Upheld, recommendations

Summary

C complained about the planning procedure followed by the council for a planning application to build a dwelling house and garage on the site of a post office in C's street. C raised a number of concerns, including that the garage drawings were not published on the council's planning portal for comment, that the correct garage floor area was not shown on the block plan and that the planning officer approved a garage of 51 square metres and then allowed a garage to be built which was clearly larger than this. We took independent advice on the complaint from a planning adviser.

The council acknowledged to C and this office that they failed to upload all relevant information on this planning application to their planning portal, including the detailed garage drawings. However, they failed to apologise to C for this failing and explain what action they had taken to prevent this type of failing from happening again. We noted that the system upgrade the council advised they were now installing to prevent errors in manual uploading was reasonable and we asked the council for evidence of the completed implementation and confirmation of its scope.

We noted that the block plan did not show the garage floor area and it was not specifically required to do so. However, they said that the garage floor area in the block plan appeared to be considerably smaller than the garage shown in the approved garage plans and elevations and it would have been good practice for the council to have ensured that all plans were consistent.

We noted that although the planning report referred to the garage as being 51 square metres, the stamped plans were what was ultimately approved and what an applicant could then implement and they showed the garage as being 77.8 square metres. The council have said that the reference to a 51 square metre garage was based on a miscalculation by the planning officer and remedial action had been taken to address this.

We were concerned that the planning report did not contain any reference to the assessment of the garage or any evidence that the potential impacts of the garage were considered in the determination of the application. We were critical of the council in this regard.

We were also concerned that, despite being advised by the council that they did not re-notify neighbours about the change in the dimensions of the garage because this was to a reduced footprint with a lower impact, we did not see any evidence that the original proposal was for a garage which was larger than the one approved by the council. As such, it was not possible to determine that re-notification of the neighbours was not required. Therefore, we upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to upload all relevant information on the planning application to their planning portal, providing incorrect/misleading information on the size of the garage in the planning report, failing to include information on the assessment of the garage and its potential impact in the planning report, and, in their complaint response, unreasonably failing to explain to C why the planning report stated that the garage was 51 square metres, when at no time was a garage of that size approved. 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 planning reports for applications to appropriately address all aspects of a development.
• For site visits on planning applications to be recorded and include information such as the date of the visit, who attended, what was considered and any photographs taken.
• Plans for development should be consistent, in that the dimensions of buildings should be the same on all stamped approved plans.

In relation to complaints handling, we recommended:

• The council's responses to complaints should address all issues raised, as required by the Model Complaints Handling Procedure.

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 support and advice worker, complained on behalf of their clients (B) in relation to a child in B's care (A).

It was decided at a Child Protection Case Conference (CPCC) that A be formally placed with B and as such, B were deemed as eligible for kinship care payments. As a result of this decision, a kinship care assessment was started but was not completed. It was also decided at the CPCC that a referral should be made to the Scottish Children's Reporter Administration (SCRA). While a full assessment was completed on A and one of their parents, this was not sent to SCRA. C complained that the partnership had unreasonably failed to carry out a kinship care assessment.

We took independent advice from a social worker. We found that the kinship care assessment which had been started following the decision of the CPCC had not been completed within the timescales set out in the Guidance on the Looked After Children (Scotland) Regulations 2009. We also found that the decision taken by the partnership that a kinship care assessment was not required had not been communicated timeously to the other agencies involved in the CPCC or to B. Finally, we found that the level of record-keeping was unreasonable.

C also complained that the partnership had unreasonably failed to make a referral to SCRA. We found that there was sufficient evidence to show that the referral should have been made at the time and that there was no evidence to support the partnership's decision that a referral was no longer required. We also found that the partnership's decision not to send the referral had not been communicated to the agencies involved in the CPCC or to B.

Finally, C complained that the partnership had failed to provide reasonable social work/kinship care support. We found that the partnership had failed to demonstrate reasonable contact with B and had failed to provide sufficient evidence to support their decision to close the case. They also failed to adequately evidence that a sufficient level of assessment had been carried out to conclude that A was no longer a looked after child (child in the care of a local authority) and that all financial payments should stop. As such, we found that the partnership had failed to provide reasonable social work/kinship care support.

We upheld all aspects of C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to B for the failings identified in this case at complaints. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.
• Complete a full kinship care assessment, in line with relevant guidance, in respect of B's care of A. As far as possible, consideration should be given to the circumstances of the household when the assessment should have been completed (not just the current circumstances). This should also take into account the fact that A was formally placed with B, and at the time B had been assessed as kinship carers.

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

• Decision-making should be clear and transparent and recorded to ensure accountability and evidence for the actions taken.
• Record-keeping should comply with relevant regulations and guidance.
• Written case records should be appropriately maintained and retained in accordance with relevant legislation and guidance.
• Kinship care assesments should be completed within an appropriate timescale, in line with relevant guidance and legislation.

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, parents of infant child (A) complained about the care and treatment that A had received from the board. C had raised concerns that A's Hickman line (a central line catheter inserted into one of the large blood vessels to allow permanent access for treatment) may be infected and had sought advice at hospital. A swab of the insertion site had taken place, however A had been discharged without further treatment. C complained that the board had failed to provide a reasonable standard of treatment to A during their admission.

C further complained that the following day at a home visit, nurses had proceeded to flush A's line (procedure required to ensure the line remains clear of blood and to prevent clotting) in spite of their concerns it might be infected and without the results of the swab testing. C asserted that as the line had been infected, A had received a septic shower (sudden systemic release of pathogens into the blood stream causing septic shock) resulting in A's sudden collapse.

In their response, the board said that as there had been no diagnosis of a line infection, A's line had been flushed in accordance with the board's Care and Maintenance policy (CVAD policy). However, reflecting on the complaint, the board acknowledged that had there been formal communication between services regarding A's swab testing the evening before, this may have influenced their decision-making to proceed with the flush. They said that as a result of the complaint, they would review and update their CVAD policy to incorporate a standard operating procedure (SOP) and checklist so as to improve information sharing between teams and in circumstances of swab testing, or concerns expressed by families, to ensure medical advice would be sought before proceeding.

We took independent advice from a paediatric nursing adviser and consultant paediatric adviser (dealing with the medical care of infants, children and young people). We found that although the board had correctly considered sepsis in their assessment of A during their hospital admission, they had failed to take appropriate account of the Sepsis 6 guidance, had failed to seek senior clinician advice, and further treatment should have been considered. We also found that in light of the known risk of sepsis associated with central line devices, and given the level of concern expressed by C, it would have been reasonable for the board to have delayed the flush of the line until after the swab results had become available. We also found that the board had failed to correctly follow their CVAD policy, specifically, nurses had not sought senior medical advice before proceeding, and the pro forma maintenance bundle had not been completed or recorded for the flushes of A's line.

C further complained that in investigating their complaint the board had failed to seek their account of events, and had only raised a DATIX (incident report) after they had made their complaint. We found that the board had failed to correctly manage the incident in accordance with their adverse event management policy and procedures which resulted in the family being denied the opportunity to present their evidence. We also found that there had been an unreasonable delay in reporting the DATIX, and the incident had not been escalated for consideration as a potential Serious Adverse Event Review.

We fully upheld all aspects of the complaint. However, in making our recommendations we took account of the board's proposed improvements to their existing CVAD policy which we considered adequate to address the failings identified.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to take appropriate account of the Paediatric Sepsis 6 guidance in their assessment of A, failing to consider further treatment in line with the Paediatric Sepsis 6 treatment pathway, failing to seek senior clinician advice and failing to ensure formal communications with the ICCN team regarding A's attendance at the paediatric unit. 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 failing to correctly follow their AEM policy and procedures by unreasonably delaying the DATIX and not escalating the incident for consideration as a potential SAER, for failing to carry out a reasonable investigation by not reporting events as a SAER or commissioning a SAER report and for failing to allow the family the opportunity to participate in the adverse review process. 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 proceeding to flush A's central venous line without the results of the swab testing, for failing to act on their concerns that the line may be infected, for failing to give fuller consideration to the known risk of sepsis associated with CVAD, for not adhering to the Hickman Patency Troubleshooting guide by failing to seek senior medical advice before proceeding with the flush and for not completing or recording the CVAD maintenance bundle for A's central venous line flushes. 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 board should ensure relevant staff are reminded of the Scottish Patient Safety Programme Paediatric Sepsis 6 Guidance when considering treatment, specifically that there is a lower threshold for consideration of sepsis in patients with indwelling devices/lines, complex medical conditions and significant parental concern. The board should ensure that where there is a lower threshold for consideration of sepsis, senior clinician advice is sought.
• The board should ensure relevant staff are reminded of the board's adverse event management policy and procedures, and published best practice (HIS and IHI guidance) with regards to reporting, managing and analysing significant adverse events. The board must also ensure effective communication with families throughout the SAER process, and during any parallel complaint investigation.
• The board should ensure that when carrying out care and maintenance of central venous access devices in the community, that the CVAD maintenance bundle, including associated checklist, is completed and recorded in the clinical records.

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, the parent of A, complained about a delay in diagnosing A's thyroid cancer. A had an emergency admission to Dumfries and Galloway Royal Infirmary with acute tonsillitis and a lump was found on their neck. This lump was subsequently excised four months later, and cancer was diagnosed the following month. C complained that no prior indication had been given that cancer was suspected, and that the delay in diagnosing this led to unnecessary operations. They also complained about a subsequent delay in informing them about identified nodules on A's lung that were being monitored.

The board told us that they recognised that an earlier biopsy could have led directly to definitive surgery, without the need for further investigations or procedures and ultimately to a quicker resolution for A. They confirmed that they developed a new neck lump clinic as a result of this complaint. We took independent advice from a head and neck surgeon. We noted that A should have had an urgent needle biopsy at an earlier point in time. This would have led to an earlier diagnosis and less surgery. We noted that an excision should only have been considered if a diagnosis was not possible from the needle biopsy. Therefore, we upheld the complaint that there was an unreasonable delay in diagnosing A's cancer. We considered that the new neck lump clinic was the best way to avoid this happening again. While we were assured that the delay did not have an impact on A's prognosis, we noted that it will have added to the distress for A and the family.

In relation to C's concerns about not being advised sooner that cancer was suspected, we noted that cancer did not appear to have been considered earlier. We were, therefore, unable to conclude that there was a failure to communicate a suspicion of cancer. We noted that the board had already acknowledged that they did not make A aware of the lung nodules when they were identified. Therefore, on balance, we upheld the complaint that communication was unreasonable. The board had already apologised for this and they told us that they had revised their process to require clinicians to copy GP letters to patients.

Recommendations

What we asked the organisation to do in this case:

• Apologise to A and C for the unreasonable delay in diagnosing A's cancer. 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:

• Neck lumps should be investigated with a needle biopsy in the first instance, and an excision should only be considered if a diagnosis is not possible from the needle biopsy. This should be undertaken urgently until cancer is excluded. This case should be discussed at the department's morbidity meeting and the findings of this investigation fed back to relevant staff in a supportive manner for reflection and learning.

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. C said that they had been incorrectly diagnosed with Avoidant Personality Disorder (APD). C said that the board had failed to carry out a proper assessment of their presenting symptoms and incorrectly relied on historic information in reaching their diagnosis. They complained that the board's diagnosis had prevented them from accessing appropriate supports and treatment for other comorbidities.

According to NHS Inform, based on statistical information from England, personality disorders can affect one in 20 people and can be very difficult to live with.

In this case, we took independent advice from an adult psychiatry adviser. We considered that the board's diagnosis had been reasonable, however the possibility of a depressive disorder co-existing with this disorder's traits, and a physical disorder contributing to mood change, had not been adequately investigated. We also found that the board did not have an appropriate care pathway for APD, that staff had been unaware of it and that there was a lack of continuity in the board's procedures for requesting both internal and external opinions. Therefore, on balance we upheld this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to carry out a reasonable assessment of their symptoms. 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 arrangements for requesting second opinions within the organisation, and external opinions, should be clarified.
• The care pathways for Personality Disorder should be clarified, and in particular the treatment options of Cluster C disorders such as Avoidant (Anxious) Personality Disorder.

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 of a delay in diagnosing their late partner (A)'s cancer by medical staff in University Hospital Monklands. A was diagnosed with a rare cancer and died three weeks later. They had been unwell for around five months and had multiple hospital attendances and admissions. C complained that appropriate tests weren't carried out in a timely manner, and that A was misdiagnosed and treated for potential illnesses they did not have.

We took independent medical advice from a consultant in respiratory and general medicine. We found that A's case was complex and unusual and that it was reasonable to consider other diagnoses more likely than cancer, and to treat these accordingly while investigations continued. However, we found that reasonable action was not taken to manage the pleural effusions (fluid around the lung) that A initially presented with. Guidelines indicate that a fluid aspiration (removal of a small amount of fluid for testing) should have been arranged to rule out infection in the pleural space (cavity between lungs and chest wall). This was not arranged until almost eight weeks later. When this was done and the result was inconclusive, guidelines recommended that a biopsy be carried out and this wasn't done either. In addition, an ultrasound scan the following day reported ascites (fluid within the abdomen), and again a fluid aspiration was indicated but wasn't carried out.

A biopsy via thoracoscopy (keyhole camera into the pleural space) was not carried out until a further 14 weeks later. A's cancer was diagnosed thereafter. We found that there were earlier indications for a thoracoscopy and missed opportunities to diagnose A's cancer from the time of their initial presentation. While we acknowledged that an earlier diagnosis was unlikely to have altered A's prognosis, we noted it would have enabled palliative care to commence and allowed the family time to prepare and make the most of the time they had left together. We upheld this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to carry out appropriate investigations in a timely manner, and for the consequent delayed diagnosis and impact of this on A and the family. 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:

• Adherence to relevant national guidelines on managing pleural disease and managing ascites. Appropriate investigations carried out as and when indicated, leading to timely diagnosis.

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 their late parent (A)'s discharge from University Hospital Hairmyres. C believed that A was not fit to be discharged and that this resulted in A having a fall, and sustaining an injury which then contributed to A's death.

We took independent advice from a physiotherapy adviser and a consultant physician and geriatrician (a speciality focussing on the health care of elderly people). We found that a comprehensive geriatric assessment was not carried out during A's admission. Given that this is a requirement outlined in the Healthcare Improvement Scotland (HIS) Care of older people in hospital standards, we considered it was unreasonable that no assessment appears to have been carried out. This may have provided a more comprehensive view of the issues affecting A.

We also found that A's case was not discussed at a Multidisciplinary team (MDT) meeting prior to A's discharge. If this meeting had taken place, the MDT could have considered whether A would have benefited from further rehabilitation (either in hospital or in the community).

Given that an MDT meeting did not take place prior to A's discharge, and given the lack of a comprehensive geriatric assessment in line with HIS standards, on balance, we considered the decision to discharge A was unreasonable. We upheld C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for not carrying out a comprehensive geriatric assessment during A's admission and for not discussing A's case at a Multidisciplinary team (MDT) meeting prior to their discharge. 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:

• Clinicians should have access to MDT meetings including all appropriate specialties to discuss patients on geriatric units who have MDT input.
• Older people presenting with frailty syndromes should have prompt access to a comprehensive geriatric assessment in line with Healthcare Improvement Scotland standards.

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

Summary

C complained that their late parent (A) was allowed to discharge themselves against medical advice. C considered that A was not fit to make this decision and that A's mental capacity had not been appropriately assessed.

We took independent advice from a consultant geriatrician (a specialty that focuses on the health care of elderly people). We found that no formal assessment of A's capacity was carried out when they were noted to be agitated, confused or not-orientated during their admission. We found that a senior doctor did not review A's decision-making capacity at the time that A expressed the wish to discharge themselves.

Therefore, we upheld C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to carry out a formal assessment of A's capacity when they were noted to be agitated, confused or not-orientated during their admission and for failing to ensure a senior doctor reviewed A's decision-making capacity at the time that they expressed the wish to discharge themselves. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

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

• Patient decision-making capacity should be kept under review and if their clinical condition changes (such as agitation, confusion, disorientation) this should prompt further review in line with the Adults with Incapacity (Scotland) Act 2000.
• Where there is evidence that the patient has experienced confusion and agitation during their admission, as in this case, senior doctors should take steps to assess the patient's decision-making capacity at the time they express the wish to discharge themselves.

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 treatment provided by the board to their spouse (A) who was initially admitted to University Hospital Monklands with a fractured leg before being transferred to Wishaw General Hospital for further management. A's condition subsequently deteriorated, in response to which they received a full dose of Tinzaparin (anticoagulant). As A showed no improvement, they underwent an exploratory laparotomy (a surgical incision into the abdominal cavity, for diagnosis or in preparation for major surgery). A few hours later, due to further deterioration, A underwent a further laparotomy. During this procedure, significant bleeding and an injury to A's spleen was identified. A splenectomy (a surgical operation involving removal of the spleen) was then performed. A's condition did not improve and they died shortly after.

We firstly obtained advice from a consultant orthopaedic (conditions involving the musculoskeletal system) surgeon. We found no failings in relation to the orthopaedic care provided to A. We then obtained advice from a consultant general surgeon. We found that while it could not be definitively said how the tear to the spleen identified at the second laparotomy had been caused, it was possible that this may have been caused some time between commencing closure of the abdomen at first laparotomy and the second laparotomy. However, we also noted that A should not have received a full dose of Tinzaparin before it was established whether they would need surgery, as this was irreversible and greatly increased the risk of bleeding during surgery. The surgical adviser told us that the dose of Tinzaparin administered prior to surgery intensified the bleeding caused by the injury to A's spleen and contributed to A's death, although they may still have died from the underlying cause of their acute illness that could not be identified during post mortem examination. We upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for unreasonably administering a full dose of injectable Tinzaparin to A before establishing whether they would require a laparotomy to explore the cause of their abdominal pain and deterioration. 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:

• Clinical staff should be aware that full-dose injectable anticoagulation should be withheld until it is clear that the patient does not require an operation due to the bleeding risk. In the event, a pulmonary embolism or deep vein thrombosis is identified.

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 a failure to diagnose their late partner (A)'s spinal cord cancer when they attended Wishaw General Hospital. They attended the Accident & Emergency Department and were referred on to the medical team for an urgent MRI scan for a suspected malignant spinal cord compression (MSSC, MSCC can happen when cancer grows in the bones of the spine or in the tissues around the spinal cord). However, this was subsequently changed to a CT scan, the result of which was normal, and A was discharged. A attended a private neurology (the science of the nerves and the nervoussystem, especially of the diseases affecting them) appointment the following week, where arrangements were made for an urgent hospital admission and a tumour in the spinal cord was diagnosed. A was left confined to a wheelchair following surgery and died around ten months later. C complained that, in not carrying out an MRI scan, the board failed to adhere to national guidance on MSCC management.

We took independent medical advice from a consultant radiologist (a specialist in the analysis of images of the body), who advised that it is normal practice to initially investigate any patient with a history of prior malignancy and suspected MSCC with an MRI of the whole spine. We, therefore, considered that it was unreasonable in A's case for the board to have carried out a CT rather than an MRI scan. It was noted that there was limited MRI scanner availability the day A presented, however, guidance allows for an MRI scan to take place within 24 hours. We found that an MRI scan should have been undertaken the following day and this omission was unreasonable. Had the MRI scan taken place, the spinal tumour would have been detected earlier. We were unable to say whether this would have had an impact on A's overall prognosis. Therefore, we upheld this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failure to conduct an MRI scan prior to discharging 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:

• NHS Lanarkshire's guidance on the management of MSCC should be reviewed to ensure that it is in line with NICE guidance. The findings of this investigation should be shared to ensure relevant learning for staff.

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.