Upheld, recommendations

Summary

C complained that the council failed to provide support to them and their child (A), who had a severe and debilitating mental illness, and that the council unreasonably failed to respond to all of their concerns.

We took independent advice from a social work adviser. In relation to the council’s failure to provide support to C and A, we found that there were unreasonable delays by the council at each stage of this case. We found that there appeared to be a lack of appropriate management oversight of the case, and a lack of follow up to ensure the best possible outcome for A was met. We also found that the overall communication with C was poor.

In relation to the council’s failure to respond to all of C’s concerns, we found that the actions which the allocated social worker said that they would undertake to progress the case had led C not to make a complaint. We found that the council’s complaint response lacked detail and clarity as to what went wrong and how this could have been avoided. In particular there should have been a clearer acknowledgement and explanation as to why their own guidelines on timescales were not adhered to. We also found that the council failed to fully acknowledge the impact on C, A and their family from those delays and that if the council considered it was not possible or appropriate to issue a joint response on behalf of the council and other partnership organisations, the reason(s) why should have been explained to C and C should have been signposted accordingly. Therefore, we upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

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

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

• Complaint responses should be informed and accurate. The council’s complaint handling monitoring and governance system should ensure that failings (and good practice) are identified and that learning from complaints is used to drive service development and improvement. The council should ensure that they carry out a robust investigation of a complaint when things go wrong. This should include examining the management and decision-making processes of a case to ensure that they have an understanding of all aspects of a case.
• Contact and referrals to social work services should be handled in a timely way and, where appropriate, allocated to a social worker without delay. Children and Young Persons’ assessments should be completed wherever possible in accordance with the timescales set out in the council’s policy. Where this timescale cannot be met, the reasons for this should be fully documented and there should be regular and proactive communication throughout the 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 South Lanarkshire Health and Social Care Partnership's handling of supported living arrangements for their adult child (A) with severe learning difficulties and significant support needs.

The partnership approved an assessment of A’s needs that included supporting them to move into their own tenancy with one-to-one support. It was noted that, long-term, the preferred option would be for A to move into a shared tenancy. C said that they worked with A’s care provider to find a suitable two-bedroom (to accommodate care staff) tenancy for A. The partnership were advised that this work progressed to the point where the care providers were looking to purchase a property for A to live in, and they told C a three-bedroom property should be the focus of the property search to achieve the ultimate aim of A securing a shared tenancy with room for another individual and care staff.

We took independent advice from a social work adviser. We found that the partnership’s assessment of A and C’s needs was reasonable. We were satisfied that the partnership’s reasoning was clear and appropriate in determining that a shared tenancy was the preferred long-term option for A, that the benefits of this (if delivered appropriately) were agreed by all involved, and that the partnership’s communication with C and other involved parties was clear and frequent throughout. We did not find that A’s assessed needs changed following the reassessment. However, it was decided at that point that the focus had to switch from providing A with a single tenancy to a shared tenancy. This decision was in line with the agreed long-term plan for A but was also, as the partnership described it, a material change from the initial proposal. It was also a change made without any prior preparation by the partnership in terms of finding a suitable joint tenant or three-bedroom property. We found that this caused an unreasonable delay to A being able to move towards independent living given plans were already advanced to secure a single tenancy that would have met A’s assessed needs. With this in mind, on balance, we upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C that the partnership’s decision caused an unreasonable delay to A’s move to independent living. 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 partnership review their handling of A’s case with a view to identifying how they may better investigate the viability of all options for independent living and progress these before reaching decisions that effectively reduce those to a single option.

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 presented to the medical practice with nausea and weight loss. Following blood tests, a significant drop in haemoglobin levels was noted and anaemia (deficiency of healthy red blood cells in blood) was diagnosed. C complained that they were not referred on to secondary care for admission or investigation at this point. A few days later, C collapsed and suffered internal bleeding as a result of a large gastric ulcer (a perforation or hole in the lining of the small intestine, lower oesophagus or stomach).

The practice advised that C was a new patient to the practice and had recently been in hospital with acute kidney injury. On first presentation they had a urine infection, which was treated with antibiotics. Following the blood test results, examinations were carried out to check for internal bleeding. No signs of bleeding had been found but C had a bladder full of urine and their catheter was bypassing. The doctor referred to district nursing for a catheter change and a repeat blood test. This was to check whether C was experiencing further kidney injury. There were no obvious signs of dyspepsia (a condition where digestion is impaired) as no heart burn was recorded.

We took independent medical advice from a GP adviser. We found that it would have been appropriate to make an urgent cancer referral based on the symptoms, but that it was reasonable not to have suspected a gastric ulcer. We also found that there was no record that the causes of the anaemia had been fully explored or that a treatment plan and safety netting advice had been considered or communicated.

We upheld the complaint as we considered that although many of the actions had been reasonable, it did not appear that a cancer referral, a treatment plan or safety netting had been properly considered, recorded or communicated. We did not consider that this had changed C’s outcome and acknowledged that the practice had taken steps to learn from the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for not fully exploring C’s symptom history and medication, for not communicating a treatment plan and for not providing worsening advice in case of deterioration. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflet.

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

• The practice should consider scheduling regular peer reviews to ensure that consultations are fully recorded including treatment plan and safety netting advice. Staff should be aware of NICE Guidelines and Scottish Referral Pathways for suspected cancer.

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

Summary

C complained about the care and treatment provided to their late parent (A). A underwent surgery to treat hypertension (high blood pressure). A few days later, A’s condition deteriorated with the cause thought to be sepsis (a life-threatening reaction to an infection). A’s condition worsened further and they were transferred to the High Dependency Unit (HDU). A died later that day.

C complained that there had been a failure to administer antibiotics that A had required and that there had been unreasonable delays in transferring A to the HDU, which resulted in A being left in a state of distress. C also complained about the conclusions that the board had reached about A’s care following a Significant Clinical Investigation (SCI).

The board stated that A had been monitored every 30 minutes and that there had been no delay in providing antibiotics to A. The board accepted that there had been a failure in communication between nursing and porter staff which had led to a delay in A being transferred to HDU. However, the board considered that this would not have resulted in a different outcome although it was acknowledged that this would have reduced A’s family’s distress.

We took independent clinical advice from an acute medicine and nursing adviser. We found that there were a number of failings in the care provided to A following the initial deterioration in their condition. This included failure to initiate tests to identify sepsis, failure to commence intravenous fluids (medical technique that administers fluids, medications and nutrients directly into a person's vein) and failure to perform necessary blood tests, as had been outlined by A’s consultant. There was also no evidence that A had received antibiotics nor had been monitored with the frequency stated by the board. We also found that nursing staff failed to escalate a further deterioration in A’s deterioration and that there had been an unreasonable delay of around two hours in transferring A to HDU. In addition, we found that several aspects of the nursing records fell below the professional standards required by the Nursing and Midwifery Council and that the board’s SCI had failed to identify areas of learning arising from this case. For these reasons, 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:

• Significant Clinical Incident reports should:
• (i) be reflective and learning processes that consider events against relevant standards and guidelines,
• (ii) ensure failings are identified and any appropriate learning and practice improvements are made and,
• (iii) be in line with Learning from adverse events through reporting and review - A national framework for Scotland: December 2019 (healthcareimprovementscotland.org)
• Treatment plans should be comprehensive and document the working diagnosis. Patients should receive the treatment plan recorded in the medical records following consultant review unless there is a change of plan. If this happens this should be clearly recorded.
• Where the cause of a patient’s deterioration is suspected to be due to sepsis, the sepsis bundle should be initiated.
• Patients should be assessed, in accordance with the NEWS guidance relative to the patient's NEWS score. Where there is deviation from this, this should be recorded. In addition, patients who are assessed to have a NEWS score of five or greater should be escalated urgently for further assessment in line with NEWS guidance. NEWS scoring documentation should be fully completed and recorded.
• For patients where there is the presence of red flags indicating an ECG, this should be acted on without delay.
• Where blood tests are requested in order to investigate a deterioration in patient's condition they should be processed and reviewed as soon as possible. Patients should receive the appropriate blood tests to adequately assess the cause of deterioration and any tests that have been specifically requested by clinicians.
• Where a deteriorating patient requires to be transferred from the ward for more intensive treatment, the transfer should take place as soon as possible and without undue delay. A record should also be made showing which member of staff has requested the transfer, the time at which the transfer was requested and to whom the request was made.
• Nursing records should be documented in real time, as far as it is reasonably practicable to do so. They should also include a clear timeline of events, the actions taken by nursing staff (including in what order) and details of all communication with relatives and other healthcare professionals.

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 actions taken by Borders NHS board in relation to diagnosing their child (A) with attention-deficit hyperactivity disorder (ADHD, a condition that affects people's behaviour, including restlessness and impulsiveness). C said that A’s initial referral was rejected and when an assessment did take place it failed to diagnose A’s ADHD. Requests for second opinions were then refused. C said that A was diagnosed with ADHD but not until some years after the initial referral and this was an unreasonable length of time.

We took independent advice from a consultant child and adolescent psychiatrist. We found that while the initial refusal of the referral and first assessment were reasonable, the decision to refuse the request for a second opinion and further assessment was not. This led to an unreasonable delay in diagnosing A with ADHD. As such we upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C and A 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:

• Where a request for a second opinion is made and the initial assessment demonstrated some indicators of a developmental disorder e.g. ADHD, then a second opinion should be carried out, particularly for developmental disorders where changes may have occurred in the intervening time period.

In relation to complaints handling, we recommended:

• Responses to complaints should be clear and 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 how the university handled their complaint that related to their disability and housing. We found that the university's decision to request further information from C about their disability to be reasonable and in line with their policy. We also considered it reasonable that the university asked C for further information about some serious allegations that they had made.

However, we found that the complaint should have been progressed to stage 2 of their complaints handling procedure from the beginning, with the delay of 18 days, which in the specific circumstances here appeared unreasonably inflexible.

On balance, we upheld this complaint as we did not believe it was properly processed and the university's communication with C could have been better.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to progress their complaint through the proper process, at the proper stage. 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 university are aware of the emphasis on them to ensure a complaint progresses through the correct process. We also need to be satisfied that the university are aware of the characteristics of a stage 1 and 2 complaint and finally that they exercise reasonable discretion when a request to progress a complaint to stage 2 is submitted out with the normal time limits.

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 is a parent who lives with their partner (B). An allegation was made that C had used physical punishment to discipline their children and the children were removed from C and B's care. C complained that the children were removed without any evidence of wrongdoing on C's part.

We took independent advice from a social work adviser. We found that the reason for the removal of the children was justified on the basis of the evidence available at the time.

However, we considered concerns about the apparent lack of investigation into allegations which were made about B, incomplete forms, and the decision to return the children to C and B's care in advance of the outcome of the case. For these reasons we upheld the complaint.

Recommendations

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

• Staff should complete all relevant sections of paperwork. Staff should reflect on the outcome of this case.

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 deceased grandparent (A) about care and treatment provided by the board during an admission to hospital following a fall and broken hip. C complained that A received poor nursing care, poor rehabilitation support, had not received enough nutrition and fluids, and had developed necrotic (dead) tissue on the back of their heels. C also complained that communication with the family and the incident management response had been unreasonable.

We took independent advice from a nursing adviser. We found that pain relief, personal care and rehabilitation support had been appropriate. However, we found that there was no evidence that assistance was provided with eating and drinking, and that fluid and nutrition charts had been poorly completed. We also found that the pressure sores on A's heels were poorly managed, that there were significant gaps in repositioning and that effective preventative measures were not appropriately implemented.

We found that information given to the family was insufficient and incorrect. We also found that the incident management response was unreasonable, as the necrotic heels were not deemed to be serious avoidable harm and therefore no serious adverse event review or duty of candour was undertaken. We therefore upheld C complaints.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for not offering sufficient support with eating and drinking and for not preventing and treating the pressure ulcers on A's heels appropriately. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.
• Apologise to C for not recognising the seriousness of the incident and the avoidable harm caused. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.
• Apologise to C for providing incorrect and incomplete information about their grandparent's condition. 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:

• Nursing staff are aware and correctly implement HIS Pressure Ulcer Prevention Standards 2020 (including introducing 2 hourly repositioning, therapeutic mattress and skin protection at the point that skin becomes red). Nursing staff know how to correctly diagnose and grade pressure ulcer damage (including “ungradeable”), correctly follow CPR for feet guidelines (such that they make timely referral to a Tissue viability specialist) and develop person centred treatment plan for the pressure ulcer. Nursing staff provide relevant handover information and relevant equipment such as therapeutic mattress and boots when moving a patient between wards.
• Nursing staff should ensure that fluid balance and MUST charts are completed to a reasonable standard. The board should also be reassured that they have appropriate processes in place to monitor performance in this area.
• That a duty of candour review is considered in the light of the SPSO findings.

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

Summary

C complained that their sibling (A) had not received appropriate care and treatment from their GP practice in relation to symptoms of an infection. C felt the on-call GP failed to arrange for A to be admitted to hospital and that the practice failed to see and examine A, who died the following day of sepsis (an infection of the blood stream).

C also complained that they were unable to access the practice, and that the practice failed to follow its emergency protocol. As such, C complained that the practice had failed to provide reasonable care and treatment to A. The practice considered the care and treatment provided to A had been reasonable.

We took independent advice from an experienced GP adviser. We found that it was reasonable for the on-call GP not to admit A to hospital as this was a decision for the Scottish Ambulance Service (SAS) to make and paramedics expressed no concerns. It was also reasonable for the practice to not examine A as they had already been assessed by the Out-of-Hours Service, the District Nurse and paramedics.

However, we fund that the practice failed to follow the emergency protocol and C and A were unable to access the practice. We also found that the practice's handling of C's complaint was unreasonable due to the quality of investigation carried out. Therefore, on balance, we upheld these complaints.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to follow the emergency protocol when they attended in person to seek an appointment for A. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

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

• For SAER's to be carried out within prescribed timescales.
• Patient Problem Lists should be appropriately summarised with major diagnoses and events to be included.

In relation to complaints handling, we recommended:

• For administrative staff to be reminded of their duty of candour.
• For all complaints to be dealt with empathetically and sincere apologies provided.

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 made a complaint about the care and treatment provided to their late spouse (A) by the board. C was concerned that A had sepsis (an infection of the bloodstream) at the time of their discharge. C considered that A would not have died had they remained in hospital.

We took independent advice from a consultant in geriatric medicine (a doctor who specialises in treating older patients) and general medicine. We found that there was a failure to properly assess A's blood and urine test results prior to their discharge. Had this been done, there would have been a greater likelihood that infection could have been diagnosed and treated prior to A's discharge from hospital. Although A may still have died had they remained in hospital, this could have given A a better chance of surviving their illness.

We found that there were failures in communication with A's family. A's family should have been provided with 'safety netting' advice about repeating A's temperature or looking for other potential signs of infection once A had returned home. We also found that there were failings in the board's handling of C's complaint. The board's own complaint investigation did not include all relevant staff for comment, the response was brief and did not provide fully accurate information in relation to A's condition.

In light of the above, we found that the board failed to provide A with reasonable medical care and treatment. 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:

• Patients whose test results are suggestive of an underlying infection should be fully and appropriately investigated, in line with recognised guidelines. When a patient is discharged, appropriate 'safety netting' advice about worsening condition should be provided.

In relation to complaints handling, we recommended:

• The board's complaints handling system and their investigation should ensure that relevant staff have the opportunity to comment, that complaint responses appropriately address the issues raised and are accurate and that failings (and good practice) are identified, and enable learning from complaints to inform service development and improvement.

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.