Upheld, recommendations

Summary

C complained about the care and treatment their adult child (A) received from the practice. A had undergone surgery to remove infected fluid on the right lung. Gabapentin (an anticonvulsant medication primarily used to treat partial seizures and neuropathic pain) was prescribed to manage nerve pain at the incision site. The practice later stopped prescribing gabapentin and A’s mental health deteriorated significantly.

C complained about the abrupt withdrawal of gabapentin. They highlighted that gabapentin had been prescribed to manage ongoing nerve pain following surgery and noted the risks of sudden withdrawal. The practice stated that prior to the discontinuation of gabapentin there had been an increase in early requests for renewal of medication, which caused concern. A had not attended appointments with the GP or with cardiology (specialists in diseases and abnormalities of the heart). The GP felt that they could not justify further prescription of controlled drugs without seeing the patient.

We took independent advice from a GP. We found that there was no record of any significant harm from gabapentin or evidence of overuse, or had there been any discussion around reducing or stopping gabapentin. We noted that gabapentin is known to cause problems during the withdrawal period and it should therefore be withdrawn slowly. We also found that no withdrawal support was given. In light of this, we considered that the practice had failed to appropriately manage A’s prescription for gabapentin and upheld C’s complaint.

We also found failings in the practice’s handling of C’s complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to A for abruptly stopping gabapentin. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.
• Apologise to A for the complaint handling issues. 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 acknowledgements should include all the information required by the Model Complaints Handling Procedure. Points of complaint should be agreed with the complainant at the outset. Points of complaint should be addressed in the response. Care should be taken with the tone of the response.
• GPs should be familiar with the guidelines for withdrawal of medicines associated with dependence.
• The practice should have a policy around how they contact patients especially when their phones are unobtainable. Alternative modes of communication like home visit, letter or taking help from a household contact to confirm phone number could help clinicians provide safe care to patients.

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 client (A). Following an incident at A’s home, A agreed with the council's Child Protection Team that their two children should be placed in the care of a relative. This was a voluntary placement under the Children (Scotland) Act 1995. C emailed the council’s social work team to inform them that A would withdraw their consent to the placement if no progress was made in their case.

A attended their youngest child’s school and attempted to take custody of their child, but was prevented from doing so by social workers and the child left in the custody of relatives. Later that day, A attended their relatives’ house and A was prevented from taking custody of the child. Social workers were not present, but police attended and then refused to intervene after speaking to the social workers.

A then agreed to the voluntary placement again. C advised A that they should withdraw their youngest child from the placement and attend their school to collect them and C informed the social workers of this advice. In response, social workers obtained a Child Protection Order (CPO). C complained to the council that they had failed to respond to A’s wishes regarding the placement. The council did not identify any substantive failings.

C complained that the council’s response was inadequate and inaccurate and that the council had failed to obtain a CPO timeously. We took independent advice from a children's social work adviser. We found that A had tried to end the voluntary placement twice and that A had been prevented from exercising their parental rights. We found that the council had failed to obtain a CPO timeously and that they had failed to adequately investigate or respond to C’s complaint. We upheld C’s complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to A for their failure to take A’s parental rights into consideration and their failure to administer the placement of A’s children adequately. The apology should meet the standards set out in the SPSO guidelines on apology available at https://www.spso.org.uk/information-leaflets.
• Apologise to C for their failure to investigate and respond adequately to C’s complaint. The apology should meet the standards set out in the SPSO guidelines on apology available at https://www.spso.org.uk/information-leaflets.

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

• Council staff should be aware of and take into account relevant guidance and legislation in a situation like this including parental rights and carrying out timeous checks of voluntary placements of children under section 25 of the Act.
• Staff dealing with complaints should be familiar with the council’s Complaint Handling Procedure, understanding the importance of communication and the need to demonstrate thorough investigation of the points raised.

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 way in which the council discharged a planning condition. C told us that planning permission for a development of new properties located next to a busy road, included a condition which required the installation of a close boarded fence and/or earth bund at least 1.5 metres tall and enhanced glazing for rooms facing the busy road to mitigate noise. The developer was required to provide detailed plans in advance which would be subject to written approval. C also complained that the council failed to refer the issue to their Enforcement Team, which C believed to be contrary to the enforcement charter.

We took independent advice from a planning adviser. We found that the process to discharge a condition should be transparent, properly recorded, and easily accessible as part of the public record. There had been failings in the way in which the decision was reached as the council failed to keep adequate records. We concluded that whilst the council appear to have considered the location and height of the fence when discharging the condition, they do not appear to have considered the quality. When new information came to light (about the quality of the fence and questioning whether the height of the fence was adequate) the council should have reviewed the evidence and reconsidered the adequacy of the information that they used to discharge the condition.

In light of the evidence, we found that there was maladministration in the way in which the council made the decision to discharge the planning condition, which was unreasonable. We also found that the council unreasonably failed to investigate C’s concerns about the quality of the fencing. As such, we upheld C’s complaints.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the way in which the decision was made to discharge planning condition 9, and particularly that the decision was not transparent or easily accessible to the public. Apologise to C for failing to reasonably investigate their concerns about the quality of the fencing and apologise to C for failing to ensure the developer carried out the agreed remedial works. 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:

• Complaints of suspected planning breaches should be investigated in line with the planning enforcement charter and all new evidence should be given reasonable consideration. Enforcement action should be considered if and when appropriate.
• Decisions to discharge planning conditions should be transparent, properly recorded and easily accessible as part of the public record.
• Agreed actions should be monitored with sufficient follow-up to ensure compliance.

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 association did not respond reasonably to reports of anti-social behaviour.

We found that there was a lack of consistency in the way that C’s reports of anti-social behaviour were recorded and indications that some incorrect information had been recorded in relation to C’s reports. The association’s policy required them to categorise reports of anti-social behaviour but some of C’s reports were not categorised, other cases were categorised in a way that was inconsistent with other evidence available and there was no evidence of how the association had arrived at the categories they had selected in most cases. Concerns about actions taken as a result of reports of anti-social behaviour are difficult to resolve given the restricted amount of information that can be shared with a reporting party or complainant. Therefore, it is important that suitable records are kept to demonstrate, when necessary, that policies were applied consistently, decisions arrived at reasonably and appropriate action taken.

We also found that C had requested to meet association staff to discuss the anti-social behaviour but this request was not acknowledged or responded to. The actions taken by the association were not always consistent with their policy and were occasionally contradictory. In most cases, the association’s records did not reasonably record what factors were considered or taken into account when reaching decisions on action to take.

We considered that the association were not able to demonstrate that their policy was applied consistently and appropriately in the case of C’s reports, and what records there are relating to C’s reports are not uniform and do not reasonably explain inconsistencies in the action the association took. Therefore, we upheld C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failure to respond reasonably to reports of anti-social behaviour. 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 should follow their anti-social behaviour procedures when handling all reports of anti-social behaviour, including the consistent categorisation of reported anti-social behaviour, meeting with reporters of anti-social behaviour, and the clear recording of decision-making in relation to reports of anti-social behaviour.

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 by the board to their child (A) during a consultation with an orthoptist (specialist in the diagnosis and treatment of eye movement disorders) and optometrist (healthcare professional who provides primary vision care) in relation to the management of A’s strabismus (a squint) and wide-angled esotropia (inward turning of the eye). C made several complaints, including the board's failure to assess the size of the squint, failure to adequately dilate A’s irides using cycloplegic drops (drugs used to paralyse muscles in the eye), issuing a prescription for glasses based on an inaccurate refraction test result, displaying poor clinical knowledge about A’s condition and poor record-keeping. C also complained about how their complaint had been handled by the board, particularly in relation to a meeting that had taken place to discuss the complaint.

In response, the board stated that, while A’s refraction test indicated a greater amount of myopia (short-sightedness) than previous tests, differences could occur for a variety of reasons, such as the amount of dilation of the irides. In patients with dark irides, such as A, dilation could be difficult but this had been recognised by the clinicians and drops to dilate were appropriately re-instilled, with the prescription issued in accordance with the test results. The board accepted, however, that there had been communication issues between the orthoptist and optometrist but measures had been put in place to improve this. The board also agreed to amend A’s notes to reflect more accurately what had been discussed at the consultation and arrange a further review of A much sooner than had been agreed.

We took independent advice from a consultant in paediatric ophthalmology. We found that A’s refraction test results were inaccurate and should have caused the optometrist to question whether A’s irides had been adequately dilated rather than issuing an incorrect prescription. We also found that the records showed that the drops instilled by the clinicians had been administered at inappropriate intervals, which had likely resulted in A’s irides being inadequately dilated. We were critical of the board’s handling of the complaint, particularly in relation to the board taking advice from an optometrist who had insufficient clinical experience of the issues under consideration. Therefore, we upheld C's complaints.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failings identified in A’s care. 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 the outcome of a refraction test indicates that a significant increase to a prescription is required, clinicians should (i) question whether the patient’s irides have been sufficiently dilated, particularly in patients with darkly pigmented irides; and (ii) consider whether it is necessary to repeat the refraction at a follow-up appointment rather than proceed to issue the increased prescription.
• Where different types of eye drops require to be administered in order to achieve dilation of irides before carrying out a refraction test, clinicians should administer each set of drops at intervals of at least five minutes.

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 and their pregnant partner (A) attended a local hospital as A was experiencing abdominal discomfort. A was examined and recommended to attend the main regional hospital, advising C to drive them there. The journey time was approximately 3 hours and on arrival A was examined and advised that labour may be starting. A was later told that labour was unlikely to be starting but remained in hospital overnight and discharged the following day.

The following week, A suffered vaginal leakage and attended the local hospital where they were examined by a clinician and advised that they suspected A’s waters had broken. A was advised to go to the main regional hospital and they were told that an ambulance was not needed. C therefore drove A to the main regional hospital.

An examination at the main regional hospital revealed that A’s waters had broken and in the early hours of the following day they went into labour. Later that afternoon clinicians gave A and C a number of options: continue with natural labour, attempt a process of augmentation (helping along a labour that's not progressing as it should), or an immediate caesarean delivery (an operation to deliver a baby that involves cutting the front of the abdomen and womb). A and C both agreed to a caesarean. The procedure was carried out and the baby (B) was delivered. However, clinicians had to resuscitate B.

A scan of B’s brain three days after birth revealed a likely injury which was later confirmed as periventricular leukomalacia (PVL, a softening of white brain tissue near the ventricles which often causes problems later with muscle control and thinking or learning problems). Following repeated scans over several weeks as the cysts continued to form, this was eventually categorised as grade three level of severity.

C raised concerns with the board regarding the care and treatment that A and B had received. C met various clinicians but remained dissatisfied. The board offered to have the events subjected to an external review but terms could not be agreed and the review was not carried out.

We took independent advice from a neonatal consultant. We found that, during both admissions, the board failed to provide reasonable care to A and their unborn child and that the board failed to fulfil their obligations under duty of candour. We upheld the complaints.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C and A for failing to provide optimal care, for failing to carry out adequate assessment, for failing to complete suitable documentation and for failing to make safe transport arrangements. 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 and A for failing to provide reasonable care by omitting to timeously administer prophylactic antibiotics to A on arrival at the regional hospital and apologise for the board failing to fulfil their duty of candour obligations when the antibiotic incident was identified. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.
• The board should offer C a final opportunity to address their outstanding questions in relation to the care of A and B in a format agreeable to both parties.

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

• Establish record keeping systems that prompt midwives to detail a full assessment and ensure there is cross checking with the consultant unit at the regional hospital.
• Establish a protocol for managing premature rupture of membranes in remote locations and commence treatment where appropriate, prior to transfer.
• Establish standard documentation and standard operating procedures for risk assessing pregnant women in remote locations, to determine the most appropriate mode of transfer to the obstetric units.

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 various aspects of the treatment provided by the board to their late parent (A) who was initially admitted to Glasgow Royal Infirmary with a fractured hip following a fall. A was subsequently discharged after surgery and received care at home from district nurses. However, A developed an infection at the site of their surgical wound and was readmitted to hospital, where they underwent several further surgeries to control the infection. A went on to develop further infections and subsequently died.

C complained that there had been a delay in carrying out surgical repair of the hip, that A had been discharged without appropriate physiotherapy follow-up, that an out-of-hours GP had failed to readmit A to hospital sooner and that nursing staff were unaware of a surgical procedure A had undergone. C also complained that there had been a delay in referring A to psychiatry, that A developed further infections, that A’s skin had not been correctly looked after, that there had been poor communication about the decision to withdraw care and that there had been errors on A’s death certificate.

We took independent advice from specialists in orthopaedic surgery, general practice community nursing and hospital nursing. We found that reasonable care had been given in relation to the choice of surgical procedures A underwent. We also found that reasonable care had been given to the management of A's infections whilst in hospital, the level of community nursing care, the management of A’s skin, PICC line (a thin flexible tube inserted through a vein to give medicine directly into the bloodstream), referral to psychiatry and end of life care. However, we found that there had been unreasonable care provided in relation to a delay in carrying out A’s initial surgery. We also found failures by an out-of-hours GP to record sufficient detail about A’s condition and ensure A was provided with prompt antibiotic treatment, requiring A to complete two consent forms for the same surgical procedure. We further found that there was a failure to discuss with A’s family a decision taken by clinicians not to perform cardio-pulmonary resuscitation (where the heart and/or breathing is re-started if it stops) of A were it to be required. We also found instances of poor record-keeping by nursing staff and errors contained within A’s death certificate. As such, we upheld this 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:

• Do not attempt cardiopulmonary resuscitation (DNACPR) decisions should be discussed with the patient or their power of attorney/next of kin and the DNACPR form should be completed appropriately.
• Patients' death certification should be completed accurately.
• Patients' nursing care should be clearly and accurately recorded. Entries should be legible, signed and dated and the use of abbreviations should be minimised.
• Patients should be given appropriately and timely treatment by out-of-hours GPs, which is clearly recorded.
• Patients should be given clear information during the surgical consent process to ensure that they are fully informed.
• Patients with a suspected hip fracture should be appropriately investigated within a reasonable timeframe.
• The nursing staff caring for a patient should have appropriate knowledge of their medical history including their care and treatment.

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 that they received from the board for their right sided hearing loss. They complained that they had been misdiagnosed and wrongly advised that a hearing aid would improve their situation, and that no surgery would help them. C later accepted a second opinion and was referred to a hospital outwith the board area where they received a different diagnosis and treatment (a bone anchored hearing aid) which they said improved their quality of life.

We took independent advice from an ear, nose and throat consultant. We found that C’s audiogram (hearing test results graph) had been unreasonably misinterpreted and C was misdiagnosed. We found that the treatment that was given (a standard hearing aid) was not suitable for C’s actual condition. We found that C should have been offered a Crosaid (a device worn behind the ear which routes sound from the affected ear to the unaffected ear), or the surgical option (a bone anchored hearing aid) which was eventually provided when C obtained a second opinion.

We also considered that C was not provided with reasonable advice regarding the use of a hearing aid, that there was a failure to take a careful history for C and pick up on the clues in the referral letter from C’s GP as to the nature of the onset of C’s hearing loss, and a failure to arrange appropriate investigations for C. We also found that there had been failures in the way in which the board had communicated with C about their hearing loss, and we were critical of the way the board investigated and responded to C’s complaint. We therefore upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for unreasonably advising them that they had otosclerosis (a disorder, sometimes hereditary, in which there is formation of new bone around the base of the bone of the middle ear, resulting in progressive hearing loss), when they had sensorineural hearing loss (resulting from damaged hair cells in the inner ear), failing to provide C with appropriate treatment for their hearing condition and failing to provide appropriate advice on the use of hearing aids. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/informan-leaflets.

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

• For the board to appropriately interpret scan results, make appropriate diagnoses in cases such as this, take into account all relevant information, including patient history/GP referral information and test results, identify and arrange appropriate investigations and provide appropriate treatment and advice on the use of hearing aid devices.

In relation to complaints handling, we recommended:

• The board's complaint handling monitoring and governance system should ensure that concerns raised are appropriately investigated, failings (and good practice) are identified and that learning from complaints is used to drive service development and improvement. There should be a review of complaints by senior staff during the board’s investigative process.

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 that their late parent (A) received at University Hospital Monklands. A was admitted to hospital to have fluid drained from their abdomen but died in the hospital a few days later. C was concerned that the drain was left in too long and caused A to suffer a perforation of the bowel, and that medical staff delayed and/or failed to investigate whether A had suffered internal damage as a result.

We took independent advice from a consultant hepatologist and gastroenterologist (a physician who specialises in the diagnosis and treatment of disorders of the gastrointestinal tract, liver, pancreas and gall bladder). We found that without a post mortem it was impossible to determine the cause of the perforation. We also found that while A's drain had been left in longer than recommended, it was unlikely that the delayed length of time the drain was left in and the subsequent perforation were related, as A did not have any immediate complications nor signs of problems from the drain for a number of days before developing a bowel perforation.

We found that the clinical action taken by the team involved in A's care at this time was reasonable. Once there was a suspicion of a perforation occurring, a chest x-ray had been carried out and this had been good practice. The board acknowledged and identified lessons to be learned and we considered the board's actions to address what occurred were reasonable. However, we found that the delay in removing the drain was unreasonable and we upheld C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the unreasonable delay in removing A's drain. 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:

• There should be good communication between the medical team (inserting the drain) and the nursing team with regards to the timing and the removal of a patient's drain.

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 elderly parent (A) was admitted to a care home to recuperate following surgery. C complained to Aberdeen City HSCP (ACHSCP) that the care home discharged A to their family home without knowing the result of their COVID-19 test and that they were not wearing a mask. The family were informed that A had tested positive for COVID-19 the day after they returned home. C also complained that the care home failed to communicate reasonably with the family about A during their admission.

In their response to C's complaint, ACHSCP acknowledged that it was best practice to have the result of the COVID-19 test prior to discharge. They explained that there was no national guidance regarding COVID-19 testing of residents being transferred from a care home to their domestic home. However, Health Protection Scotland guidance was that the risks should be discussed with the resident's family, specifically when there is an ongoing outbreak as there is a risk that the service user may be incubating the virus and could transmit to other household members. ACHSCP acknowledged communication with the family could have been better and that A was not supported to communicate with the family.

We found that there was no national guidance regarding COVID-19 testing of residents being discharged from a care home to their domestic home. However, we also found that it was evident that there was some ambiguity about what the discharge procedures should be and that there was a missed opportunity for ACHSCP and the care home to firm up their policy on safe discharging residents to their domestic home. As a result, A was discharged home having unknowingly tested positive for COVID-19 and the family were prevented from having a discussion to consider the risks.

We noted that it was accepted by all parties that A was not wearing a mask when they were discharged and that this was in breaching of COVID-19 hygiene protocols. In addition to this, we found that the standard of communication with the family fell below the expected standard. Therefore, we upheld C's complaints.

Recommendations

What we asked the organisation to do in this case:

• ACHSCP should apologise to C for the failure to communicate with the family about A's COVID-19 test to allow the family to assess the risks and for discharging A without knowing the result of the COVID-19 test. ACHSCP should also apologise for the failure to communicate with the family about A's wellbeing during their admission. 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.