Upheld, recommendations

Summary

C complained about the care and treatment that their child (A) received from a dentist at the dental surgery. C raised a number of concerns, including that the dentist failed to detect decay in A's tooth and provide appropriate treatment for this, and failed to carry out a radiograph (a type of dental x-ray) on A's tooth sooner.

We took independent advice from a dentist. We found that the dentist failed to record the presence of a mark on A's tooth during their third appointment, assess if there had been any deterioration of that mark, carry out further investigations and carry out radiographs at an earlier stage. We also found that the dentist's notes had extremely limited detail added and were below the expected standard. Given the failings in the detection and treatment of the decay in A's tooth and in carrying out a radiograph sooner, we upheld C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to A and C for failing to record the presence of the mark on A's tooth, assess if there had been any deterioration of that mark, carry out further investigations and carry out radiographs at an earlier stage. 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:

• In cases of this type, dentists should assess if there have been any deterioration of marks on patients' teeth and carry out further investigations, as appropriate.

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 board regarding the care and treatment provided to their late parent (A). Following a diagnosis of bladder cancer, the board identified that A would require heart surgery before they would be fit enough for bladder surgery. They referred A to another health board to provide that surgery, but this took a number of months to arrange and carry out. C told us that, by the time the heart surgery was completed, A's cancer had progressed to a point where treatment was no longer possible.

We took independent advice from an oncology consultant (a doctor who specialises in the diagnosis and treatment of cancer). We found that the board failed to identify radiotherapy as a possible alternative treatment, despite this advice being given by their oncology team. In addition, we found that the board had mishandled the referral to the other health board for heart surgery, failing to ensure that the other board were made aware of the urgency required. Then, when there were inevitable delays in surgery as a result, the board failed to identify that the window for treatment was closing.

For these reasons, we upheld C's complaints.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to provide A with a reasonable standard of cancer treatment. 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:

• A full range of treatment options should be considered when deciding on a treatment plan, and reconsidered if the viability of the original plan changes.
• All referrals made to other boards for treatment should include full details of any time sensitivity around treatment. Where it is unclear if treatment can be provided quickly enough, direct communication should occur between the relevant teams to explore this and alternative treatment options.

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

Summary

C complained about the care and treatment their parent (A) received from district nurses in relation to the management of sores/ulcers on their legs while resident at a care home. In particular, C complained that district nursing staff had failed to adequately monitor and treat A's sores/ulcers to such an extent that dressings would become saturated in exudate (fluid), requiring care home staff to apply further dressings. C stated that this had led to A developing significant infection requiring admission to hospital, where they died a short time later. C further complained that district nursing staff had failed to identify the deterioration in A's legs and had not alerted A's GP nor made a referral to a specialist tissue viability practitioner (a specialist in aspects of skin and soft tissue wounds including acute surgical wounds, pressure ulcers and all forms of leg ulceration).

In response to C's complaint, the board stated that A had been reviewed frequently by district nursing staff, who had not identified any signs suggesting that A's legs had become infected. The board concluded that district nursing staff had delivered consistent and appropriate care and that referral to a tissue viability specialist had not been indicated.

We took independent advice from a district nursing adviser. We found that there were a number of failings in relation to how A's sores/ulcers had been managed, specifically that wound assessments carried out were incomplete and not carried out at the required frequency and that the wound dressings used were inappropriate, often contradicting the findings of examinations, and contrary to current guidelines. We noted that district nursing staff had failed to carry out baseline observations and tests to check for the presence of infection or sepsis (blood infection) despite noting that A was as “flat” and “lethargic”. We also found that the district nursing staff's record-keeping was poor and not in accordance with relevant professional standards given there was no documented record of interactions with A on certain dates.

For these reasons, we upheld C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to provide A with reasonable care and treatment. 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 board'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 board should comply with their complaint handling guidance when investigating and responding to complaints.

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 council failed to reasonably respond to reports of anti-social behaviour that C had made against their neighbours. C felt that the council had not taken their concerns seriously and that they had been passed around between staff members with no one taking a lead role or responsibility for handling their concerns.

We found that the councils procedures and processes for investigating anti-social behaviour were detailed, robust and good practice approaches to handling reports of anti-social behaviour. However, the council failed to provide evidence that these processes had been considered or followed in their handling of C's reports, and made no reference to the specifics of those procedures in their responses to C's complaints or our investigation.

As such, we upheld C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to reasonably investigate and respond to their 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.
• Carry out an interview with C under Stage 1 of their process, to ascertain what problems, if any, they are still experiencing, and action those through the remaining stages of the anti-social behaviour procedures, as appropriate.

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

• The council should follow their anti-social behaviour procedures when handling all reports of anti-social behaviour, and clear records should be kept of all steps taken.

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 attended hospital for gastroenterology procedures (medicine of the digestive system and its disorders). Upon waking from the procedures, C reported experiencing a painful tingling sensation in their mouth, left hand and foot. C informed the nurses of their symptoms and a consultant carried out an assessment. Following the assessment, C was deemed fit for discharge as no clinical concerns were identified. However, C's symptoms persisted upon returning home. They attended an emergency GP appointment the following morning and the GP concluded that C had had a stroke. C was readmitted to hospital for further investigations. A CT scan confirmed that C had suffered a stroke.

C complained that the board's staff unreasonably failed to identify that they had had a stroke following their procedure. We found that, whilst staff identified that C's symptoms indicated they may have had a stroke and an assessment was carried out with this in mind, the assessment was insufficiently detailed and, in light of C's presenting symptoms, further investigation by a neurologist (specialist of the nerves and the nervous system, especially of the diseases affecting them) should have been arranged. Therefore, we upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to fully consider the possibility of a stroke prior to discharging them and for failing to seek input from the specialist stroke team. 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 involved should reflect on C's case and give consideration as to where improvements could be made in their practice to ensure that symptoms of stroke are adequately investigated as soon as possible and input from stroke specialists is obtained in clinically appropriate cases.
• The board said that they would be running education sessions for all staff to raise awareness regarding early signs and symptoms for stroke and the appropriate action to take.

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 adult child (A) received from the board over a two year period. A had previously suffered an acquired brain injury and since then had developed obsessive compulsive disorder, post-traumatic stress disorder and anxiety, as well as experiencing delusional thinking and periods of psychosis (a mental disorder in which thought and emotions are so impaired that contact is lost with external reality). C raised a number of concerns, including that the board claimed A was reviewed regularly when they were not, that no psychological support was provided for A, that there was a lack of support from the local mental health team, that there was no clear local treatment plan and that in the care programme approach, needs identified were not met, matters were not escalated and no solution was found.

We took independent advice from a consultant psychiatrist (a medical practitioner specialising in the diagnosis and treatment of mental illness). We found that A's records showed that they received regular reviews during the period in question and that the letters on these showed a high level of clinical input. However, the evidence showed that there was a delay of over five months from the date of A's discharge from psychiatric hospital and the issuing of the discharge letter, which we found was unreasonable and, for a patient with less clinical/multi-professional input and family interaction, would likely have resulted in significant clinical risk.

We found that the overall level of support A received was reasonable. However, we found that there was a lack of focus by the board on the organic elements of A's presentation and how these may have contributed to their psychosis and we were critical of the board's failure to utilise locally available specialist advice which resulted in a lack of psychology and neuropsychiatric input in A's case. We found that these failings were significant and, on balance, we upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C and A for failing to focus on the organic elements of A's presentation and failing to utilise locally available specialist advice on psychology and neuropsychiatry in A's case. 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:

• In cases such as this, the board should consider organic elements of patients' presentations and utilise locally available specialist advice on psychology and neuropsychiatry.
• The board's patient discharge letters should be issued in a timely fashion.

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 provided by the board to their parent (A) whilst admitted at Glasgow Royal Infirmary. A had been admitted with low blood iron levels and a two-week history of back pain, queried to be a spinal fracture of osteoporotic (weakened bones) or pathological (caused by a disease) origin. Following A's admission, they suffered a “controlled fall”. Twelve days later, A complained of being unable to move their legs. An MRI scan of the spine was carried out, which confirmed that A had suffered a fractured vertebra causing spinal cord compression affecting A's ability to move their lower limbs and control bowel and bladder functions. A was subsequently treated conservatively due to their age and comorbidities.

C complained about the circumstances surrounding the fall A suffered and that staff had not recorded details of the incident under the Datix reporting system as required. C considered that A had sustained the spinal injury during this incident and that the lack of Datix report meant that there had been a delay in identifying the injury.

The board accepted that a Datix report had not been completed as required at the time of A's fall but that this had not prevented A from being assessed. The board also stated that a Datix report had been completed retrospectively and that the incident had been reviewed by the hospital falls team. The board stated that it was not believed that A's fall had caused the spinal fracture, which may have been present in advance of A's admission.

We took independent advice from consultants in emergency and general medicine. We found that despite A presenting to the A&E with a queried spinal fracture, no neurological examination was carried out nor was any consideration given to performing an X-ray of A's spine. This was unreasonable practice. In addition, the board's failure to complete a Datix record of the fall A suffered was also unreasonable although it was impossible to say with any certainty that this incident had caused A's spinal fracture.

We found that the board were unable to produce any evidence to show that a Datix record into A's fall had been completed retrospectively or that the incident had been reviewed by the hospital falls team.

In view of the above failings, we upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for unreasonably failing to carry out a neurological examination of A, for not considering whether an X-ray of A's spine was required following their presentation to the A&E at Glasgow Royal Infirmary and for providing inaccurate information in their complaint response. 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:

• In patients who present to A&E with new onset back pain, a neurological assessment should be performed as part of baseline medical examinations. Where the cause of new onset back pain in patients is suspected to be an osteoporotic or pathological fracture, consideration should be given to performing X-ray imaging to investigate the possibility. Any decision not to proceed with X-ray imaging, should be documented in the clinical records.

In relation to complaints handling, we recommended:

• The board should ensure that information provided in response to complaints is factually accurate and that, where the board has confirmed specific actions have been taken in response to a complaint, evidence of this can be 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 complained about the treatment a family member (A) had received from the board. A was admitted to hospital three times over a short period with severe stomach and back pain. Following A's third admission, they were diagnosed with kidney failure and discharged to receive palliative care. A died a short time later. C complained that the board had missed opportunities during A's earlier admissions to identify their deteriorating kidney function. C said that an earlier diagnosis could have prolonged A's life expectancy as treatment could have commenced sooner.

C also complained that on A's second admission, their discharge had been unreasonably managed by the board. C complained that A was left all day in the discharge lounge in their nightwear and that staff failed to properly communicate A's discharge arrangements to the family. A was later returned to their nursing home in a taxi instead of an ambulance. C said that this was extremely distressing and undignified for A, and had been unacceptable given A's age and poor health.

We took independent clinical advice from a consultant geriatrician (a specialist in the care of the elderly). Whilst there had been a reasonable approach to investigating A's symptoms on their first admission, we found that there were missed opportunities by the board to diagnose A's kidney failure and infection, and the family's concerns had not been given appropriate consideration during the second admission. On the third admission, there was a delay in the clinical consideration of A's abnormal blood results, and in recognising the severity of their condition. We also noted from the board's own investigations that there had been a failure to move A's personal belongings between wards. Therefore on balance, we upheld this aspect of the complaint.

We also found that A was not clinically fit to be discharged from hospital following their second admission, and given their age, fragility and poor health, that their discharge arrangements had been poorly managed. These failings included A's lengthy wait in the discharge lounge, and A's transportation in their nightwear via taxi. We further noted from the board's own investigation that A had been discharged with the wrong discharge letter and medication, and that there had been a failure to communicate A's discharge arrangements to the family. As a result, we upheld this aspect of the complaint.

We also provided feedback to the board in respect of their record-keeping, reminding them of the importance of ensuring patient records are detailed and fully documented.

Recommendations

What we asked the organisation to do in this case:

• Apologise to A's family that opportunities were missed to diagnose A's kidney failure and infection, and for not properly taking account of their concerns during A's second hospital admission. 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's family for discharging A from hospital when they were not clinically fit, and for the poor management of A's discharge arrangements. The apology should meet the standards setout in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.
• Apologise to A's family for the delay in the clinical consideration of A's abnormal blood results, and in recognising the severity of A's condition during their third hospital admission. 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:

• Ensure abnormal blood results in a patient's clinical records are followed up appropriately.
• Ensure that relevant staff have appropriately reflected on the complex nature of this case.
• If a patient is elderly, frail or in poor health, patient discharge arrangements should be carefully assessed to ensure that they are appropriate, taking account of discharge wait times, a patient's clothing and methods of transportation.

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 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.