Upheld, recommendations

Summary

C complained about the care and treatment received by their young child (A). A had a complex congenital (from birth) heart condition. C complained to the board after A received heart surgery, which had been part of the treatment planned for A. C complained that the board did not reasonably respond to C’s concerns prior to A’s operation. C also complained about the timing of A’s admission to hospital and the timing of the operation.

We took independent advice from a consultant paediatric cardiologist (specialist in children’s heart problems). We found that, overall, the board provided excellent care to A and a successful outcome was achieved through A’s surgery. We found that the timing of A’s operation was reasonable considering A’s age. However, we also found that A was not provided with appropriate follow-up plans in relation to care provided before A’s surgery and that A should have been admitted to hospital three days earlier. On balance, we upheld C’s complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failings identified in this 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:

• Patients should receive timely admission to hospital and follow-up appointments, based on their clinical needs and presentation.

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 reasonably respond to their complaint about the way a form was completed by the GP at their GP Practice.

We found that while the board provided regular updates, apologised for the delay and reasonably managed C’s contact, the length of time responding to the complaint and the inaccuracies of the updates provided to C, were unreasonable. The response to the complaint was unclear and did not answer all of the points raised by C. As such, we upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failures in this 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:

• Complaint responses are issued as soon as possible, with the response responding to the main points raised and agreed with the complainant, and any required updates accurately reflect the reasons for the delay.

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 process around a Looked After and Accommodated Child (LAAC) review meeting for their child (A) and the decision taken to end A’s residential placement.

We took independent advice from a social worker. We found that the decision making was based on an appropriate needs assessment and that it was reasonable for the council to consider Self-Directed Support (SDS) options for respite, rather than continuing to fund a full time residential placement that A did not need. However, neither the assessment nor the LAAC review specified what form of respite was considered appropriate for A and why. It should have been made clear to A and C that overnight residential support was no longer required and why external agency respite options were not appropriate.

We also found no evidence that the draft assessment was shared with A and C for their comments, and no record of discussion with the parents about the respite options prior to or at the LAAC review meeting. It was not clear how the council concluded SDS was in A’s best interests, or that this had been properly communicated to or discussed with C.

We upheld C’s complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the shortcomings identified in this investigation. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.
• Provide C with an explanation in respect of external respite options, and why they were considered unsuitable for A.

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

• Key decisions and changes need to be properly documented, explained and communicated. In complex cases such as A’s, case supervision sessions should go over in some detail communication with parents – what information has been shared, what explanations given about actions taken / decisions or recommendations made. LAAC meetings and minutes should detail how best interest decisions were made.

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 and school staff failed to reasonably respond or act when C told them about domestic violence witnessed by their child (A). C said that the council had breached their duty of care and Child Protection obligations in respect of A by ignoring C’s concerns about the domestic abuse that they were suffering and failed to provide A with appropriate support.

The council did not uphold C’s complaint. They considered that C and their family had received an appropriate level of support in line with the council’s policies and procedures.

We took independent advice from a social worker. We found that there was a failure by school staff to reasonably respond to, or act upon, C’s reports of domestic violence witnessed by A. We found that staff should have contacted the council’s Joint Child Protection Team for advice and guidance following C’s initial disclosure of domestic abuse. Therefore, we upheld C’s complaint.

We also identified a concern that council staff may not fully recognise what constitutes domestic violence. It encompasses more than just physical violence and includes a range of behaviour as outlined in relevant legislation. We provided the council with feedback on this point.

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.

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 way that the partnership handled their complaint about the care and treatment provided to C’s late sibling. C said that the complaint process had been long and difficult to follow and it had been hard to obtain a clear and final complaint response from the partnership. C stated that they had to make their own enquiries to determine whether the complaint had been closed and they had been inappropriately referred to another internal complaint process. C also complained about staff conduct during complaint meetings, specifically citing instances of rude and defensive behaviour, as well as a failure to keep meeting notes.

The partnership considered that they had reasonably handled C’s complaint in line with the correct complaint handling procedure (CHP).

We found that it had been unclear which CHP had been followed (the council or NHS) and that there was a failure to comply with timescales. The partnership’s complaint handling did not consider the separate significant adverse event review undertaken by the partnership. Additionally, inaccurate information was provided about the stages of the CHP and the point at which C could escalate the complaint to the SPSO. Finally, we found that the partnership failed to apologise to C for the failings identified in their own complaint investigation. While we could not reach a decision on the behaviour of staff during meetings, we found that they failed to keep written records of complaint meetings. We upheld C’s complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to reasonably handle their complaint and for the failings identified following their own investigation of the complaint. 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:

• Complaint investigations should be managed in accordance with the appropriate complaint handling procedure. The complaint response letter should be clear and fully address all of the points of concern raised, and an apology should be offered when failings have been identified. A written record of complaint meetings should be kept and timeously shared with the complainant. The organisation should have good oversight of how a complaint is progressing, which ensures correspondence with the complainant is clear, consistent and concise.

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 service provided in respect of their grandchild (A). C complained that A was not being provided with a stable home environment by their parent (B). C was concerned about the condition of B’s home and whether A and their siblings were being adequately supervised and kept safe. C also expressed concerns over other adults in B’s home.

C said that the partnership did not take their concerns seriously and had failed to ensure A’s health and wellbeing. This included whether sufficient home visits took place, and the decision not to initiate child protection proceedings, or make a referral to the Scottish Children’s Reporter (SCRA). C also raised concerns about social work documentation and processes relating to Interagency Referral Discussions (IRD) and Child’s Plans.

We took independent advice from a social worker. We found that the partnership’s explanations and assurances to C, with respect to the number and nature of home visits, did not match the available records and that there had been a failure to carry out robust and timely assessments of B’s home. Where home visits did take place, there was a lack of evidence that key concerns related to the condition of specific areas of the home were addressed. Regarding the referral to the SCRA, we found that while the IRD stated that ongoing assessment would determine if a SCRA referral was required, there was no indication of the parameters of the ongoing assessment or what timescales were in place. Furthermore, the IRD did not state by whom, or by when, actions should be completed and lacked clarity regarding roles and responsibilities. Similarly, the Child’s Plan lacked clarity and contained significant omissions. Therefore, we upheld C’s complaints.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for these 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:

• The partnership should ensure that where they have involvement in relation to concerns raised about the welfare of a child, that relevant documentation is completed and monitored to a reasonable standard.
• Where concerns are raised about the wellbeing of a child, reasonable, timely and robust action should be taken to assess and investigate the situation.

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) by the board. A, who had a history of breast cancer, was admitted to hospital with pain and vomiting. Tests were carried out and A underwent a liver biopsy. Following the biopsy, their condition deteriorated and they died a few days later. C felt that A’s death was premature and was hastened by the actions of the board.

The board said that CT scans showed that A had an abnormal liver and an MRI was requested. This wasn’t completed until eight days later due to high demand. The liver biopsy was undertaken the same day. When A began to deteriorate, an urgent CT scan showed that A was bleeding from an injury to the branch of the cystic artery from the biopsy site. The board said that this is a known complication of a liver biopsy. The bleed was successfully treated but A deteriorated further and died. A had shown signs of potential infection and was commenced on antibiotics. The post-mortem stated that the cause of death was ‘complications of liver biopsy and metastatic breast cancer in liver’, and could not conclude to what extent the infection contributed to A’s death.

We took independent advice from a consultant general and colorectal surgeon. We found that the MRI did not appear to have been reviewed prior to proceeding to biopsy and the breast team were not notified of the CT scan results. We also noted that A was not referred to the breast cancer multidisciplinary team (MDT). We found that antibiotics should ideally have been administered within one hour of deterioration and sepsis considered as a main cause of A’s deterioration. A was also given a cystic artery embolization (a minimally invasive procedure that blocks or closes the blood vessel) and two units of blood despite having a normal blood count and no evidence of significant bleeding. Therefore, we upheld this part of C’s complaint.

C complained about communication with A and A’s family, stating that A was not given sufficient information about their condition or results from tests. A’s family were unaware of test results until after A’s death. We found that communication with A and A’s family was unreasonable and that there had also been an absence of communication with the breast team and MDT, which was a missed opportunity. We upheld this part of C’s complaint.

C complained that the board unreasonably failed to undertake a Significant Adverse Event Review. We found it was unreasonable for the board not to have undertaken a Significant Adverse Event Review. This was a missed opportunity to reflect on A’s care and treatment, and identify learning from these events. We upheld this part of C’s complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failure to provide reasonable care and treatment to A, the failure to communicate to a reasonable standard and the failure to undertake a Significant Adverse Event Review. 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:

• Plans for investigations, especially of an invasive nature, should be adequately discussed with the patient, including where there is a suspicion of malignancy.
• Relevant clinical teams should be involved, especially where investigations were initiated prior to admission. Sepsis should be appropriately considered as a reason for deterioration, and wherever possible, antibiotics be administered within an hour of deterioration. Appropriate treatment should be given based on clinical signs and symptoms.
• Significant Adverse Event Review’s should be completed in line with the national framework and the board’s own protocols.

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 reasonable care and treatment to their late parent (A). A became acutely unwell with uncontrollable diarrhoea, severe abdominal pain and vomiting. After visits from both a community nurse and out-of-hours GP, C called for an ambulance. The ambulance crew called ahead to the hospital to have A admitted, as per the board’s alternative admission pathway. As agreed during the call, A was taken to the Acute Medical Unit (AMU) but there was no bed for A on arrival. Initial observations and ECG/bloods were taken but A was found unresponsive a short time later and died of a cardiac arrest.

The board apologised that no bed was available for A. They reviewed A’s case and concluded that the appropriate referral pathway was followed. However, they acknowledged that patients with undifferentiated (undiagnosed) abdominal pain should not be admitted to the AMU.

We took independent advice from a consultant physician in acute and general medicine. We found that the board failed to obtain key information to determine which pathway should be followed. This resulted in A not entering the correct pathway. We found that the board failed to escalate A’s care and treatment in line with relevant guidance and with their own policy. We found that A’s care was compromised by the board’s alternative admission pathway. It is possible that the outcome may have been different had the correct pathway been accessed. We upheld this part of C’s complaint.

C complained that the board unreasonably failed to carry out a Significant Adverse Event Review (SAER) following A’s death. After being notified of our investigation, the board commissioned a SAER. Although we welcomed this, the board did not provide assurance that they have adequate systems in place to identify, investigate and learn from adverse events. The board’s failure to commission a SAER following A’s death did not meet the standards outlined in the relevant guidance, and was unreasonable. Therefore, we upheld this part of C’s complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to carry out a SAER. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.
• Apologise to C for the failings our investigation has 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:

• Patients should be admitted to the correct care pathway on the basis of their presenting symptoms. When accepting patients with undifferentiated gastrointestinal symptoms, local teams should be aware of the presence or absence of abdominal pain. Teams should ensure that they ask this specific question when accepting patients.
• Patients should be managed in line with their presenting symptoms. Observations should be carried out in line with the board’s escalation policy.
• There should be a robust process in place for reviewing all unexpected deaths, and, where appropriate, prompt commissioning of SAERs. Learning from these events should be disseminated and shared across teams in line with national guidance.

In relation to complaints handling, we recommended:

• Complaint investigations and case reviews should respond to all of the main points raised, identify failings where appropriate and take learning from what happened. We offer SPSO accredited Complaints Handling training. Details and registration forms for our online self-guided Good Complaints Handling course (Stage 1) and our online trainer-led Complaints Investigation Skills course (Stage 2) are available at https://www.spso.org.uk/training-courses.

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). Scans revealed findings that were suggestive of bladder cancer. Over a number of further admissions, A received treatment to resect (remove) a bladder tumour, fit and remove catheters, treat infection and generally manage A’s condition. Eventually, it was decided that A’s condition should be managed palliatively, and A was discharged home.

C complained that the medical and nursing care and treatment A received from the board was unreasonable and that the communication with A and their family was unreasonable.

The board said that A was not medically or psychologically fit for further management of their condition and they were not a candidate for chemotherapy or radiotherapy. A was referred to palliative care once it was identified that they were also not a candidate for surgery. The board said A chose not to share their diagnosis for a number of weeks and were unwilling for discussions to take place with their family.

We took independent clinical advice from a consultant urologist (specialists in he male and female urinary tract, and the male reproductive organs) and a registered nurse. We found that the surgical care was of a reasonable standard and that the board adopted a holistic approach. However there was a failure to detect the bladder tumour when it was initially suspected and a failure to follow up with A about their nephrostomy (a thin tube inserted through the skin directly into the kidney to allow urine to drain into an external drainage bag) and JJ stents (a thin flexible tube placed to help urine flow). We also found that there was a delay in organising an inpatient CT scan, failures in relation to discharge planning and a failure to care for A’s skin and pressure damage.

In relation to communication, we found that the board failed to tell A that there was a suspicion of bladder cancer at an appropriate time and it was unreasonable for the board not to communicate with A’s family when arranging discharge.

We considered that the board failed to provide reasonable care and treatment to A and failed to communicate reasonably with A. Therefore, we upheld these parts of C’s complaint.

C complained that the board failed to handle their complaint reasonably. We found that the board’s investigation and response contained a number of factual inaccuracies, particularly with the accuracy of dates and order of events, and that important information was omitted from the response. Therefore, we upheld this part of C’s complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to provide reasonable care and treatment to A, failing to communicate reasonably with A and their family, and failing to provide a reasonable response to C’s complaints. 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:

• Discharge planning should take into account the patient’s ability and motivation to complete required self-care tasks such as catheter and nephrostomy care. Patients should be issued with a copy of the discharge letter where appropriate. When a patient does not live independently family members should be informed of their discharge to ensure there is appropriate care in place.
• There should be nurse specialist support for patients with urological cancers. Nurse specialists should contact the patient within a reasonable timescale. Patients should be assessed to ensure suitability before phone consultations are carried out. Patients should be supported, where possible, when bad news is being communicated to them. Relevant updates should be given to a patient in a timely manner.
• There should be adequate trainee supervision during surgical procedures in keeping with the trainee’s experience. Patients should be informed of investigation findings if they are suspicious of a cancer diagnosis. When there is a suspicion of cancer further investigations should be carried out with due diligence. Relevant findings should be discussed with the patient and recorded in the medical notes.
• A pathway should be in place to ensure that patients with nephrostomies and/or JJ-stent are followed-up in line with best practice time frames.
• Inpatient scans should be carried out within a reasonable time frame.
• Wound charts should be in place for pressure wounds and there should be subsequent weekly assessments. Care rounding should be delivered to the frequency required to prevent pressure damage. Patients should be appropriately moved position to avoid worsening pressure damage.

In relation to complaints handling, we recommended:

• Complaint responses should be factually accurate. Details such as dates and the order of events should be supported by what is recorded in the medical records, and these should be checked for accuracy before the response is issued. Complaint responses should be completed in line with the NHS 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 complained about the care and treatment that their late parent (A) received while in hospital. A suffered a fall and broke their hip. C complained that A was never provided with a falls monitor despite being assessed as a falls risk. C also said that there was a delay in reporting the fall and having A assessed.

The board apologised to C for the fact that, due to a lack of falls alarms, A had not received one. They explained that additional alarms had been obtained to ensure a sufficient supply on the ward. They also accepted that a ‘top to toe’ examination should have been carried out following A’s fall and that there was a delay in identifying that A had a broken hip. They explained that a full review of A’s fall was underway, and if any learning points were identified, they would be acted upon. In addition, a teaching session had been carried out to ensure best practice was followed at all times. The board provided us with details of the learning points that had been identified as a result of the complaint.

We took independent advice from a registered nurse. We found that there was no evidence that A received timely risk assessments or person-centred care. Although a fall with harm was apparent from A’s misaligned leg, this went unnoticed. Basic assessments, including pain assessment, were not conducted, resulting in a delay in recognising A’s pain. Additionally, wound charts were not completed, and there was a failure to follow policy regarding pressure ulcer prevention, malnutrition, and wound assessment and management. While the board had taken action in response to the complaint, we considered that there were still areas for learning and improvement. Therefore, we upheld C’s complaint.

We also found that the board’s complaint response had not been open, transparent, and accurate. The board had failed to identify a number of failings in A’s care and treatment. Additionally, the board had not provided this office with all relevant information in response to our initial enquiry. A significant number of relevant documents were only made available to us after a follow-up enquiry. We made recommendations to address this.

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 board should ensure that nursing staff are aware of their responsibilities for completing relevant documentation in relation to person centred care planning, risk assessment and wound assessment and that the documentation is to the standard required. The board should ensure that there is a consistency of approach from nursing staff when a patient places themselves on the floor and the board’s guidance on what nursing staff should be doing is followed.
• The standard and content of patient documentation in relation to person centred care planning, risk assessment and wound assessment should comply with all relevant guidance and policies and with best practice.

In relation to complaints handling, we recommended:

• Complaint investigations should be carried out in line with the NHS Model Complaints Handling Procedure. They should be accurate in their findings and conclusions, clear, and supported by relevant evidence, such as medical records.

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