Upheld, recommendations

Summary

C complained to the board about surgery they received on a semi-urgent basis. C complained that the surgery had been inadequate and that they had been unable to fully consent to it due to time pressure and a lack of information. C also complained that the board’s subsequent management of their pain medication was unreasonable. In particular, C complained that they had not been informed of the potential for opiate pain relief to become habit-forming. The board responded that the surgery had been performed correctly and that a lengthy consultation had been held with C prior to surgery by the operating consultant neurosurgeon (a surgeon who specialises in surgery on the nervous system, especially the brain and spinal cord).

We took independent advice from a consultant neurosurgeon. We found that the surgery had been performed to a reasonable standard and that the board’s management of C’s pain medication was also reasonable.

However, we identified a lack of records illustrating any discussion with C about the potential benefits, risks or complications of surgery prior to the operation. We also identified a lack of records illustrating any discussion with C regarding the potential for opiates to become habit-forming.

In the absence of such records we were unable to say whether C received appropriate information. Therefore, on balance, we upheld both complaints.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C that there was no contemporaneous evidence that C was reasonably informed of the potential risks and complications of surgery or of the potential for morphine to become habit-forming. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

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

• There should be complete records of discussions with patients about the potential risks and complications of surgery prior to surgery.
• There should be records of discussions with patients regarding the potential for morphine to become habit-forming.

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 brother (A). A’s consultations with the practice took place when COVID-19 restrictions were in place and as such, a number of their appointments were held via phone.

A had been complaining of a persistent sore throat and tongue. A also said that they had been reporting a lump in their neck. A was referred to the Ear, Nose and Throat (ENT) department and was diagnosed with oropharyngeal cancer (a type of cancer that begins in the cells of the tonsils). C complained that there was a delay in referring A to ENT for further investigation.

We took independent advice from a GP. We found that there was a poor standard of record keeping by the practice. The records did not always demonstrate that an adequate medical history was obtained or that adequate safety netting and follow-up advice was provided. We also identified that the wrong antibiotics were prescribed on one occasion and that the wrong test for glandular fever was performed. We were concerned that the practice’s own investigation of the complaint did not identify any of these failings.

We considered that there was likely a delay of 15 days in referring A for further investigation. While this was not significant, in light of the other failings identified, we upheld the 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:

• The medical centre should ensure that staff are confident and knowledgeable in carrying out physical examinations.
• The medical centre should ensure that the Significant Event Analysis addresses both clinical care and treatment and internal processes.
• The medical centre should ensure the standard of record-keeping meets General Medical Council Good Medical Practice standards.
• The medical centre should have a policy to review their cases or seek medical advice, especially when several consultations occur and the case is non-responsive or atypical.

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 council's social work involvement with their child (A). A had a range of conditions that affected their development and behaviour. A was placed in residential care and was made subject to a legal order via the children's hearing system.

A was transitioning out of children's services and into adult services. C raised a number of concerns with the council about the support provided by the council when arranging A's transition. Whilst the council upheld aspects of C's complaint, C remained dissatisfied with the council's response and brought their complaint to us.

C felt that some aspects of the council's response were unclear, that they had not taken responsibility for what had gone wrong, and that they misunderstood some of the family's concerns.

We took independent advice from a social worker. We found that the council could have done more to facilitate clear communication with C and to involve C in A's care planning and assessments. We also found that the council unreasonably excluded C from certain aspects of the decision-making process for A. We upheld all of C's complaints.

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:

• Social work staff should allow enough time to carry out the appropriate planning and assessment work, consider if a capacity assessment should be sought at an early stage, and take a holistic view of the needs of the young person and their wider support networks.
• Social work staff should take into account the young person's wishes about their family's involvement in the decision-making process. Social work staff should meet with families to discuss and address any issues prior to children's hearing/review meetings and try to agree a course of action to present to the Children's Panel/review officer.
• Social work staff should endeavour to use emails to contact clients/their families, when that is their preference, as it is more effective and efficient than corresponding by post.
• Unless there is good reason not to, social work staff should arrange a face-to-face meeting or a phone call to discuss sensitive matters, rather than communicating the information in writing.

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 the owner of nurseries which provide childcare. During normal operation, C receives funding to provide an amount of childcare hours to parents without charge as these are funded by the Scottish Government. During the COVID-19 pandemic, the advice was for childcare providers to close their businesses unless they were providing critical childcare for keyworkers. C closed their businesses during this time.

When arranging to reopen their business, C sought advice from the council on whether or not C can or should charge parents for critical childcare. The council told C that critical childcare should be free at the point of delivery and that C should not charge parents, however, they also advised that C could charge in certain circumstances. The council told C that they should use funding they received during the lockdown to cover costs when the nurseries reopened. C felt that the advice they received was in contradiction to advice that they received from the Scottish Government.

C had previously raised a complaint with the council about funded hours (prior to the impact of the pandemic) and, in light of this, when C complained about the advice they were given, the council decided that the complaint should not be investigated via their complaints handling procedure. This office took an early view and asked the council to investigate the complaint and provide a further response. After a further response was issued, C remained dissatisfied and brought their complaint to us.

We found that the advice given by the council was, at times, contradictory and did not appear to be in line with the guidance issued by the Scottish Government. We also found that the council did not appropriately investigate C's complaint at the time it was raised, or when this office asked them to undertake further work.

In light of this, we upheld C's complaints.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for providing unclear and conflicting information about the right to charge parents fees, and for the failure to investigate C's complaint appropriately when it was initially submitted and when asked to do so by this office. 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 ensure that advice given is clear, consistent, and in line with the relevant guidance, policy or procedure.

In relation to complaints handling, we recommended:

• The council should ensure that complaints are recognised, logged, and responded to in line with the Model Complaints Handling Procedure (MCHP). When this office asks the council to carry out further work on a complaint, they should ensure that they respond in line with our request. When required to carry out further investigation, the council should ensure that the complaint is logged and responded to in line with the MCHP. If the council is unclear what this office is asking them to do, they should engage with us to clarify prior to beginning any further work. When the council receives complaints about specific members of staff, they should ensure these are investigated in line with the MCHP, paying particular notice to the guidance on investigation and who should investigate/respond to a complaint (i.e. someone not involved in the complaint).

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 client (A) that the council had unreasonably failed to provide A with kinship care assistance, including financial support. A became the carer to their family member (B) when B's parent was unable to care for them.

We took independent advice from a social work adviser. We found that a number of contemporaneous records were missing. The record-keeping failures in this case mean that there is no record of whether the council have met their legal and procedural obligations. In particular, there is no definitive record of whether a Section 25 order was signed and rescinded or why the decision to carry out a comprehensive assessment and refer to the Children's Reporter was not followed through.

We found that these record-keeping failures had left the family in an unreasonable position where there is difficulty corroborating what happened and therefore placing them at a disadvantage in terms of accessing a kinship care assessment and any appropriate allowances. In the absence of records, we considered that the council had unreasonably failed to take sufficient account of the evidence available from the family and the social worker involved at the time (both of whom indicated that a Section 25 order was signed). Based on the evidence available, we considered that it was likely that a Section 25 order was signed and at that point B became a looked after child which means they became an eligible child in relation to kinship care under the Children and Young People (Scotland) Act 2014. We also noted that the Kinship Care Assistance (Scotland) Order 2016 extended the definition of an eligible child to include a child who was previously looked after.

In light of the above, we considered that the council failed to provide A with reasonable kinship care assistance. As such, we upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to A for failing to maintain case records regarding A and B's involvement with social work, failing to take sufficient account of the evidence available which indicated that a Section 25 order was signed, making B a looked after child and an eligible child in in relation to kinship care. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.
• Complete a kinship care assessment, in line with relevant guidance, in respect of A's care of B. As far as possible, consideration should be given to the evidence available indicating that a Section 25 was signed, making B a looked after child and the circumstances of the household when the assessment should have originally taken place (not just the current circumstances). If, following the assessment, the council is satisfied of eligibility, consideration should be given to the backdating of any kinship allowance to when it would have commenced had the council appropriately considered the evidence available indicating that a Section 25 was signed.

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

• Where written records are not available due to a failure in record-keeping, information from families and social work staff should be appropriately taken into account.
• Written case records should be appropriately maintained and retained in accordance with relevant legislation and guidance.

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 advocacy worker, complained on behalf of their client (A) in relation to the council's decision not to make payment of kinship care allowance in respect of children in A's care. C stated that A was entitled to receive kinship care allowance on the basis that both children, whom A had been caring for following the death of a parent, had initially been looked after by the council given that the children's surviving parent had agreed to transfer responsibility for their care to the council immediately following the other parent's death. A had also secured residency rights in respect of the children by obtaining an order under section 11 of the Children (Scotland) Act 1995, which C stated was to be considered as a kinship care order in terms of the Children and Young People (Scotland) Act 2014.

In response, the council stated that, while the agreement of the children's surviving parent had been sought to transfer their care to the council after the death of the other parent, it had ultimately not been necessary to proceed on this basis given that A had stepped forward to care for the children almost immediately. Accordingly, the children had never been formally looked after. In addition, the council stated that A and the children's extended family had chosen to look after the children themselves on a private basis without the need for further input from the council's social work department. For these reasons, the council considered that A was not entitled to receive kinship care support.

We took independent advice from a social worker. We found that A had stepped forward to care for the children within a matter of hours of the council seeking the children's surviving parent's agreement to transfer their care to the council. We agreed with the council's position that it had ultimately not been necessary for them to proceed further in this regard and, accordingly, the children had never been formally looked after by the council. We further agreed that A and the children's extended family had also decided to look after the children on a private basis without the need for further social work input. However, we considered that A had agreed only to care for the children on a temporary and emergency basis until the wider family had been able to decide on how the children should be cared for. Accordingly, a period of around three weeks had passed between A stepping forward to care for the children and the decision being taken by the family to care for them on a private basis, during which time it was not certain that A would agree to care for the children on a full-time basis.

We also noted that the council had remained actively involved in decisions about the children's welfare during this period. For these reasons, there was evidence to suggest that the children had been at risk of becoming formally looked after and that the council should have treated A as an informal kinship carer during the three week period, providing them with the appropriate financial support. We further noted that, as A had subsequently obtained an order under section 11 of the 1995 Act, it would be open to them to make an application to the council to be assessed as a kinship carer. We considered that the council's case records did not clearly show the justification for decisions that had been made and that there was evidence to suggest that the council had failed to carry out necessary checks prior to placing the children with A, as set out in the council's own policies. We also found that the council had failed to handle C's complaint in accordance with the relevant complaints handling processes in place at the time.

For these reasons, we upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to A for failing to assess A regarding the need to provide support and financial assistance under section 22 of the Children (Scotland) Act 1995 or section 50 of the Children Act 1975, failing to communicate reasonably with A in respect of the legal basis on which the children were residing with A and thereafter, and failing to handle the complaint made on behalf of A in accordance with the Social Work Model Complaints Handling Procedure. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.
• Calculate the amount of financial assistance that A would have been entitled to receive for the period specified and make payment of this amount to A.
• Advise A how they can make an application to be assessed as a kinship carer. Should it be decided that A is entitled to kinship care assistance, the council should also give consideration to whether this should be backdated, in view of the fact that A was not advised that they could make such an application when C made known A's wish to be considered as a kinship carer.

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

• The council should ensure that the checks set out within their Looked After Children procedures are carried out prior to agreeing to children being cared for by adults with whom they are unfamiliar, unless there is clear evidence why the checks are not required.
• When decisions are made about the long-term living arrangements for children with whom the council's social work department has been involved, the council should ensure that all parties are sufficiently clear as to the legal basis on which those arrangements have been made.

In relation to complaints handling, we recommended:

• Complaints should be handled in line with the Local Authority Model Complaints Handling Procedure, which can be found here: https://www.spso.org.uk/the-model-complaints-handling-procedures.

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 sibling (A) about the treatment A had received from the Golden Jubilee National Hospital. A had emergency surgery to repair a dissected aorta (a tear in the heart) and a pacemaker fitted. Following A's surgery, they suffered a ventricular fibrillation (abnormal heart rhythm) resulting in cardiac arrest. It was later established that A's ventricular fibrillation had been caused by an incorrectly programmed pacemaker. C complained to the hospital about how this could have occurred.

We took independent advice from a cardiologist (a doctor who can diagnose, assess and treat patients with diseases and defects of the heart and blood vessels). We found that A's external pacemaker had been incorrectly programmed and there was a failure to manage the resulting R on T event (when the temporary pacemaker delivers an electrical impulse to the heart at an inappropriate time causing an abnormal rhythm) leading to A's cardiac collapse. We found that the hospital had failed to provide A with a reasonable standard of treatment and upheld this aspect of C's complaint.

C also complained that following A's cardiac arrest, A was discharged too early from hospital and had not been provided with clear information regarding their cardiology rehabilitation and aftercare, resulting in a delay in A receiving appropriate follow-up appointments.

We found that A's post-surgical out-patient review had been delayed by seven weeks without explanation. We also found that the hospital's post discharge communication practice had contributed to the delay in A receiving appropriate cardiology follow-up and cardiac rehabilitation from their local health board. While we found that A's discharge was reasonable, the hospital had failed to provide A with appropriate cardiology aftercare. On balance, we upheld this aspect of C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to A and A's family for contributing to the delay in A receiving appropriate cardiology follow-up and cardiac rehabilitation. The apology should meet the standards setout in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.
• Apologise to A and A's family for incorrectly programming A's external pacemaker and for failing to manage the resulting R on T event leading to A's cardiac collapse. The apology should meet the standards setout 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 all junior medical staff rotating through ITU/HDU are trained in temporary pacemaker programming and troubleshooting.
• Ensure appropriate post discharge communication pathways are in place to ensure patients receive timely follow-up from their local health board.
• Ensure post-surgical follow-ups are timely and in line with discharge summary.

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 at Perth Royal Infirmary after falling and injuring their wrist. C complained that the care and treatment they received was unreasonable and as a result, they had been left with continuing pain and loss of function in their wrist for which they are awaiting surgery.

We took independent advice from a senior nurse practitioner, a consultant radiologist (a doctor who specialises in diagnosing and treating disease and injury through the use of medical imaging techniques such as x-rays and other scans) and a consultant orthopaedic surgeon (a specialist in the treatment of diseases and injuries of the musculoskeletal system).

In relation to C's initial attendance at A&E where they were seen by a nurse practitioner (NP), we found that the NP recognised from their clinical assessment that C may have sustained a fracture to their wrist and appropriately had the wrist x-rayed. However, it was recorded in C's clinical notes that the x-ray showed no bony injury, which indicated the NP had wrongly interpreted the x-ray as being normal. However, the discharge letter from A&E to C's GP stated a different diagnosis suggesting that the fracture was identified. We only received an explanation from the board for the conflicting diagnoses, which was that the NP had made a mistake in recording there was no bony injury, at a late stage in our investigation. We noted that the treatment the NP provided to C in referring them for an x-ray and making a referral to the virtual fracture clinic was appropriate.

We found that the doctor who later reviewed C's case at a fracture clinic correctly identified that C had sustained a fractured wrist. However, the board accepted that C should have been referred to see an orthopaedic consultant at an earlier stage. We noted that the board had apologised to C for this and taken action to address what occurred.

Finally, we found that given C's medical history and their significant medical co-morbidity, it was reasonable to take a conservative approach and to not perform surgery at the time.

Taking into account all of the evidence and the advice we received, on balance, we upheld C's complaint.

It was clear from our investigation of C's complaint that the board's own complaint investigation did not address the issue of the interpretation of the x-ray in relation to C's attendance at A&E. This was despite C raising this specifically in their complaint to the board. We also considered that it was a failure in complaint handling that A&E only learned about C's complaint after this office issued the draft decision on the complaint, and we were only provided with an explanation for the conflicting diagnoses recorded in C's clinical records at a late stage in our investigation. We made a complaint handling recommendation to address this.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the conflicting diagnoses recorded and the failure by the board in their complaint handling in relation to C's attendance for a wrist fracture. 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:

• Information regarding a patient's diagnosis should be accurately recorded in their clinical records.

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 board failed to provide their child (A) with reasonable care and treatment. C understood that A had a condition known as paediatric acute-onset neuropsychiatric syndrome (PANS) or paediatric autoimmune neuropsychiatric disorder associated with streptococcus (PANDAS, infection-induced autoimmune conditions that disrupt children's normal neurologic functioning). A had been given intravenous immunoglobulin (IVIG, the use of a mixture of antibodies to treat a number of health conditions) treatment but this had been discontinued and stopped suddenly. C stated that the treatment should not have been stopped and wanted this treatment to be available to A in the future if A needed it.

We took independent advice from a consultant neurologist (a specialist in the diagnosis and treatment of disorders of the nervous system). We found that the treatment was not suitable for A and the possible diagnoses for A's condition. We considered that it was appropriate the treatment stopped. However, we noted that it should never have been given as a treatment at any stage. We also found that the board sent spinal fluid for testing to a laboratory in England that did not arrive there. While this was not the outcome C was seeking, we upheld the complaint on the basis that IVIG should not have not have been given to A at all.

Recommendations

What we asked the organisation to do in this case:

• Apologise to A for putting in place a treatment plan for intravenous immunoglobulin (IVIG) when this was not an appropriate 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:

• Ensure clinical staff are aware of the circumstances in which IVIG is an appropriate treatment.
• Ensure insofar as possible, that a similar situation with fluid sent for testing does not arise in future.

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 failed to appropriately investigate their urinary symptoms over a two-month period; in particular, that they failed to take blood tests and arrange a prostate check. C was later admitted to hospital with an acute kidney injury and urinary retention.

We took independent medical advice from a GP, who considered that the practice had unreasonably failed to examine C's prostate in light of their persistent urinary symptoms and repeated negative results for infection. Therefore, we concluded that there was a failure to reasonably investigate C's urinary symptoms and we upheld this complaint. However, the practice provided us with evidence that reflection and learning had already taken place through a Significant Event Analysis and we were satisfied that appropriate learning had been demonstrated. We recommended that the practice should apologise to C for the identified failings but made no further recommendations.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to examine their prostate in light of their persistent urinary symptoms and repeated negative results for infection. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

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