Upheld, recommendations

Summary

C complained about the council’s handling of their correspondence in relation to an alleged bus lane contravention. C said that the council responded to their request for the record (evidence) of the contravention, made under subsection 8(5) of the Bus Lane Contraventions (Charges, Adjudication and Enforcement) (Scotland) Regulations 2011 with a notice of rejection under subsection 10(b) of the Regulations. C said that this resulted in them being prematurely moved on to the ‘appeal to the adjudicator’ stage of the process, and they did not have a proper opportunity to make representations to the council.

The council said that they had treated C’s correspondence as a representation against the contravention due to C’s use of the word ‘alleged’ in reference to the contravention, because C appeared unhappy with the issue of the charge notice.

We reviewed all of the evidence provided by both C and the council, as well as the relevant Regulations. We considered that the council had unreasonably interpreted C’s correspondence as being representations against the charge notice, as the evidence supported C’s position that they were making a request for the record of contravention. We considered that this resulted in C missing out on the opportunity to properly make representations to the council before being moved on to the second stage of the appeal process set out in the Regulations. We upheld C’s complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to appropriately respond to their request for information under the Bus Lane Contraventions Regulations. 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 be able to correctly distinguish the difference between representations and requests for information in relation to charge notice correspondence, and respond appropriately.

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 actions of the council in carrying out roof repair works on a block of flats as an emergency repair, without seeking prior agreement from shared owners. C also raised concerns that the invoice charged for excess materials. C’s flat was let to the council through a management agent, and the council initially sent the invoice for the works to the agent. C complained that the council did not send the invoice to them directly, and they did not receive it until around two years later.

The council noted that the required repair constituted a health and safety risk, and was therefore classed as an emergency and carried out as soon as possible. They confirmed the works were visually checked by a council official before being signed off, and they refuted that excess materials had been charged for. They advised that the opportunity had been taken to clean the gutters while scaffolding was erected, and acknowledged this did not meet the definition of an emergency repair. They confirmed it is normal procedure to send invoices to the party listed on the national landlord registration database, and that in some cases this is the agent. The council considered the delay in the invoice reaching C lay predominantly with the agent, although they accepted they delayed for around six months after the agent had asked them to send the invoice directly to C.

We were satisfied that classification of the works as an emergency was a matter for the council’s discretion, and that their policy entitled them to carry out such work without owners’ agreement. We were unable to evidence that owners were charged for excess materials, but we noted the gutter cleaning work was not an emergency and should not have been carried out without owners’ consent. We were unable to confirm the party listed on the landlord database at the time of the works, but we noted the council contributed to the delay in the invoice being issued directly to C. On balance, we upheld this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for their part in the delay in issuing the invoice to them, and for the failure to seek owners’ agreement for the gutter cleaning works. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.
• The council should waive the charge for gutter cleaning works.

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

• The agreement of all owners should be sought for mutual repairs, unless all the repair work fits the definition of an emergency. The council should remind relevant staff of the importance of adhering to the terms of their Mutual Repairs and Shared Costs Policy in this regard.

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, parents to two children with additional support needs, complained about the social work service provided by the council. C complained that the council failed to provide overnight respite care to meet the family's assessed need. The council upheld the family’s complaint and accepted that there had been a reduction in respite provision. The council explained this situation was beyond their control, as joint overnight respite was not currently available from the service provider and no suitable alternative was available at the time.

We took independent advice from a social worker. We found that the council’s assessment documentation should have been more clearly worded to avoid ambiguity. We concluded that it was unreasonable for the council to rely on care arrangements that were ‘subject to availability’ as a long-term position and we considered that they should have done more to explore alternatives. We upheld this aspect of the complaint.

C also raised concern that the council unreasonably declined to consider new respite arrangements despite acknowledging that the current arrangements were inadequate. At the time, the family was awaiting the outcome of an appeal to the Additional Support Needs Tribunal. The family declined the council’s offer of a full-time placement for one of the children on a short-term basis. The council said it was not reasonable to fully explore the family’s support proposals given the uncertainty of the tribunal outcome and the family’s circumstances. We acknowledged this, but found that it was not reasonable for the council to decline to consider interim respite arrangements. We upheld this aspect of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to the family for failing to meet their assessed needs for overnight respite, and for declining to consider alternative arrangements pending the Tribunal outcome. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.
• Consider providing some nights of joint overnight respite or a mutually acceptable alternative (as a one-off provision), in recognition of the period of unmet need and the family’s ongoing difficult situation.

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

• The council should be open to discussion and continue to explore alternatives with families in light of changing circumstances. Where families exercise a right to appeal a decision about longer-term educational placement, this should not preclude their interim respite needs being considered (particularly where their assessed needs are not being met).
• The council should ensure their strategic commissioning takes into account the future needs of all families requiring support. Conditional arrangements should primarily be used in the short term (while action is taken to ensure the need can be met over the longer-term).

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

Summary

C complained about the treatment their child (A) received within A&E at Western Isles Hospital. A was initially seen by a doctor who diagnosed a migraine. A They returned to A&E when their condition deteriorated, and was seen by another doctor, who diagnosed a migraine and possible virus. Following a third visit to A&E, A was diagnosed with a rare condition which is a complication of sinusitis. C complained that one doctor was dismissive and did not take A’s symptoms seriously.

We took independent advice from an A&E consultant. We noted that A was diagnosed with a rare condition that A&E staff would not be expected to diagnose. However, we considered that signs were missed that A had a potentially serious underlying condition. While they were satisfied that both initial doctors who saw A initially carried out appropriate examinations, we noted that the blood tests results were not consistent with the diagnosis of migraine or viral infection. We considered that A should not have been discharged before all the blood results were available. We also considered that A should have been reviewed by a senior doctor before discharge on the second attendance, given that it was an unplanned return. We concluded that there was a failure to take appropriate action, which resulted in a delay in investigating and accurately diagnosing A’s serious underlying condition. Accordingly, we upheld this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C and A for discharging A from A&E on two occasions without blood tests results having been identified and acted upon; for not arranging senior review on the second occasion; for the diagnosis being inconsistent with the blood results; and for the consequent delay in further investigation and accurate diagnosis of a serious underlying condition. 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 returning to A&E with the same complaint should be reviewed by a consultant. The board should consider developing a policy for senior review of unplanned emergency department return patients, if one is not already in place.
• The board should feed this decision back to Doctor 1 and Doctor 2 in a supportive manner and ask that they reflect on A’s case, especially with regard to the abnormally elevated neutrophil white blood cell count.

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 family member (A) about a delay in diagnosis of A’s type 2 Diabetes Mellitus (an adult onset diabetes, occurs when the body cannot produce sufficient insulin to absorb blood sugar - T2DM).

A was initially diagnosed with type 1 Diabetes Mellitus (T1DM) by their GP and began taking insulin. Over the following years, A was reviewed in the board’s diabetes clinic at varying intervals. After a number of years, and after further tests were performed, A’s diagnosis was changed to T2DM, and their treatment was altered.

In response to our enquiries, the board said they considered that A’s care was appropriate and that there was no delay in diagnosis. We took independent advice from a consultant diabetologist (doctor specialising in the diagnosis and treatment of diabetes). We found that there was an unreasonable delay in diagnosing A with T2DM. We found that it would have been reasonable to consider a potential diagnosis of T2DM at the time of the initial T1DM diagnosis, or soon after. We also found that the treatment used for T2DM could have been provided to A much earlier and we noted that there were a number of opportunities over the following years to reconsider the basis for the diabetes and thus additional treatment options. We upheld C’s complaint and made recommendations.

Recommendations

What we asked the organisation to do in this case:

• Apologise to A for the unreasonable delay in reaching a correct diagnosis for their diabetes. 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:

• Clinicians should remain mindful of diabetes patients with atypical presentations when considering a diagnosis. Patients should receive the appropriate treatment for their condition.

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, an advice and support service worker, complained on behalf of their client (A) regarding care and treatment A received from the board. A presented to University Hospital Monklands with abdominal pain, which had been treated as a urinary infection. It was thought that the symptoms were related to their kidneys. A had a scan days later and as a result was diagnosed as having a twisted right ovarian cyst which required surgery. C complained that there had been a misdiagnosis and delay in carrying out a scan. They questioned whether the ovary would not have needed to be removed had the correct diagnosis been made earlier. C also complained that A’s mobility and pain were not properly assessed, and compression stockings were not provided.

In responding to the complaint, the board apologised that there had been a breakdown in communication regarding the scan and advised that this would be discussed with the doctor in further detail. In terms of the nursing care provided, the board did not identify any failings.

We took independent advice from a consultant general and colorectal surgeon (a surgeon who specialises in conditions in the colon, rectum or anus) and from a registered nurse. In terms of the medical care, we found that A’s ongoing pain three days after being treated for urine infection was uncommon and that a diagnosis of kidney stones or another cause of pain should have been considered. We considered that a scan should have been carried out on the day it was originally planned and it was unreasonable care that this did not happen. However, we did not consider that A’s outcome of undergoing surgery and having an ovary removed would have been affected by the delay in the scan. Nevertheless, we found that the delay resulted in A being in pain for longer and acknowledged that this was distressing for them. We upheld this complaint.

In terms of the nursing care, we found it was reasonable not to have provided A with compression stockings. However, we considered there were failings in a mobility assessment not being carried out, and there was no clear care plan for their persistent and unresolved pain. Had there been so, this may have led to escalation to medical staff; a review of their pain; and expedited some of tests, if it was recognised pain was becoming difficult to manage in the context of an undiagnosed cause. For these reasons, we upheld this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to A for the following aspects of their care: that there was no differential diagnosis or a plan on management clearly recorded; that there was no medical review of A’ pain and observations documented; that there was no explanation about why the original plan for a CT scan was changed to an ultrasound scan and then changed back; that there was a delay in performing a CT scan; and that A’s mobility was not reasonably assessed or at least documented. 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:

• Clearer record for pain relief and management is required to accurately assess pain with escalation to medical staff as appropriate.
• Documentation on rounds should provide adequate reflection of clinical examination, review of observations, possible diagnosis, and plan of management.
• Nursing staff should ensure, where relevant, a patient’s mobility is assessed and documented.

Summary

C complained about the care their parent (A) received during an admission to Queen Elizabeth University Hospital. A was admitted following a fall at home and had a further fall in hospital, resulting in a fracture to their right shoulder. C complained that A’s fall in hospital could have been prevented, if ward staff had followed the board’s falls prevention protocols, had correctly assessed A’s risk of falls and had taken appropriate measures to ensure their safety on the ward.

We took independent advice from a nurse. We found the record-keeping was unreasonable and not of the required standard in relation to the assessment and prevention of A’s fall and also the incident reporting of the fall. The falls risk assessment was completed within the stipulated policy timescale of 24 hours from admission. However, the decision not to undertake this during the immediate admission appeared to have been taken by a student nurse without oversight from a registered nurse. We found no evidence to confirm what interventions, besides bed rails, had been put in place to prevent A from falling.

The incident report of the fall lacked clarity and consistency. The incident was initially miscategorised as minor and was not updated to serious when the fracture was diagnosed, so the relevant escalation and review was not triggered. The board indicated that a review had subsequently taken place, but we saw no evidence of this or of the learning and improvement derived from it. The adverse event review findings were not discussed or shared with C, as they should have been in keeping with national Being Open in NHS Scotland guidance. We upheld this complaint. We also found that the board did not respond to C’s complaints in a timely and robust manner.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the identified inadequacies in record-keeping surrounding A’s fall; for the lack of supervision of the student nurse who assessed A; for failing to share with C a copy of their adverse event review; and failing to investigate C's complaint in a timely and robust manner. 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 review their performance with regard to the Being Open principles to ensure that appropriate systems are in place to share the outcome of incident reviews with patients and family members.
• The board should review their procedures to ensure accurate reporting, and appropriate review and investigation, of adverse events.
• The board should review their record-keeping in this case to ensure that nursing staff are meeting the standards required of them in this respect.
• The board should take steps to ensure that appropriate supervision of student nurses is in place.

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) during an admission to Aberdeen Royal Infirmary. C complained that during the admission, they did not see A being provided with nebulisers (a device which helps to moisten the airways; or allow medicine to be administered as a vapour) or oxygen therapy. C also felt that A was not given appropriate pain relief, particularly towards the end of their life, and that A’s condition and potential outcome were not explained to C and their family.

We took independent advice from a consultant in acute medicine. We found that the management of A’s need for oxygen was reasonable. The evidence that had been provided suggested that A was receiving regular nebulisers, however there was no medication record to confirm this and this was unreasonable.

There was no evidence that A was in unrelieved pain towards the end of their life and the prescription of medication and documentation regarding this matter was reasonable.

We considered the timing of the conversation with A’s family regarding Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) was likely reasonable, but some of the documentation around this conversation was not reasonable.

On the basis of the lack of evidence regarding the prescription of nebulisers, and poor documentation of the initial DNACPR conversation, we upheld C’s complaints.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failure to provide a record of the nebulisers prescribed for A; and for the lack of documentation around the initial Do Not Attempt Cardiopulmonary Resuscitation conversation.nThe 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:

• DNACPR conversations should be documented with an appropriate level of detail.
• There should always be complete records of prescribed medication.

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) who died from an aggressive and complicated form of cancer. C considered that there was a lack of urgency in the board’s actions and there was no clear plan for A’s treatment.

The board confirmed that they carried out a number of investigations and referred A’s case to the National Sarcoma Team in order to seek their view. Further tests were requested and a referral was made to the Acute Pain Service. The board said that while no definitive diagnosis was reached, there had been a plan to pursue radiotherapy; however, A’s condition quickly deteriorated and they died.

We took independent advice from a consultant gastroenterologist (a physician who specialises in the diagnosis and treatment of disorders of the stomach and intestines). We found that the treatment plan of A’s condition was reasonable and we did not consider there was a lack of urgency. However, we concluded that, at the point when significant changes were observed in a scan compared to a scan performed some months prior, the board should have held a local multi-disciplinary team (MDT) discussion and/or referred to a cancer of unknown primary (CUP) (where the place cancer began is not known) MDT to discuss A’s case. This may have resulted in a more faster and possibly would have led clinicians to concentrate more on pain relief. On balance, we upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to hold a local MDT and/or refer to a CUP MDT at the point the significant changes were observed in the scan. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

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

• Clinical managers should reflect on this case with regard to whether there was a missed learning opportunity at the point the significant changes were observed in the scan.
• The board should give consideration to how they could strengthen their multi-disciplinary teams to enable them to meet more regularly to discuss cases with different specialists.

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

Summary

C complained about the care provided to their parent (A) after A suffered an unwitnessed fall. C said that A had deteriorated continuously from this point, whilst the board said that A had not shown any significant signs of distress until later, when they began to deteriorate significantly. A was transferred to Forth Valley Royal Hospital, where they were found to have fractured ribs and a pneumothorax (collapsed lung). C did not believe that A was examined quickly enough after their fall and considered it unreasonable that the examination had failed to identify the serious injuries A had sustained.

We took independent medical advice. We found that A’s care and treatment fell below a reasonable standard. There was an excessive delay in providing A with a medical examination and there was inadequate investigation of A’s subsequent symptoms. In addition, A’s mental deterioration and existing diagnosis of dementia were not taken into consideration in the assessment of their condition or in the communication with their family.

We upheld both of C’s complaints on the basis that A’s care and treatment was not of a reasonable standard. As the board had concluded staff had followed the board’s procedures after A’s fall, we found that these procedures were not adequate and required review.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failings identified in A’s care and treatment.
• Apologise to C for the procedural inadequacies identified by this 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:

• National Early Warning Score monitoring should be increased when appropriate, demonstrating that the patient’s condition and medication have been taken into account.
• Pain in patients with cognitive impairment should be managed effectively, taking their impairment into consideration.
• Possible delirium should be identified and investigated.
• Staff should be aware of the potential for a typical presentations of acute illness in frail older people and when further investigation should be considered.

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.