Upheld, recommendations

Summary

C complained about their experience at the primary school of their child (A) who has additional support needs. C requested independent mediation with the school and a Co-ordinated Support Plan (CSP) for A. C complained that the council failed to reasonably handle these requests, and that they did not reasonably apply their Unacceptable Actions policy in C’s case.

The council said that an internal mediation process had been put in place and a member of staff was mediating with C on behalf of Education Services. The council said that this went well, so there was no requirement to involve an independent mediator. We found that C was not reasonably informed about the start of the internal mediation process.

The council acknowledged that there was a slight delay in handling C’s request for a CSP. We found that the council failed to meet the eight-week timescale for responding to requests for CSPs, as set out in the council’s policy and statutory guidance. We also found that the council did not reasonably inform C that they had the right to make a reference to the Additional Support Needs Tribunal

The council said that the Unacceptable Actions policy has been applied correctly. We found that the council failed to provide C with a warning letter prior to restricting C’s contact, and that there was a delay in the council’s response to C’s appeal of the decision to apply the Unacceptable Actions policy. Additionally, we found that the council should have referred to relevant policies and guidance in investigating C’s complaints about their request for a CSP and the application of the Unacceptable Actions policy. Therefore, we upheld C’s complaints.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failings identified by this investigation. 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:

• Requests for establishing whether or not children or young people require a CSP should be responded to within the eight-week timescale set out in the council policy and statutory guidance. The council should inform persons making a request of their legal right to make a reference to the Additional Support Needs Tribunal if the eight-week period has elapsed and no decision has been made.

In relation to complaints handling, we recommended:

• When investigating a complaint, staff should consider what information they need about what should have happened, including any relevant policies or procedures that apply.

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 to the council that they had unlawfully carried out repairs to the communal roof and chimney of a block of properties in which C owned a flat by not seeking permission first. C said they had not received a letter which the council said that they had posted advising of the intended works. C also questioned the council's decision to categorise the repair works as an emergency. C said that the council should have notified other owners when water penetrated the council owned property originally , and before the repair work was carried out.

The council said The Tenements (Scotland) Act 2004 allowed for initial emergency repairs to be completed without the need to consult with other owners. As the contractor subsequently recommended a full roof replacement and chimney removal, the council gave the other owners the opportunity to obtain their own quotes for the work required. As no response was received from C to the letter advising them of the intended works, the work was completed and C was liable for their share of the costs.

We found that it was reasonable for the council to categorise water ingress as emergency work and carry out temporary repairs. However, it was less reasonable to continue to categorise the repairs as emergency work after this, noting that the council did not request a survey until the following year. Having made a temporary repair, the council could have used the time available to consult the other owners to obtain a properly made scheme decision in accordance with the legislation. We also found that there was unreasonable delay in advising the other owners about the extent of the works which were required, and the associated cost. We thereby upheld the complaint

We provided feedback on complaints handling, noting that the council may wish to consider reminding relevant staff about the importance of keeping complainants informed about any delay with the consideration of their complaint, and also about the council’s normal practice of placing invoices on hold until an investigation into a complaint has been completed.

Recommendations

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

• The council should have clear procedures in place for when repairs are required to council owned properties in communal buildings, when there is no factor and responsibility for repairs and costs are shared between multiple homeowners. These procedures should be followed to ensure decisions are properly reached.

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 was assessed for the purpose of diagnosing gender incongruence, over a period of two years. Gender incongruence was diagnosed and C started gender affirming hormone treatment (GAHT). Less than a year later, due to new information which had come to light, the diagnosis was removed, treatment withdrawn and C was discharged from the gender clinic.

C complained that they had not been informed at the time of diagnosis that it could be removed or treatment withdrawn. C did not consider that the information was new, as it had previously been available to clinicians. C noted that no-one had discussed this information with them and it appeared that the multi-disciplinary team (MDT) had inappropriately made the decision based on risk rather than clinical assessment.

The partnership advised that information was presented to the MDT, which placed doubt on the diagnosis. Subsequently the MDT recommendation was to revoke the diagnosis and advice was given to the GP to withdraw GAHT.

We took independent advice from a consultant psychologist specialising in gender. We found that the partnership should have carried out and documented a further assessment of C to consider whether the information changed the diagnosis, prior to making a decision. We upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for revoking the diagnosis without giving C the opportunity to comment and without carrying out and documenting further specialist assessment. Apologise for failing to thoroughly investigate the complaint. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.
• Clinical staff should have a conversation with C about the information which has come to light. A specialist assessment should be carried out to fully evaluate C’s clinical picture. If the partnership are unable to do so they should explain why and explain what next steps may be available to C.

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

• Decisions to revoke diagnosis such as adult gender incongruence and related treatments should be in accordance with relevant national guidelines.
• Prisoner diagnosis and treatment should be based on clinical factors rather than perceived prisoner risk.

In relation to complaints handling, we recommended:

• Complaints should be responded to in line with the Partnership’s complaints procedure on receipt and it should not require SPSO to become involved before this happens. The complaint response should address the points raised by the complainant.

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 adult child (A) by the partnership. A had received care from mental health services for several years prior to their death by suicide. C complained that the partnership failed to reasonably share information with A’s family and failed to involve them in A’s care. C also complained about the HSCP’s complaint handling.

We took independent advice from a consultant psychiatrist. We found that the partnership had failed to evidence that there was any discussion with A about sharing information with their family or involving family in care and treatment, including risk assessment. We considered that not to have had this discussion, or to have had the discussion and failed to document it, was unreasonable. We upheld this aspect of C’s complaint.

We found that there were delays in the partnership responding to C, and that they did not answer all points of the complaint. We upheld this complaint about complaint handlings.

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:

• Records should be comprehensive and completed in line with professional standards. In particular, mental health services should seek to discuss involving family in care planning and risk assessment. These discussions and outcomes of such should be documented; and revisited regularly.

In relation to complaints handling, we recommended:

• Complaints should be responded to in a timely manner and in line with obligations under the NHS Model Complaint Handling Procedure. Complaint responses should attempt to address individual concerns, or explain why that is not possible.

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 to the partnership about the care and treatment of their late spouse (A). A suffered from Progressive Supranuclear Palsy (a rare neurological condition that can cause problems with balance, movement, vision speech and swallowing). A was admitted to a community hospital for care and support of their complex needs. C complained about unreasonable falls prevention, nutrition, personal hygiene and incident management. C was concerned that there was little information in the medical notes to show that A was being reasonably cared for. They noted that A had fallen on several occasions, that A had dirty hair, had not been washed and was not receiving enough to eat and drink.

The partnership advised that A was on continuous intervention during the day and 15 minute observations at night for falls prevention, and that falls risk assessments were carried out as part of routine care, although did not provide evidence of this. They advised that Person Centred Care Plans (PCCP) were recorded in A’s records, risk assessments were completed and updated regularly and all staff were receiving personalised one-to-one training on documentation and PCCP.

We took independent advice from a nurse. We found that there was insufficient evidence of falls risk assessments or malnutrition assessments in the records provided, that there were significant gaps in care rounding records and a 5 day period during which A was not offered a wash. We found this to be unreasonable and upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C that the care provided did not meet A’s basic needs or keep them safe. 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, a tenant of Albyn Housing Society Ltd, reported antisocial behaviour (ASB) from a neighbouring family who were also tenants of the association. The ASB related to an overwhelming and pervading smoke and smell as a result of the neighbouring family’s cannabis smoking. The association reported having visited the family and the volume and frequency of smoke and smell reduced. Over the next several months, C made three further reports of the same ASB recurring, including reporting deterioration in their own and their family’s respiratory health. On each occasion the association reported visiting, or attempting to visit, the neighbouring family it resulted in temporary reductions in the volume and frequency of smoke and smell.

When C complained that the association had not responded reasonably to the reports, the association’s response indicated that they considered that they had taken reasonable action. C felt that they had no option but to end their tenancy and raised their complaints with SPSO.

We found that the association did not progress matters in line with a number of parts of their ASB Procedure regarding administration, categorisation and investigation of reports of ASB, subsequent review of progress, consideration of possible solutions to the reported ASB, or taking into account how the situation had developed over a number of months. The association did not explain to C that evidence and corroboration was required to enable them to take action, and they did not follow through with their belated requests that C keep a log of dates and times when issues arose. The association also failed to keep reasonable records of the actions that they did take or pursue and fulfil actions they indicated they intended to take. We upheld C’s complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C that they did not take reasonable action in response to C’s reports of ASB from neighbouring tenants. 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 association’s actions in response to reports of ASB are in line with their ASB Procedure, including actions being reasonably or consistently recorded and reasonably considered including consideration of progression within the ASB Procedure when further reports about the same matters are made.

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

Summary

C complained about the care and treatment provided to their adult child (A) by the board. A had received care from mental health services for several years prior to their death by suicide. C complained that the board failed to reasonably share information with A’s family and failed to involve family in A’s care. C also complained about the board’s adverse event review process, and their complaint handling.

We took independent advice from a consultant psychiatrist. We found that the board had failed to evidence that there was any discussion with A about sharing information with their family or involving family in care and treatment, including risk assessment. We considered that not to have had this discussion, or to have had the discussion and failed to document it, was unreasonable.

The board told us that records were kept briefer than they would normally, because A was an employee of the NHS and was concerned about their records being kept confidential. We did not consider this to be a reasonable position to take, as all patients, including those who are NHS staff, should be confident that their records will be kept confidential. We considered it unreasonable that the board had not addressed this concern. We upheld C’s complaint about information sharing and involvement of family.

In relation to the adverse event review process, we found that the board had not appropriately taken account of C’s view on the scope of, and information to be contained within the review, and because it did not identify the failings in care. We upheld this aspect of the complaint.

Finally, we considered the board’s handling of C’s complaint to be unreasonable. This was because answers to multiple questions about care and treatment were responded to using generic and repetitive phrasing, the complaint response contained several inaccuracies and C was not made aware that some aspects of the complaint could only be responded to by another organisation until the final complaint response,. We upheld this aspect of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failings with regard to information sharing and involvement of A’s family, the adverse event review process and the complaint handling and 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:

• Adverse event review teams should be open to the requests of family when making decisions about scope and information contained in the final report. Adverse Event Reviews should be a reflective and learning process that appropriately consider events in sufficient detail to ensure failings and any appropriate learning and practice improvements are identified.
• Patients who are also employees of the NHS should have confidence that records will be confidential.
• Records should be comprehensive and completed in line with professional standards. In particular, mental health services should seek to discuss involving family in care planning and risk assessment. These discussions and outcomes of such should be documented and revisited regularly.

In relation to complaints handling, we recommended:

• Where some aspects of a complaint cannot be responded to by the board, the board should coordinate responses or make the complainant aware that they need to approach another organisation at the earliest possible point. Complaint responses should attempt to address individual concerns, or explain why that is not possible. Complaint responses should be accurate.

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 treatment and diagnosis in respect of issues C had with their leg over a period of 18 months and being diagnosed with deep vein thrombosis (DVT). In C’s view, the practice missed various opportunities to diagnose DVT or refer onwards to an appropriate specialist. C also raised concerns about the general treatment that they received from when they presented with a lesion on their left leg. The practice had acknowledged that there was a delay in diagnosing C’s DVT. However, there remained uncertainty regarding when the practice should have diagnosed a DVT or explored the possibility of this diagnosis.

We took advice from an independent GP adviser. In respect of the DVT, we found that this was a more difficult case of DVT to diagnose. However, there were signs that the practice unreasonably missed. C attended a consultation after they had been on a flight. We found that, from this point onwards, there was an unreasonable failure to fully take into account risk factors and symptoms pointing to an alternative diagnosis of DVT. There were also missed opportunities to carry out appropriate investigations that would have supported or ruled out such a diagnosis. We considered that there was less certainty over whether the DVT was present prior to C’s flight. We upheld this complaint.

In respect of the more general care of C’s leg, we found that this was initially of a good standard. However, this became less reasonable as the months went on and C’s symptoms persisted. We found that, at a certain point, the practice were not treating C’s symptoms proactively. We also considered an apparent absence of a dermatology referral, despite C’s records indicating that this was part of the treatment plan. For these reasons, we upheld this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to diagnose or explore the possibility of DVT, for failing to treat C’s leg issues pro-actively after a period of time and for not following through on a referral to dermatology. 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:

• DVT should be explored as a possible diagnosis when relevant symptoms and risk factors are present, even when another diagnosis is considered more likely. Treatment for potential DVT should be provided in line with SIGN, NICE or other relevant guidance unless there is a specific reason not to do this. If a decision is taken not to follow relevant guidance, then the reason for this should be recorded.

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 relative (A) in relation to the nursing care and treatment that the board provided to A in hospital following orthopaedic surgery. A received nursing care in hospital before being transferred to another hospital for rehabilitation, where they died. In the second hospital, A was found to have a large wound on their foot and C complained that they had been unreasonably transferred with this.

We took independent advice from an experienced nursing adviser. We found that the wound care management that A received was unreasonable. We also found that it was unreasonable for the board to transfer A to another hospital without documenting this on the transfer document and without an adequate wound care management plan in place. We therefore upheld these complaints, although we found that the board had subsequently taken action to support improvement with regards to care rounding and pressure ulcer prevention.

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:

• Adequate wound healing management plans should be in place for staff to follow prior to transferring patients to community hospitals.

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 standard of care and treatment provided by the board to their late parent (A) during two hospital admissions and the communication around this. C also complained about the way that A was discharged and when they felt that they were unfit to be discharged. A was hard of hearing and a non-English speaker. C said that the failings led to a great deal of mental and physical stress and A’s premature death shortly after the second discharge.

We took independent advice from a consultant physician specialising in medicine for older adults. We found that while aspects of the care and treatment were reasonable, there were failings. The board failed to communicate adequately in relation to A’s care and treatment. In particular, in relation to the seriousness of A’s illness and ensuring that A’s family understood that A was at the end of their life, and the lack of an in-person professional translator for A. Finally, we found that A was not discharged in a reasonable way on the second discharge home, that they should have been reviewed by a senior clinician and had all the relevant tests and investigations carried out and reviewed, and that on discharged, should have had all the required support from the community in place to meet their needs. We upheld the 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:

• Patients and their family should be informed of significant treatment events.
• Patients should be discharged when they have been appropriately reviewed by a senior clinician and all relevant tests and investigations, have been carried out and reviewed.
• Patients should be discharged with all the required support from the community in place to meet their clinical needs.
• Patients who have a hearing impairment or do not speak English as a first language (or both) should have appropriate language support to enable them to fully access NHS services in the same way as patients who do not have barriers such as disability and language.

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.