Upheld, recommendations

Summary

C complained about the way that the university handled their complaint.

We found that the university did not communicate clearly with C regarding the procedure being used to investigate their complaint. We also found that the university failed to adhere to their Complaints Handling Procedure (CHP) and the Model Complaints Handling Procedure (MCHP) when determining that all of C’s complaints should not be considered as a complaint under the CHP. As a result of this, C was not kept updated or given a timescale for when the investigation into their complaint was expected to conclude, there was a significant delay of nine months in C receiving a response to their complaint, C was not kept updated with the reasons for the delay in issuing the complaint response and was not provided with a revised timescale. C was also told that they could not approach us to consider their complaint and they were not signposted to this office.

We also found that the university did not respond to the complaints C raised in writing about how the investigation was carried out and that the university’s CHP states that complainants will be expected to complete the appropriate complaint form for complaints considered at investigation stage. This is not a requirement of the MCHP.

Therefore, we upheld C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to communicate clearly with C regarding the procedure being used to investigate their complaint, failing to adhere to their CHP and the MCHP when determining that all of C’s complaints should not be considered as a complaint under the CHP, not keeping C updated or providing a revised timescale for when the investigation into their complaint was expected to conclude, failing to respond to C's written complaints, the significant delay in responding to C's complaint, not keeping C updated regarding the reasons for the delay in issuing the complaint response and not providing them with a timescale for when they could expect a response, telling C that they could not approach this office to consider their complaint and not signposting C to this office in the complaint response. 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 necessary systems should be in place to ensure that complaints are handled in line with the university’s CHP and the MCHP and that all staff responsible for dealing with complaints should be aware of their responsibilities in this respect.
• The university’s CHP should reflect the MCHP.

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 had failed to reasonably maintain and repair their property. We found that there had been delays in carrying out repairs to C’s heating system and windows and that the level of communication about the delays was unreasonable. We also found that C was left without central heating for a period. Therefore, we upheld this complaint.

C also complained that the council failed to maintain an agreed reasonable adjustment that they would not be contacted or visited in the morning. C said that despite complaining to the council about breaches to the agreement, the problem continued. We found that the limited capacity of the council’s systems to record, effectively communicate and implement an agreed adjustment was a significant factor in the council’s failure to provide C with a service in line with the agreed adjustment. Although comments in the council’s complaint files indicated that officers were aware of these issues, it was unclear to what extent, if any, steps were taken to escalate or resolve the issues with the systems. Therefore, we upheld this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the delays in carrying out the repair works and the poor communication in connection with this, and the repeated failure to adhere to the agreed service adjustment. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.
• Once C’s central heating system had been replaced, consider a claim from C for reimbursement of the extra expense they incurred due to the faulty boiler operation.
• Provide C with a schedule for the repair work and temporary rehousing arrangements.

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

• The council should have effective systems in place to ensure that the housing services provided can be adjusted in line with the duty to make reasonable adjustments for disabled customers.
• Where the council have informed a tenant they will carry out repair work, officers should keep the tenant updated about any delays. Tenants must have a satisfactory provision for heating their property.

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 partnership’s handling of a child protection concern relating to their children whereby they were removed from C’s care overnight. The key points to C’s complaint were that the social worker who attended their home did not clearly identify themselves and explain their role, provide adequate information about the options available or their rights, and the children were removed without their consent.

The partnership said they were satisfied that they acted appropriately and within their responsibilities under Section 25 of the Children (Scotland) Act 1995 and that C did not object to the children’s removal.

We reviewed the relevant case records and sought independent social work advice. Our investigation did not find adequate evidence to show that the social worker properly introduced themselves or inform C of their rights. We identified that there was a failure to contact health and education for further information, to contact C the following day, and to interview the children within a reasonable timescale. As such, we concluded the partnership did not follow reasonable process when responding to the child protection concerns raised. Therefore, we upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to follow reasonable process when responding to the child protection concerns raised. 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 should ensure the findings of this investigation have been reflected on and learning is shared with the relevant department.

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 A (an adult who lives as a tenant in supported accommodation provided by the partnership) about the partnership’s communication with A’s welfare guardian (B). A, B and C are siblings.

Following incidents between A and other individuals, B emailed A’s carers to make a suggestion about A’s care. A’s carers responded by email and copied their manager into the email for their information. The care manager subsequently emailed the carers to remark on comments they had made to B but accidently sent a copy to B.

B emailed the care manager shortly after to complain. B considered that the care manager’s email instructed A’s carers to withhold information about A’s care. Neither the care manager, nor the partnership responded to B’s email. C subsequently emailed the partnership to complain on B’s behalf. C reiterated B’s initial complaint. C also complained about the failure to reply to B’s email.

In the partnership’s response, they did not uphold C’s complaint about the contents of the care manager’s email. However, they upheld C’s complaint about the failure to respond to B’s email.

We took independent advice from a social work adviser. We found that the content of the care manager’s email was inappropriate. We considered that the email encouraged A’s carers to reduce the amount of information provided to B specifically to reduce their feedback about A’s care. We also considered that the partnership had failed to adequately investigate B’s and C’s complaint. Therefore, we upheld these complaints.

Recommendations

What we asked the organisation to do in this case:

• Apologise to B and C separately for the care manager’s inappropriate email and for failing to respond to B’s complaint or adequately investigate B’s and C’s complaints. The partnership should also apologise for providing inaccurate information in its previous apology and for suggesting that it was the responsibility of B and C to ensure that they receive responses to issues they raise. The apologies should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.
• The partnership should investigate if any information about A that should have been shared with B has been withheld and, if so, share this with B.

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

• All complaints should be handled in line with the partnership’s complaint handling process.
• Social workers are required to communicate with members of the public in an appropriate, open, accurate and straightforward way.

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 one of their twins (A) at delivery and in the neonatal unit after delivery at Queen Elizabeth University Hospital. C was concerned, in particular, about blood loss at birth, the delay in a blood transfusion being carried out, a delay in blood pressure being taken, record-keeping and communication.

We took independent advice from a consultant obstetrician (a doctor who specialises in pregnancy and childbirth) and a consultant neonatologist (a doctor who specialises in the medical care of newborn infants, especially ill or premature newborns).

We found generally that the evidence in the records showed a safe and appropriate delivery. We found that the blood loss at birth was within the standard parameters for twins delivered by caesarean section, although it is accepted that it was not possible to establish the total blood loss for A. We also found a blood transfusion was carried out within an appropriate timescale. However, A did not have their blood pressure taken until three hours after being admitted to the neonatal unit. We found it would be standard practice for a ventilated and unstable baby on a neonatal unit to take a non-invasive blood pressure reading. The board did not have a policy requiring this. Therefore, we upheld this complaint.

In addition the board accepted their record-keeping during delivery was not of an appropriate standard. They also recognised that communication required to be improved, and they have taken steps to address both of these issues. We identified concerns about record-keeping in the neonatal unit and this has been brought to the board’s attention.

Recommendations

What we asked the organisation to do in this case:

• Apologise to A’s family for the failings this investigation has identified. The apology should meet the standards set out in the SPSO guidelines on apologyavailable at www.spso.org.uk/information-leaflets.

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

Summary

C’s parent (A) had a history of heart problems and suffered a cardiac arrest. Investigations at that time led to a diagnosis of deep vein thrombosis (DVT, a blood clot in a vein). Four years later, A’s heart condition had deteriorated and they were assessed for a possible heart transplant. These investigations indicated severe pulmonary oedema (a condition caused by excess fluid in the lungs) and significant emphysematous changes (emphysema is a condition in which the air sacs of the lungs are damaged and enlarged, causing breathlessness) which meant A was not a suitable candidate for a transplant. The presence of emphysema was previously unknown to A. A died the following year due to heart failure with emphysema listed as a secondary cause. The doctor completing A’s death certificate found mention of mild emphysematous changes in the discharge letter around the time of the diagnosis of DVT. This was the first time A’s family had been made aware of these early findings.

C complained about A’s care and treatment. The board responded that mild emphysema is a very common incidental finding in CT scans of patients, such as A, who are cigarette smokers. The board said the degree of emphysema found was mild and would not have contributed to A’s symptoms or altered the plan for investigation at the time or the care provided to A subsequently. The board gave their view that there was no treatment that could have been offered that would have prevented the progression of the emphysema. The board apologised that they did not provide more information to A about the results of the CT scan at the time and advised that the case had been shared with the cardiology team and the importance of scan results being discussed with patients and recorded in their notes had been reinforced. C was unhappy with this response and brought their complaint to this office.

We took independent medical advice from a consultant in respiratory and general medicine. We found that, although the discharge letter included mention of mild emphysematous changes, emphysema was not included in A’s list of diagnoses and this meant that the board did not reasonably record the findings of the scan in A’s medical records and that a formal diagnosis of emphysema should have been recorded. We also found that A was not reasonably informed of the finding of emphysema or given any of the information recommended in the relevant guidance beyond general smoking cessation advice. While we also noted that stopping smoking was the only effective treatment available for emphysema, what cannot be known is whether a formal diagnosis of emphysema would have had any effect on A’s ability to stop smoking.

We also found that a reduced gas transfer result should have been followed up with a CT scan of A’s lungs. However, this would not have changed A’s treatment or overall outcome.

Overall, despite the board’s failures, C received treatment compliant with relevant guidance and these failures did not materially impact the subsequent progression of the disease or A’s eligibility for a heart transplant. On balance, however, we upheld the complaint that the board’s treatment of A unreasonably failed to take into account the finding of mild emphysematous changes in A’s early scan.

Recommendations

What we asked the organisation to do in this case:

• Apologise to A’s family for the specific failings identified. The apology should make clear mention of each of the failings identified and 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:

• Relevant board staff are aware of the relevant guidance in respect of incidental findings of emphysema on CT scans and of the need to follow up significantly reduced gas transfer results with a CT scan of the lungs.

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 practice refused to provide their late parent (A) with an in-person GP appointment. A had a history of lung cancer which had been treated with radiotherapy (a treatment of disease, especially cancer, using high-energy radiation) previously. A contacted the practice by phone to report pain in their right leg and buttock. A was not seen in-person due to COVID-19 guidance, however a telephone consultation was arranged. The consulting GP considered that A’s symptoms likely resulted from sciatica (back and leg pain caused by irritation or compression of the sciatic nerve) and prescribed treatment for this. Further phone consultations followed with the GP and others at the practice on four other occasions. The consultations consisted of a mixture of planned contacts by the GP and unplanned contacts by A. C later contacted the practice and expressed concern that A’s condition had not improved. C asked for A to be seen in person. A was seen by a GP that day. A’s case was discussed with an oncology (cancer) nurse specialist. It was agreed that A’s condition required further investigation. A was subsequently referred to an oncology clinic and was diagnosed with metastatic lung cancer. A died the following year.

We took independent advice from a GP. We found insufficient evidence to suggest that the practice had refused any request from A for an in-person appointment. However, we did find that there had been a unreasonable delay in providing A with an in-person appointment. On consideration of relevant guidance, the clinical record and specialist advice we found that A should have been seen in-person on the third contact they had with the practice. We considered that the delay in providing A with an in-person appointment was brief and were unable to conclude that the delay had a material impact on A’s prognosis.

In the circumstances, we upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C that there was an unreasonable delay in providing A with a face-to-face appointment. 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 findings of this investigation should be fed back to the staff involved, 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 provided to their late spouse (A) who had a history of superficial bladder cancer (early bladder cancer when the cancer cells are only in the inner lining of the bladder and has not spread beyond it) and prostate cancer. C complained about the care and treatment provided during two short admissions to Borders General Hospital. A was passing blood in their urine and had unexplained pain. C specifically complained that A was not thoroughly assessed and that further investigations should have been carried out. A chest x-ray was later performed which identified a shadow on A’s lung. A’s condition deteriorated and they died a few weeks later.

The board confirmed that they considered the care and treatment provided to be reasonable and that there was no suggestion at the time to indicate that further tests were necessary.

We took independent advice from a consultant uro-oncologist (a specialist in diagnosing and treating cancers of the male and female urinary tract and the male reproductive organs) with a speciality in dealing with bladder and prostate cancer. We found that there was a failure to take the appropriate action in response to the findings of a previous cystoscopy (bladder examination using a narrow tube-like telescopic camera) which showed a thickened bladder, and that during the first admission it was incorrect to state that the findings of this procedure were normal. We also considered that the board failed to fully investigate the cause of A’s bleeding, nor the thickened bladder, and that not enough regard was given of A’s deterioration. We upheld the complaints, concluding that these failings led to a delayed diagnosis of A’s cancer. However, we acknowledged that these failings did not impact on A’s ultimate prognosis.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the identified failings. 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:

• Staff should fully understand the importance of taking into account the patient’s medical history, accurately report on previous test results and ensure that symptoms are fully investigated.

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) that the council had unreasonably failed to handle a request for kinship care assistance. A assumed care of their grandchildren and applied for and was granted a residence order. A one-off payment along with weekly payments were paid by the council. While a kinship assessment was commenced, it was approximately three years later before A was told that they were not an approved kinship carer and that the weekly payments would be stopped.

C complained to the council that the decision to stop the weekly payments was unreasonable and that A had been treated poorly by the council. In addition, C complained that the kinship assessment had restarted three times with three different social workers which had made this a distressing process for A. Also, the grandchildren were incorrectly not being recognised as being ‘at risk of becoming looked after’.

We took independent advice from an adviser with a background in social work and children and family services. We found that there were significant delays in concluding the kinship assessment which had not adhered to the timescales set out in the Guidance on the Looked After Children (Scotland) Regulations and the Adoption and Children (Scotland) Act 2007. We also found that the outcome had not been communicated to A as per this guidance. While it is for the council to determine whether or not a child is at risk of becoming looked after, we accepted the advice we received that, in this case, the council had failed to evidence that they carried out a sufficient level of assessment to conclude whether or not A’s grandchildren were at risk of becoming ‘looked after’. In addition, we found that the council had failed to carry out an in-depth assessment of the family’s circumstances, particularly the six months before the residence order was granted, under the terms of the National Guidance. Finally, we found that the council’s communication with A was unreasonable.

For the reasons detailed above, we upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to A for the failings identified by the investigation. 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 council should reconsider the situation at the time it was first presented to them, with respect to whether the children were at risk of being accommodated (as outlined by Section 71 (5) (a) of the Children and Young People (Scotland Act 2014) given there was no legislative security in place for them against a father who was alleged to be a risk to the children and who had parental rights and responsibilities that A did not have. Depending on the outcome of the above reconsideration the council should reassess whether there is a requirement to now carry out a kinship assessment. A should be notified of the outcome. The council should consider revisiting the robustness of assessment and risk assessment and how this is quality assured to ensure that the right questions are being asked at the outset and that ongoing assessments are addressing the issues such as those highlighted by the Kinship Panel.

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, who had a history of cancer, attended a medical practice, for which the partnership was responsible, with various non-specific symptoms. The practice made a working diagnosis of polymyalgia rheumatica (a condition that causes pain, stiffness and inflammation in the muscles around the shoulders, neck and hips) and a trial of steroids was commenced. Around five weeks later, A was referred by the practice for an ultrasound scan with a query of malignancy, which found metastatic (spread of cancer from the primary tumour) disease in the liver and a bladder mass. The practice referred A to the urology department (a specialty in medicine that deals with problems of the urinary system and the male reproductive system) at a local hospital. However, A’s cancer had progressed and no further treatment could be provided. A died a short time later.

C said that the practice should have considered the possibility of a cancer recurrence much sooner before trialling steroids to treat possible polymyalgia rheumatica. C also complained that the practice had not informed A of the results of the ultrasound scan and disputed the practice’s claim that C’s sibling had been informed. C further complained that the practice should have been aware of delays in A’s treatment following referral to secondary care and taken steps to expedite the treatment.

In response, the partnership stated that there had been no delay in requesting appropriate scans and said that A had received the best possible care the practice could offer during A’s illness. The partnership also stated that the records showed the practice had discussed A’s care with C’s sibling in their capacity as power of attorney.

We took independent advice from a GP adviser. We found that, while it was reasonable for the practice to commence a trial of prednisolone (medication used to treat a wide range of health problems including allergies, blood disorders, skin diseases, infections and certain cancers) to treat the working diagnosis of polymyalgia rheumatica, the lack of immediate improvement should have made the practice consider another diagnosis. Given A’s history of cancer, we considered that referral for ultrasound should have happened sooner. We also could not find any record confirming that A had been informed of the results of the ultrasound scan nor that C’s sibling had been informed. However, we did not consider that there was any responsibility on the practice to send any reminders to secondary care about A’s treatment, given no specific concerns had been raised about this.

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 inform A that the ultrasound scan performed showed possible liver metastatic disease and failing to refer A for an urgent ultrasound or CT scan to investigate the possible recurrence of cancer.
• Apologise to C for the unreasonable delay in responding to their complaint, for not providing updates or an explanation for the delay or when a response could be expected, and for not responding to their additional correspondence. 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 practice should give consideration as to where improvements could be made to their practice to ensure that cases of possible recurrent cancer are investigated as soon as possible.
• The relevant clinicians should be reminded of the need to ensure that patients should be kept fully informed about their diagnosis and involved in decisions about their treatment and that patients are presumed to have capacity to make decisions about their treatment. If it is considered that a patient is unable to understand and/or retain information given to them, an assessment of capacity should be carried out.

In relation to complaints handling, we recommended:

• The partnership's complaint handling governance system should ensure that responses to complaints are in line with the NHS Scotland 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.