative actions that were not reliant on funding decisions. We have taken all of the above into consideration when making our recommendations.

Recommendations

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

• Board staff are mindful of the importance of communication with the family members of neurodiverse patients and adequately take the concerns of family members into account when assessing risk.
• The board develop a contingency plan to address failings in communication through training and team development of relevant staff that does not rely on external new funding, which could include building in awareness-raising and training within the development of revised CMHTs; and developing “Neurodiversity champions” within each team as sources of greater expertise to spread information and awareness.

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 Social Security Scotland (SSS)'s handling of their transfer application was unreasonable. C received Disability Living Allowance (DLA) which was administered by the Department for Work and Pensions (DWP). C’s condition had deteriorated significantly since their assessment for DLA and made enquires about how to report this. C understood that they were to submit an application to SSS (who were assuming responsibility from DWP for administering disability benefits in Scotland) to transfer from DLA to Adult Disability Payment (ADP).

It took more than six months for SSS to identify that C had followed the incorrect process, despite C attempting in the intervening period to check up on the progress of their application. When the correct process was explained to C, C requested a copy of the form they had submitted but they were told that this would require a Subject Access Request. This caused a further delay. Ten months after the form was originally submitted, SSS wrote to C with a transfer outcome letter. They stated that C’s ADP needed to be reviewed and enclosed a paper form for completion. This caused significant distress to C, who had submitted the same form ten months earlier. C complained about the SSS's handling of their transfer application.

We found that SSS did not give sufficient consideration to C’s circumstances when maintaining their position that C followed the wrong process. We considered that SSS should have identified that C’s application had been submitted incorrectly at the time of receipt. SSS could then have signposted C appropriately to DWP. Therefore, we upheld C's complaint.

We welcomed SSS’s decision to make an ex-gratia payment to C during our investigation, in recognition of a missed opportunity to identify the incorrectly submitted claim and calculating C’s award from that time. In response to our decision, SSS agreed to make a further backdated payment to the date the documentation was received by SSS.

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/meaningful-apologies.
• SSS should consider making an additional ex-gratia payment to C, to put C in the position that they would have been in had they been signposted to DWP when they first submitted their application, thereby triggering the transfer process at that time.

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

• SSS should review their process, giving consideration to whether this should involve screening applications on receipt, with signposting as required. (We recognise that the process of transferring benefits from DWP to SSS may be sufficiently advanced to render this unnecessary.)

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 on behalf of their parent (A) who is a tenant of the housing association. C complained that the association did not undertake roughcast render works at A’s property within a reasonable timescale. A was concerned about the condition of the roughcast render at their property after some had fallen. An inspection carried out found that repairs were required.

Over six months later, no work had been undertaken and more roughcast render fell from the property. A complained to the association about the length of time it had taken for the roughcast render works to be undertaken. The complaint was upheld and the association said they were in the process of procuring a contractor which they estimated would take four to six weeks.

When this time had elapsed, C escalated A's complaint with the association to stage 2 of their complaints procedure. The association reiterated their previous apology and that they were in the process of appointing an alternative contractor. The association said that they hoped works could begin within a month and that dampness and mould would be treated once those works had been completed. They said that they would provide an update when the programme of works was ready to commence. C was unhappy with this response and raised their complaint with this office.

We found no evidence of a proper assessment of the scale of the required works until approximately five months after the need for repairs was confirmed. We also found no evidence of the association taking action to appoint a contractor until more than six weeks after their stage 2 response to C. The association did not assess the urgency of the required works, nor did it consider how failing to undertake them had impacted, or could impact, A’s living conditions. There was also no evidence of structured or consistent action being taken to progress the matter. Therefore, we upheld C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to A that they did not did not take reasonable steps to have roughcast render works progressed and completed at A’s property within a reasonable timescale. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/meaningful-apologies.
• The association should contact C to ensure any outstanding roughcast render and associated works repairs are completed within a reasonable timescale, and that the progress of these are reasonably monitored.

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

• The association carry out repairs within a reasonable period of becoming aware that they are needed, in line with the terms of the Scottish Secure Tenancy Agreement.

In relation to complaints handling, we recommended:

• The association’s complaint responses should make clear whether the complaint has been upheld and complainants are updated as promised. The association should take action to address areas for improvement identified in their investigation of complaints. The association should proactively monitor and follow up on actions promised in complaint responses. 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.

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 Scottish Prison Service (SPS) failed to take reasonable steps to ensure that they had prompt access to medical attention. C stopped taking prescribed medication after experiencing side effects and submitted a request to be seen by a nurse. C was not seen by a nurse during the following two-week period despite their symptoms worsening. C was then informed that they would be seen by a nurse that day but this did not happen. C raised this with prison staff who advised a call had been placed to NHS 24 instead, given healthcare staff were no longer available. C was later informed the call had been ended due to the expected wait time.

In response to C's complaint, the SPS said that the correct procedure had been followed by staff in attempting to call NHS 24. However, it was recognised alternative arrangements could have been made to facilitate the call.

We found that it was unclear whether C’s request for medical attention was communicated properly by SPS to healthcare staff. Whilst a reasonable attempt was made to contact NHS 24, and the SPS acknowledged the call could have been facilitated despite the wait time, the SPS did not explain what action had been taken to remedy matters. While there appeared to have been a protocol in place for such situations, it was not clear that prison staff were aware of this.

C also complained that the SPS failed to handle their complaint reasonably. We found that the SPS’ handling of the complaint was poor because not all of the issues raised by C were responded to and they did not communicate what remedial action was taken. The SPS also failed to provide accurate information in response to our initial enquiries. Therefore, we upheld C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to take reasonable steps to ensure they were given access to appropriate medical attention. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

In relation to complaints handling, we recommended:

• The SPS should ensure it handles complaints in line with Part 12 of the Prison Rules and the SPSO Statement of Complaints Handling Principles.

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 dental care and treatment that they received. C underwent root canal treatment (RCT) on their lower right tooth. C said that this was not performed appropriately and that they should have been referred earlier to an endodontist (a dentist with special training to treat problems affecting the inside of the tooth). C was also concerned that the dentist had caused injury to the inferior alveolar nerve (a nerve that runs through the lower jaw, providing sensation to the lower teeth, gum, lip and chin), left a gap in their tooth and caused a dent to another tooth.

We took independent advice from a dentist. We did not find conclusive evidence that the dentist caused injury to the inferior alveolar nerve or a dent to C's tooth. We noted that the dentist did refer C to the endodontist but we did not find conclusive evidence that this should have happened sooner. However, we concluded that the dentist did not follow current guidance on endodontic practice. There was no evidence of the use of special tests or periapical radiographs (an x-ray that shows the entire tooth, from the crown to the root tip and surrounding bone) taken before the RCT was performed. As such, it was not possible to determine the case complexity. The dentist also used incorrect solution to irrigate the tooth canal and used an old method for assessing the quality of the radiograph imaging taken. 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/meaningful-apologies.

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

• The dentist should take the following actions. Read through the Professional duty of candour from the General Dental Council and make reflective notes. Read through A Guide to Good Endodontic Practice and make some reflective notes. Read through Section 5.4.1 of Guidance Notes for Dental Practitioners on the Safe Use of X-ray equipment (Second Edition, 2020) and make some reflective notes. Read the following article (https://www.dentalprotection.org/uk/articles/tempted-to-change-the-records) from Dental Protection and make some reflective notes. Undertake a CPD course on Endodontics (e.g. Turas online courses from British Endodontic Society) https://learn.nes.nhs.scot/59573

In relation to complaints handling, we recommended:

• The dental practice’s complaints procedure should be revised to ensure it aligns with SPSO’s Model Complaints Handling Procedure: www.spso.org.uk/the-model-complaints-handling-procedures. If further assistance is required with this, the dentist / practice can contact the SPSO’s Improvement, Standards and Engagement Team: https://www.spso.org.uk/training or NHS Lothian.

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 communicate appropriately with their partner (A) regarding charges for treatment. A is a non-UK resident and was charged for non-urgent treatment at hospital following an accident. C complained that A was not informed of the financial liabilities they would incur prior to their treatment, despite having confirmed that they were a non-UK resident and having repeatedly tried to ascertain this information. According to the relevant guidance, any liability to charging should be explained from the outset and patients should be asked to sign an undertaking that they agree to this, ideally before treatment commences.

In their response to the complaint, the board said that the correct process had been followed, and that the variation to the standard processing of A’s case was due to the local address information that was initially recorded. The board confirmed that further training and advice would be provided for clinical teams to ensure that they are fully aware of the guidance and how to advise potentially liable patients appropriately.

We found no evidence that the guidance was followed in A’s case. We considered it a failing on the board’s part that A’s overseas address was not recorded at their initial presentation, noting that their overseas status was documented in the records at that time. We also found that there was a missed opportunity to follow up on matters when A’s relative contacted the Private and Overseas Financial Team with an enquiry a few days after A’s initial presentation at the hospital. Therefore, we upheld C's complaint.

We acknowledged that the board had taken significant steps to improve their service following C’s complaint. A's insurer had also settled the outstanding sum. Therefore, we made no financial recommendation.

Recommendations

What we asked the organisation to do in this case:

• Apologise to A for the failings we have identified. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/meaningful-apologies. We note that the board do not intend to pursue A for any outstanding treatment charges not covered by A’s insurer. For A's records, and for the avoidance of any doubt, we request that the board’s apology letter includes a statement confirming that no outstanding sums are owed to the board.

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

• All relevant staff are familiar with how to input patient details on the MPI screen. All staff are aware of the Private and Overseas Finance Team contact details.

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 nursing care provided to their late parent (A) during their admission to hospital. A arrived at the emergency department before being admitted to a ward. While in hospital, A lost weight and had difficulty eating. Due to delirium, A’s mobility was poor and they experienced a number of falls whilst in hospital. This resulted in a broken hip requiring surgery.

In response to the complaint, the board agreed that there had been multiple failings in relation to the management of A’s diet and reduction in weight. When mobilising A, it was explained that staff did so in accordance with physiotherapy assessments and a number of measures were put in place to prevent A from falls. However, the board acknowledged that due to staffing levels, A did not receive the level of care that they should have.

We took independent advice from a nursing adviser. We found that basic nursing care could not be evidenced in A’s case due to a lack of individualised care planning and delivery. We found that the care provided to A was inadequate and inconsistent and was not provided to the standard required. Therefore, 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 report. 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:

• Nursing documentation should be completed to standard required.
• Patients should receive appropriate nursing care.

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.