Upheld, recommendations

Summary

C complained about the care and treatment they received from the board. C received a positive bowel screening result and attended a screening clinic shortly after. A colonoscopy (an exam used to detect changes or abnormalities in the large intestine (colon) and rectum) was arranged but was unsuccessful. C later underwent a successful colonoscopy which identified a rectal polyp (a small cell clump that grows within your body).

C’s polyp was initially considered to be benign (not harmful). They were referred for an endoscopic ultrasound (EUS) scan in another NHS board area. This identified that C had type two rectal cancer. C complained about what they considered to be a misdiagnosis by the board. They also complained about delays in the board carrying out a successful colonoscopy and arranging for an EUS to be carried out.

We took independent advice from a general and colorectal surgeon (a general surgeon who specialises in conditions in the colon, rectum or anus). In respect of the colonoscopy, we noted that there was a delay of around 24 weeks from C’s positive bowel screening until a successful colonoscopy was carried out. Although the delay was not wholly down to the board, we considered this length of time to be unreasonable. We noted that C was effectively placed at the back of the queue each time an appointment was not successful. We concluded that the board should have done more to progress C’s case following the failed colonoscopy. As such, we upheld this aspect of the complaint.

C’s second complaint was that the board unreasonably failed to diagnose that they had cancer following tests. We concluded that the board treated C’s polyp as being suspicious of cancer from the outset. However, we identified clear delays within the treatment pathway, which meant C’s cancer was not identified until later. This meant that cancer was either present during earlier tests, or developed in the months leading up to a later test. We concluded that the overall timescale could have been reduced significantly had the board reviewed C’s treatment options earlier. We upheld this aspect of the complaint.

Finally, C complained about there being a delay in the board arranging for an EUS to be carried out. We identified that the delay was partly due to the other board that the referral was made to. However, we noted that the referral was made with no apparent follow-up for more than two months. There was then a further two-month delay after the other board responded to say an EUS would be arranged urgently. We concluded that more could have been done to follow up on the referral made to the other board. In addition to this, we concluded that more could have been done in terms of looking at the overall waiting time experienced by C, given that the EUS was not essential. In light of this, we upheld this aspect of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the unreasonable delay in carrying out a successful colonoscopy; for the unreasonable delay in the treatment pathway that contributed to a delay in C’s cancer diagnosis; and for contributing towards there being an unreasonable delay in an endoscopic ultrasound being carried out, given this was a non-essential procedure. The apology should meet the standards set out in the SPSO guidelines on apology available at HYPERLINK "http://www.spso.org.uk/information-leaflets" www.spso.org.uk/information-leaflets .

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

• If a referral to another board is required for a procedure such as an endoscopic ultrasound, this should be followed up appropriately. Consideration should be given to whether the benefits of making a referral to another board for a procedure such as an endoscopic ultrasound outweighs the risks caused by the delay in treatment resulting from this.
• A successful colonoscopy should be carried out within a reasonable timescale after a patient receives a positive bowel screening test result.
• If a patient fails to attend a colonoscopy, or the procedure cannot be completed, there should be a reasonable and patient-centred policy for rescheduling appointments.
• The pathway for diagnosing rectal cancer in a patient should be progressed within a reasonable timeframe. Consideration should be given to the timescales involved in managing complex polyps.

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 to us about the board regarding treatment of their child (A). A became unwell and was referred to Victoria Hospital, where they were diagnosed as having gastroenteritis (inflammation of the stomach and intestines) by a paediatric nurse practitioner and discharged home. Three days later, A suffered a seizure and was readmitted to the hospital. They were transferred to a hospital in another health board area and diagnosed as having pneumococcal meningitis (a life-threatening infectious disease that causes inflammation of the layers that surround the brain and spinal cord). They remained in hospital where they later died.

C complained to the board about their initial assessment and treatment of A. They complained that A was misdiagnosed and that staff did not follow the correct procedures when reviewing their condition. C also felt that A should have been seen by a doctor before the decision was made to discharge them.

The board arranged for a Significant Adverse Event Review (SAER) to be carried out by doctors not involved in A’s care. The SAER identified a number of areas where the board could have acted differently in A’s case. However, C still had a number of concerns and asked that we conduct a further review of the case.

We took independent advice from a consultant paediatrician. We found that, overall, the SAER had appropriately identified the key failings in the board’s care, including that the original diagnosis of gastroenteritis was unreasonable based on A’s symptoms. However, we found some additional failings in record-keeping, and highlighted that we would have expected the misdiagnosis to have been identified when the nurse practitioner discussed A’s case with a doctor before discharge. We also considered there had been failings in the handling of C’s subsequent complaints.

For these reasons, we upheld all of C’s complaints.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to provide A with reasonable treatment, failing to reasonably diagnose A, failing to keep reasonable records about A's treatment, and failing to reasonably communicate with them. 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 being consulted by nurse practitioners, doctors should be able to identify potential misdiagnosis.
• When the content of a telephone call is relevant to the care record of a patient, the clinical record should be updated with details of this.

In relation to complaints handling, we recommended:

• When comments or input is required from multiple clinicians, this should be clearly coordinated and organised to avoid unnecessary delay.
• Where complaints investigations are delayed, complainants should be kept up to date on progress and given detailed reasons for the delays when requested, particularly in sensitive cases involving a death.

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) about a failure to provide them with reasonable care and treatment for a rectal prolapse (a condition where the rectum protrudes through the anus).

We took independent advice from a consultant colorectal consultant (a surgeon who specialises in conditions in the colon, rectum or anus). We found that A’s initial symptoms were indicative of haemorrhoidal disease (swollen veins in the lower part of rectum and anus). We noted that A was appropriately treated with banding (a procedure whereby the base of the haemorrhoid is tied with a small rubber band to stop the blood flow to the haemorrhoid as first line treatment). A later developed a full thickness prolapse and treatment for this changed accordingly at that time. We did not consider A had been misdiagnosed as their condition deteriorated over time.

However, prior to the full thickness prolapse developing, we noted that the team continued to give A painful banding treatment for two and a half years when there was little prospect of improving A’s symptoms. Whilst A’s consent was given for this, we could not see any notes to indicate that there was a discussion with A about possible surgical removal of haemorrhoids which would have been reasonable to expect. We therefore upheld the complaint on the basis that it would have been reasonable to expect alternative treatment was discussed.

C also complained about the board’s failure to provide a clear response to the complaint. We found that, whilst in the complaint response there was reasonable general information about prolapses, there was no reference to A’s specific case. A thought that they had been misdiagnosed. The board did not explain the decisions made by the clinical team and how they were informed by A’s symptoms at each appointment. This would have provided A with the information they were looking for and it was reasonable for A to expect this would be provided. We upheld this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to A for failing to keep contemporaneous records of discussions and decisions in the clinical records, failing to consider surgical treatment for a third degree prolapse (where the patient has to push the piles back in) when banding failed to improve symptoms of haemorrhoids and failing to provide a clear response to the complaint which referred to A’s particular experience. The apology should meet the standards set out inthe SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

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

• To ensure clinical staff discuss, assess and document alternative treatments.
• To ensure clinical staff keep accurate records of appointments, examinations and discussions.

In relation to complaints handling, we recommended:

• Responses to complaints should be specific to the patient in question and address all points raised.

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

Whilst C was carrying out works to replace their business's boiler, they discovered that water running through their meter had been supplying two neighbouring businesses, because the meter had been incorrectly fitted years before. They complained to Business Stream (BS) and requested a refund for the amount they had been overcharged. BS accepted liability for the incorrect charging but only offered to refund five years' worth of charges, asserting that the older charges had prescribed (expired) under the five-year limit in the Prescription and Limitation (Scotland) Act 1973 (the 1973 Act). C complained to BS that this was unfair, particularly considering that the company had been paid twice, as their neighbours were also BS customers, but BS refused this. C's said that BS had unfairly failed to consider refunding them the full amount.

We found no evidence that BS had fully considered the complexities of the 1973 Act, in order to calculate when, and if, the debt should have prescribed. Despite repeated requests from C and this office to provide an explanation of their legal position, they were unable to explain this in sufficient depth to justify their approach. In addition, their policies on prescription were suggestive of a blanket approach to applying the five-year limit in all cases, without considering potential exceptions. We considered that these factors were evidence that BS had failed to fairly consider refunding C in full. Towards the end of our investigation, BS did provide a reasonable legal rationale to suggest that the debt should be prescribed. However, we were critical of the fact that C had to resort to complaining to our office before this was forthcoming.

In addition to refunds that were legally required, BS told us it was their policy was to consider whether an ex-gratia (voluntary) payment was appropriate to extend refunds beyond the usual five years, taking account of the specific circumstances of the case. However, there was no evidence that they had considered C's specific circumstances, despite their request, insisting it was unfair for them not to pay. In addition, their policies on ex-gratia payments lacked clarity and consistency. Again, we considered these factors were evidence that BS had failed to fairly consider refunding C in full. Ultimately, we were of the view that, regardless of any legal liability, it was fundamentally unfair for a business providing a public service to refuse to refund the full amount. This was because BS recognised they were incorrectly paid twice for the services in question and so a refund would not represent a loss for them. For these reasons, we upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to fairly consider their request for a full refund and for unfairly withholding the refund. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/informationleaflets
• Business Stream should provide C with a full refund for the amount they were overcharged. This should be calculated using historic consumption of the other properties in question, where available. Otherwise a fair and justifiable methodology, consistent with that previously used, should be employed to calculate the refundable amount.

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

• Whenever considering whether to apply a prescriptive limit to refunds, Business Stream should fully consider a customer's personal circumstances against all of the relevant legislative requirements and clearly record their rationale.

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 lack of action in relation to reports of anti-social behaviour about a neighbour made by C and their family over a number of years.

The council had accepted in their complaint response to C that there had historically been a failure to appropriately record and take action on reports of anti-social behaviour, and we considered this failing to be unreasonable. We therefore upheld the complaint. We noted that following the case being taken over by a new officer and a new manager, the council had acted appropriately, including meeting with C and their family and taking action on the reports of anti-social behaviour. We considered that much of this, potentially, could have been done at an earlier point, however, we acknowledged that things now appeared to be being handled in line with relevant guidance and took this into account when making recommendations.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C and their family for failing to appropriately record and take action on reports of anti-social behaviour and the impact this had on them as a family. The apology should include an acknowledgement that, had appropriate recording taken place, this may have resulted in earlier action being taken. 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:

• Reports of anti-social behaviour should be recorded and acted on in line with the antisocial behaviour policy.

In relation to complaints handling, we recommended:

• Complaint responses should be transparent regarding the failings that have been identified in complaint investigations.

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 to us about the council, who they had rented a garage from for years. C was concerned that the council had not informed them of the presence of asbestos in the garage, which C only became aware of after repair works were carried out to the roof.

We found that, although the council did not appear to have a legal duty to inform C, they had clear policies on asbestos which committed to '… doing all that is reasonably practicable to prevent exposure of its employees and others to airborne asbestos particulates.' Given this wide-ranging commitment, we considered that the council should have considered notifying C on sign-up, but there was no clear evidence of this.

We also found that there was insufficient record of the initial inspection carried out after C reported the repair required to the roof. This made it difficult to assess whether asbestos containing material had been damaged (which could potentially pose a risk). In the absence of clear evidence that no such material was disturbed, we consider that the council should have notified C of the presence of asbestos when the repair was reported. For these reasons, we upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to notify them of the presence of asbestos in their garage. 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:

• All inspections involving asbestos containing material should be adequately recorded and tenants should be warned if material is potentially disturbed or damaged.
• The council should consider notifying garage tenants of the existence of asbestos on sign-up.

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 unreasonably removed their child (A) from their care following an incident at A's nursery. C said that the council removed A from their home without a court order and said they did not enter into a voluntary agreement that A would be cared for by their other parent, as had been suggested by the council.

We took independent advice from a social worker with experience with children and families. We found that the council failed to take account of the court order which appeared to be already in place for A and stipulated the arrangements for A's care, when deciding to place A with their other parent, particularly as the council were changing these arrangements. We noted that as a court order appeared to be in place, it was not automatic that parental rights could be exercised by either parent without the consent of the other, as the council had stated. If the arrangement following the nursery incident was not mutually agreed and went against C's wishes (which appeared to be the case), then in order to remove A from C, even if placing them with their other parent, there should have been a legal framework to enable this to happen - such as applying for a child protection order, if the council believed it was unsafe for A to remain in C's care. We considered that the council's actions were unreasonable and were not in A's best interests.

We were also critical of the council for failing to minute the multi-agency welfare meetings to discuss A's care and the changes to this, and of the council's record-keeping. We considered that there was a lack of clarity in respect to the action taken and the legal basis for doing so, including a lack of evidence that this was shared with C in a transparent way. We upheld C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to take account of the court order for residence that appeared to be in place for A prior to removing A from C and stipulating conditions for their care; and failing to produce minutes of multi-agency meetings held regarding A's care. 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:

• A record of multi-agency meetings should be available to ensure that there is a shared understanding of the concerns and the plan for the child and so that the parents and child have an opportunity to have their views recorded. The record should state clear outcomes, which include who is accountable for taking any action forward, in accordance with sections 33 and 34 of the Children and Young People (Scotland) Act 2014, which outlines the requirement in respect of a child's plan.
• In cases of this type, the council should take account of a court order for residence, prior to removing a child from a parent's care and stipulating alternative care arrangements.
• Social work records should clearly evidence the action taken in cases of this type, including any legal basis for taking that action.

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 brought a complaint to us about the care and treatment given to their late spouse (A) who had a diagnoses of myeloma (a type of cancer arising from plasma cells found in the bone marrow). C told us the reasons they considered the board had provided A with unreasonable clinical care and treatment were that there had been a delay in the diagnosis and treatment of endocarditis (an infection of the endocardium, which is the inner lining of the heart chambers and heart valves); there had been a lack of communication about A's state of health, and their prognosis was not communicated until three days before they died. Finally, A had been discharged home although they were very ill.

C also raised a number of concerns about the nursing care and treatment given to A, in particular that there had been a lack of communication and that the level of general nursing care and treatment was unreasonable.

We took independent advice from a consultant in cardiology, a consultant in acute medicine, a haematology consultant and from a nurse. We found that overall the cardiology care and treatment was reasonable, also that the care and treatment from an acute medicine perspective was appropriate. We also found that the haematology care given to A was reasonable and in line with the British Society of Haematology and UK Myeloma forum 'Guidelines for screening and management of late and long-term consequences of myeloma and its treatment'. However, we considered that there had been poor communication with A's family, in particular around the significant risk associated with their illness and the risk that their condition would ultimately prove to be untreatable. The board had accepted there were gaps in communication and detailed the action taken to improve communication with the patient and their family. As such we upheld the complaint.

In relation to the nursing care and treatment given to A, we found that there was clear documentation of care needs, ongoing evaluation and assessment, with escalation to medical staff when required. The nursing care in relation to the administration of medication overall was also reasonable. However, we found that communication was unreasonable in relation to care. The board accepted failings in relation to communication and detailed the action to be taken.

Given the failings in relation to communication which forms part of ensuring patient centred care, on balance, we upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C and the family 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.

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 their late relative (A) received. A became unwell whilst abroad and was treated in hospital, at which time their blood thinning medication was stopped. Upon A's return home, they sought advice from their medical practice and arrangements were subsequently made for A to be admitted to hospital. After a period of six days, A was discharged from hospital. Their blood thinning medication was not restarted pending investigations. A then suffered two strokes and later died.

C complained about a number of issues related to: communication; failure to manage blood thinning medication; no head scan being performed prior to A's first stroke; the time taken to perform scans; matters related to an echocardiogram (a scan used to look at the heart and nearby blood vessels); management of the first stroke; and that a post mortem was not performed. C also complained that the board failed to respond to additional complaint correspondence they had sent.

The board's investigation identified areas of care that were of an unacceptable standard and they made a number of recommendations to address the failings.

During our investigation, we took independent advice from a consultant geriatrician (a specialist in medicine of the elderly). We did not identify evidence of unreasonable practice in the board's care in relation to a head scan not being performed prior to A's first stroke, nor did we identify any failings related to the management of A's first stroke. Nevertheless, we found that there were unreasonable failings related to communication; management of A's blood thinning medication; the echocardiogram and the post mortem. We, therefore, upheld this complaint.

We also investigated C's concerns about the board's handling of their complaint. We found that there were issues raised in C's additional letter that were not fully addressed by the board. We considered that a clear written response should have been provided to C. We concluded that it was unreasonable that the board did not provide a written response to the points laid out in C's additional correspondence. We, therefore, upheld this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C and the family for the unreasonable failings in A's care and treatment and for the inaccurate reference in the Significant Adverse Event Review report that it was the GP's recommendation that A did not go on holiday. 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:

• Appropriate consideration should be given to the restarting of blood thinning medication following clinical procedures, such as biopsy.
• Comments made by families during the Significant Adverse Event Review process should be reasonably responded to.

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

Mrs C complained that the board failed to deal with her complaint in a reasonable way. Mrs C made a complaint and received an acknowledgement but did not hear anything back for seven months. Mrs C asked for an explanation about the delay in keeping her informed and when the health board expected to be in a position to respond to the complaint. In all emails, Mrs C asked to be contacted by email. The health board responded the following month by letter saying that the matters raised were not new (as Mrs C had made several complaints previously) and they were handling the complaint under their unacceptable actions procedure.

In reaching our decision, we did not reach a judgement on whether the issues raised were new, but considered whether the health board handled the complaint in a reasonable way and whether their actions were in line with their unacceptable actions procedure.

During our investigation, the health board acknowledged their response to Mrs C was insufficiently clear about why they had determined that no further response to the complaint was required and that there was an unacceptable delay in responding to her complaint. Moreover, whilst we appreciated the health board did not email because of concerns about security, we considered that as long as complainants are made aware of any data protection concerns when receiving confidential information by email, then staff should respect a complainant's preferred method of contact. In addition, we found that staff should have signposted Mrs C to this office in their response in line with the NHS Model Complaints Handling Procedure (MCHP). Furthermore, there was no evidence that the health board complied with their unacceptable actions procedure in a number of respects. Overall, we found that the health board did not deal with Mrs C or her complaint in line with their procedure and we upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C for failing to deal with her complaint in a reasonable way. The apology should meet the standards set out in the SPSO guidelines on apology available at https://www.spso.org.uk/information-leaflets.

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

• Complaints should be dealt with in line with the MCHP and, where appropriate, the board's unacceptable actions procedure. The MCHP and guidance can be found here: 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.