Upheld, recommendations

Summary

C complained that there was an error in carrying out their child (A)'s dental surgery at the Royal Hospital for Children. A had been referred by an orthodontist (medical professional dealing with the prevention and correction of irregular teeth) to have two teeth removed. C raised concerns that they had removed the wrong tooth (A's front tooth) and left in the two teeth they were supposed to remove.

The board said that their oral and maxillofacial surgery clinicians (OMFS, specialists in treating diseases and injuries of the mouth and face) had appropriately reviewed A's original treatment plan. The board explained that their OMFS clinicians had tried to contact the orthodontist to explain that A's original treatment plan was not clinically possible.

We took independent advice from a consultant OMFS. We found that A's treatment plan should not have been changed without consulting the referring orthodontist and agreeing the changes with them. We found that the clinical rationale for changing A's treatment plan was not clearly recorded. We also found that the changes were not communicated clearly enough to C and A in a manner that they could understand. We upheld C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failings identified in A's 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.

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

• Patients should be given complex information in a way that they can understand and clinicians should check their understanding.
• The reasons for clinical decisions should be clearly recorded. This includes recording any discussions with senior staff that inform clinical decisions.

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 nursing care that they received whilst an in-patient at Forth Valley Royal Hospital. C complained that during their stay in the hospital there were errors in the administration of their medication and that they were manhandled by a member of staff when trying to get out of bed. They also said that there was a delay in providing pain relief after this incident.

We took independent advice from a nursing adviser. We found that, overall, the care given to C with regards to moving and the handling of pain control was reasonable. However, while we found no evidence that their medication dosages were incorrect and we were satisfied that C's medication was given as appropriate, there was an occasion when a prescribed dose of morphine was not recorded as being given. While we had no reason to doubt C's recollection of events which had led to them complaining they had been manhandled, there was no record of the incident in the clinical records and the staff member's recollection was different to C's account of what happened. However, C's pain score had not been checked at this time and had it been checked, this may have shed a light on the matter. We found that the failure to record C's pain score was unreasonable.

On balance, because of the failure to administer all C's morphine doses as prescribed and because of the failure to record C's pain score, we upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failure to administer slow acting morphine as prescribed or record the reason why it was not given and for failing to record pain scores on the morning specified. 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:

• Pain scores should be recorded appropriately and in a timely manner.
• All medication prescribed should be recorded as being given or where medications are not administered, reasons for this should be documented.

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, who is a solicitor, complained on behalf of their client (A). A lived alone and received 24-hour care from a private company in their adapted home. A's home care provider notified the partnership that they were withdrawing their services to A. When this happened A had to go into residential accommodation. B, who is A's parent, said that the residential accommodation was unsuitable. C complained about this and then complained to our office about a delay in receiving a response to that complaint. Our office made a discretionary decision to progress the complaint in light of significant complaint handling delays. We decided to consider the substantive matters, as well as the complaint handling process.

We sought independent advice from a social work adviser. A had a support needs assessment (SNA) and an outcome based support plan (OBSP) carried out by the partnership. We found that the assessment should have considered all options under Self Directed Support (SDS) legislation, however option one, direct payments, had not been explored. We found that there were significant delays in responding to the complaint. The partnership's information about what they would and would not consider a complaint was unhelpful. We upheld both complaints.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C and A for not considering all options under SDS legislation. Apologise to A directly for the delay in responding to the complaint. Confirm that any future assessment of A's needs will include consideration of all SDS options. 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:

• Remind staff of the importance of considering all options under SDS legislation.

In relation to complaints handling, we recommended:

• Complaints should be handled in line with the Model Complaints Handling Procedure. Complaints should be responded to within 20 working days or, where this is not possible, adequate explanation must be given alongside a reasonable timescale for the response.

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

Allegations were made against C that they entered into inappropriate financial arrangements with clients to whom they provided homecare services. C complained about the way that the partnership conducted the investigation into those allegations and the impact this had on them and their business.

In terms of the Adult Support and Protection (Scotland) Act 2007 Code of Practice (the Code of Practice), we found that the partnership had a clear responsibility to determine whether service users of C's company were at any risk when dealing with C. Any investigation into the actions of C or their staff would be matters for the Scottish Social Services Council (SSSC) or the Care Inspectorate.

We considered that when the partnership were made aware of the allegations against C, they quickly commenced inquiries with C's clients under Adult Support and Protection legislation, and in line with the Code of Practice. These inquiries led them to conclude that there was no immediate risk to the service users and no further action was necessary. However, given the nature of the allegations and advice from the police, the partnership considered it appropriate to notify the SSSC and the Care Inspectorate. We found this to be reasonable.

It was the SSSC, rather than the partnership, that investigated the allegations against C and accordingly we would have expected the SSSC, rather than the partnership, to notify C of these allegations and seek evidence from them. That said, we considered the partnership's communication with C could have been better and that a lot of correspondence could have been avoided, had the partnership explained their role and the decisions they make more clearly to C from the outset. On balance, we upheld C's complaint.

During our investigation, the partnership told us that they had learned from what occurred with C. They explained they had set up a joint operational Social Work, Adult Support and Protection, Care Inspectorate and Police sub-group to provide a forum for the sharing of information, assessment of risk, and agreement of actions, leads, timescale and communication. We also noted that the partnership were in the process of updating their Adult Support and Protection Large Scale Investigation Procedures, which they said should formalise these arrangements. We welcomed this action.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failings identified in their communication with C. 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.

Summary

C and their late spouse adopted a number of siblings outside of their local authority area. C complained about the lack of post-adoption support provided by the partnership, including lack of adoption support plans and lack of support provided to C and the children during C's spouse's diagnosis with terminal illness and subsequent death. C also raised concerns regarding the impact the lack of support had on the adoption. C further complained about communication and issues regarding documentation recording.

We took independent advice from a social work adviser. We found that the partnership failed to meet its legal and regulatory obligations across a number of areas, including case recording and documentation, supervision visits, and the provision of Adoption Support Plans when this was requested by the adoptive parents. We found that exceptional support was identified as being needed for this family and the partnership failed to provide this. We considered that the partnership's failure to provide adequate support to the family was likely to be a contributory factor to the breakdown in the adoption. We also found that some communication between the partnership and C was unreasonable. While later communication was more reasonable, there was a lack of awareness of the impact of the failure in service at the start of the placement on the relationship, and we considered this to be unreasonable. As a result, we upheld this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to maintain a reasonable level of contact and support with them and their 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:

• Adoption Support Plans should be reviewed, particularly when there have been major changes, in line with the relevant legislation.
• Children should be visited within one week of placement and as deemed appropriate thereafter until adoption is granted in line with the relevant legislation. Recordings of these visits should be made. (Adoption and Children (Scotland) Act 2007, Regulation 25/27 of the Adoption Support Services & Allowances (Scotland) Regulations 2009).
• There should be adequate communication at all times during a fostering and adoption placement that is appropriate, open, accurate, and fully takes into account the needs of the placement.
• The provision of Adoption Support Plans should be considered in line with the relevant legislation and guidance and this should be appropriately documented.

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 child (A) was born with a rare congenital condition where the urethra does not develop properly and underwent reconstructive surgery as a baby. A's doctors said that A had a 60% chance of being dry by the age of ten but would need further surgery when they are older. A had been potty trained, and no longer wore nappies, however they experienced incontinence leaks during some activities. A's health visitor referred A to the board's incontinence service to receive continence products.

The board's continence service said A did not meet the criteria for continence products as they had not reached the age of four, as per the guidance for the provision of continence containment products to children and young people. C complained that A was eligible under the guidance after two years of age, given A's disability. C also complained that the decision on A's eligibility was made against advice of the health professionals working with A.

We took independent advice from a paediatric nurse. We found that the guidance says children under four would not normally be given continence containment products, however this could be considered where continence issues are as a result of a child's disabilities. We also found that the board failed to complete a comprehensive paediatric continence assessment in A's case. We were also critical that the board did not take in to account the clinical opinion of the health professionals working with A. As a result, we found that the board did not reasonably assess A's eligibility for containment products and upheld this element of the complaint.

C also complained that the board's handling of their complaint was unreasonable. We found that the final complaint response was issued without taking into account the comments from A's GP. Additionally, we found that the board did not handle C's complaint in line with the NHS Model Complaints Handing Procedure (MCHP). As a result, we upheld this element of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apology 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.
• Assess A's eligibility for containment products in accordance with the guidance.

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

• Children and young people should be assessed for containment products in accordance with the guidance, including carrying out comprehensive paediatric continence assessments when indicated.

In relation to complaints handling, we recommended:

• Complaints should be handled in line with the NHS 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 about the board's management of a retinal detachment (when the thin layer at the back of the eye becomes loose) and other issues affecting their eye. C attended hospital with a small hole in the centre of the retina and subsequently attended a number of appointments with the board's ophthalmology department (specialists in the study and treatment of disorders and diseases of the eye). Due to the condition of C's eye, a “watch and wait” approach was taken.

C later experienced a deterioration in their eye and attended an emergency clinic. A scan was carried out and C was discharged home on the basis that the eye remained stable. C was concerned that the examining consultant did not carry out additional tests or provide any treatment in light of the deterioration in their vision. C travelled abroad on holiday the following month and their eye deteriorated further. They attended a local ophthalmologist who identified a full retinal detachment. C underwent retinal reattachment surgery.

C complained that the retinal detachment should have been diagnosed at the emergency appointment and that, had it been diagnosed, they would have undergone surgery, avoiding the expense of private treatment abroad.

We took independent advice from a consultant ophthalmologist. We found that changes to the eye were visible on the scan taken at the emergency appointment. We considered that this should have led to a more detailed examination of the eye and that a retinal detachment would likely have been identified at that point. We upheld C's complaint. However, even if a retinal detachment had been identified at that point, it would have been a matter for the professional judgement of the surgeon as to whether surgery was advisable. It would not have been unreasonable for the surgeon to have advised against surgery, given the condition of C's eye and the risks association with surgery.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to identify and act upon the changes visible when they attended the emergency clinic. 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:

• Share this decision with the staff involved in C's treatment with a view to identifying ways of avoiding similar problems for future patients.

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 to us on behalf of their client (B) about the care and treatment provided to their child (A). Over a ten-year period, A had several referrals to the board's children and adolescent mental health services (CAMHS) on both a routine and emergency basis. C raised various concerns, in particular about delays in diagnosing A and that A was not admitted for in-patient psychiatric treatment following incidents of self-harm or attempted suicide.

We took independent advice from an adviser in child and adolescent psychiatry. We found that aspects of A's care and treatment were unreasonable. In particular, we found that there was an unreasonable delay in assessing A for adult attention deficit hyperactivity disorder (ADHD, a behavioural disorder that includes symptoms such as inattentiveness, hyperactivity and impulsiveness); that A was given an emergency assessment that fell below a reasonable standard; the other professionals involved in A's care did not have a clear understanding of the level of input they could expect from CAMHS; and that there was a lack of evidence CAMHS tried to adapt their approaches to better engage A. We upheld the complaint.

In relation to complaint handling, the board provided us with additional electronic records when they responded to our draft decision and not at the outset of our investigation. We have made a recommendation to address this.

Recommendations

What we asked the organisation to do in this case:

• Apologise to B 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:

• When a young person has regular multidisciplinary meetings, CAMHS should have a clear understanding of the level of input they will be required to provide from the outset in consultation with the other professionals, and provide appropriate input in line with this clarification. This should be documented appropriately.
• When a young person with autism spectrum disorder and/or ADHD is not engaging with treatment, clinical staff should recognise this might be because of their condition(s) and try to adapt their approaches to better engage them.
• Young people presenting with symptoms of ADHD should be appropriately and timeously assessed, taking into account relevant clinical guidance.

In relation to complaints handling, we recommended:

• Full documentation, including electronic records, relating to the matters under investigation should be collated and supplied to this office in response to our initial request for information.

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 spouse (A). A suffered from progressive lung disease and required prostate surgery. There was a significant delay in performing A's surgery, during which time A's health deteriorated. A was discharged home following their operation, but was readmitted the following day and died shortly afterwards.

C believed that A would have survived had the operation been performed sooner, as their health would have been better. C also said that A's death certificate was inaccurate, as it stated that A had died from community acquired pneumonia. C said that A had not been well when they were discharged, had been at home for less than 24 hours and had spent the majority of that period in bed.

We took independent medical advice. We found that A's condition had not been properly monitored following their operation, as the board's assessment had been based on assumptions about A's condition prior to admission. This meant that A had been discharged without evidence of a deterioration in their condition being properly considered. We also noted that it was not possible to determine that A's pneumonia was 'community acquired'.

We considered that A's care and treatment had fallen below a reasonable standard. However, we noted that it is not possible to be certain what the outcome would have been had A been operated on sooner.

We also found that C's complaint had not been handled to a reasonable standard. The board had initially informed this office that it had nothing to add to its response to C's complaint. However, following our enquiries, the board accepted that it was unlikely that A had acquired pneumonia in the community. Additionally the board's complaint investigation had failed to identify that A's condition was not properly assessed prior to discharge.

We upheld both of C's complaints.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to asses A's condition, incorrectly describing their pneumonia and issuing an inaccurate death certificate. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.
• Assist C with obtaining a corrected death certificate.

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

• Medical staff should correlate information about a patient's condition on admission, such as oxygen saturation levels as part of the patient's assessment prior to discharge.
• The board should remind relevant medical staff that, when issuing a death certificate, careful consideration needs to be given to ensuring it accurately reflects the cause of death.

In relation to complaints handling, we recommended:

• Complaint responses should respond to all of the points of complaint raised by a complainant.

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 underwent sequential cataract surgery (a surgical procedure to replace the eye lens with an artificial one when the cataract makes the vision cloudy, specifically, in this instance, monofocal lens implantation). C complained that the board had failed to communicate reasonably with them prior to the cataract surgery, including that the risks and benefits were not explained to them and that their concerns following first cataract surgery were not taken seriously.

We sought independent advice from an ophthalmologist adviser (specialist in the branch of medicine that deals with the anatomy, physiology and diseases of the eye). We found that there was no record that C was given information about the risks and benefits of the surgery. The lack of written information about the risks and benefits of the procedure was unreasonable. We noted that this was contrary to the General Medical Council's guidance to keep an accurate record of the exchange of information. We also found that there was no record of what was discussed with C following the first cataract procedure. As there is no written record, we were unable to determine what was discussed with C when they raised concerns.

In light of the above, we considered that there was a failure to communicate reasonably with C prior to the cataract surgery and we upheld C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for not giving them information about the risks and benefits of monofocal lens implantation and for not recording what was discussed with them following the first cataract procedure. 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:

• Discussions with patients following cataract procedures should be clearly recorded.
• Patients should be advised of all material risks and benefits of cataract procedures and the discussion should be clearly recorded, in accordance with relevant standards 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.