Upheld, recommendations

Summary

C complained that there was an unreasonable delay in providing their parent (A) with a diagnosis of pancreatic cancer.

We took independent advice from a consultant radiologist (a doctor who specialises in diagnosing and treating disease and injury through the use of medical imaging techniques such as x-rays and other scans) and a consultant gastroenterologist (a physician who specialises in the diagnosis and treatment of disorders of the stomach and intestines). We found that radiology unreasonably failed to detect and report pancreatic cancer from a scan taken five months prior to diagnosis and that there was an unreasonable failure to hold a multi-disciplinary team meeting between radiology and gastroenterology with imaging. We also found that there was an unreasonable delay in investigating the cause of A's pancreatic insufficiency as it would have triggered further imaging. We considered that earlier detection may have improved A's quality of life because they would have had a management plan for palliative care sooner. We upheld this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C and their family for the delay in diagnosing A's pancreatic cancer at the three points detailed in the decision. 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:

• Regular multidisciplinary meetings should be arranged where difficult cases are discussed with imaging and clinical information available.
• The board should encourage the use of multiplanar reformatting facility (involves the process of converting data from an imaging modality acquired in a certain plane, usually axial, into another plane).
• The board should ensure all organs are assessed for CT reporting.
• To ensure radiological errors are reviewed with all reporting radiologists and radiographers to facilitate shared learning.
• To view this case as a learning opportunity that a lower threshold for suspicion of pancreatic cancer should be adopted by clinicians.

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 care and treatment they received from the board when they were admitted to Inverclyde Royal Hospital with severe abdominal pain was not reasonable. C raised issues regarding lack of a laparoscopy (a type of surgical procedure that allows a surgeon to access the inside of the abdomen and pelvis without having to make large incisions in the skin being performed), and delays in receiving a CT scan and antibiotic therapy. C had concerns that these issues contributed to the major surgery they ultimately underwent for suspected appendicitis (a painful swelling of the appendix).

We took independent advice from a general surgeon. We found that while a laparoscopy would have been helpful in diagnosing C's condition, it was not unreasonable that the board did not perform one in C's case. However, we found that a CT scan should have been performed earlier in C's admission, particularly when the decision was made not to perform a laparoscopy. We further found that it was unreasonable not to provide antibiotic therapy earlier in C's admission, given their presentation with features of infection. We found it was likely that, had the board performed a CT scan earlier, C would have undergone surgery earlier or received antibiotic therapy sooner, and this would have altered the clinical course with earlier and more minor surgery. As a result, we upheld this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failings identified in their 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 managed so that they receive treatment and scanning based on their clinical presentation at the appropriate time.

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

Summary

C attended the minor injuries unit at Queen Margaret Hospital and was unhappy with the way they were dealt with by a member of staff in the reception area. C considered that the board's investigation of their subsequent complaint was incompetent and lacked professionalism.

We found that the board failed to take timely and robust action to investigate and respond to C's complaint. The complaint was initially dealt with as a concern at C's request, however, we considered it should have been dealt with as a formal complaint investigation from the outset, or at least immediately upon C expressing dissatisfaction with the response to their concern. It was not logged as a complaint until the board met with C a few weeks later. The timescale for responding to C's complaint was excessively beyond the 20 working day target timeframe.

There was ongoing confusion as to the identity of the individual C's complaint was about, which was never resolved. The board did not take robust steps to try to identify and obtain written statements from the individuals present. By the time they requested CCTV footage of the incident, it was no longer available. C continued to seek answers and had two post-complaint meetings. We found that there was a failure to adequately follow up on agreed actions points from the first of these meetings. Overall, we concluded that the board's handling of the complaint was unreasonable and we, therefore, upheld this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failure to take timely and robust action to investigate their complaint, including the failure to treat the complaint as a complaint from the outset and quickly pursue relevant evidence; the failure to respond to the complaint within the required timescale; and the failure to adequately follow up on agreed action points from a post-complaint meeting. 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 complaint investigations conform to the NHS Model Complaints Handling Procedure, particularly in terms of timeliness, thoroughness, and how to deal with complaints where a person states they do not wish to complain.

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) when A was an in-patient at Dumfries and Galloway Royal Infirmary after being transferred from another hospital. A had been commenced on Sando K (a medication used to treat and prevent low potassium levels). Three days later, A's potassium levels were found to be high. A's condition deteriorated and they were transferred to the critical care unit. C complained about the board's management of A's potassium levels and kidney function.

We took independent advice from a consultant in acute medicine. We found that that there was a failure to note A's potassium levels were normal the day after being transferred and subsequent failures to check this on the following two days. Whilst we found that it was not A's potassium levels which resulted in their admission to the high dependency unit, we considered the failings to be unreasonable and we upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C and A for the failure to provide reasonable care and treatment in relation to A's potassium levels and kidney function during their admission. 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:

• Sando K should only be administered when required, and patients on Sando K should have daily reviews to ensure it is still required.

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 parent (A) about the care and treatment provided by the practice. C considered that there was a failure to carry out reasonable physical examinations and appropriate tests based on the symptoms A presented with, prior to A receiving a diagnosis of untreatable Signet Ring Cell Carcinoma (a type of cancer).

We took independent advice from a GP. We found that there was a failure to refer A for an urgent investigation or for an urgent ultrasound due to their weight loss, new diabetic diagnosis and age. We upheld this aspect of the complaint. We found there was a failure to carry out a physical examination of A on two occasions and also a failure to ensure that an urgent referral letter was sent to the colorectal (conditions in the colon, rectum or anus) service within a reasonable timeframe. Therefore, we upheld these aspects of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to A and C for a failure to refer A for an urgent investigation or an urgent ultrasound; a failure to carry out a physical examination of A; and a failure to ensure an urgent referral letter was sent within a reasonable timescale.The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets

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

• Ensure clinical staff are aware of colorectal referral guidelines relating to the need for a physical examination of a patient prior to referral.
• Ensure relevant clinical staff are aware of referral guidelines for newly diagnosed diabetes and weight loss.

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 owned a holiday let property and received water and waste services from Wave. C said they were paying approximately £200 per quarter for the waste and water services to the property. Months after commencing services with Wave, C received new, backdated bills increasing the amount by over £4000 for the period which C considered was incorrect. After investigations and amendments some charges were removed, however, C remained of the view that the increased charges and demands being received for the same were incorrect and submitted a complaint.

We found that there was a significant delay in a meter reading for the property being actioned. This meter reading showed usage more than six times over the anticipated amount, but bills were not issued showing this increased usage until some months later. On investigation it appeared that the most likely cause for the increased usage was a leak, however, C was not advised about the possibility of applying for a leak allowance until after the six-week period for submitting a claim had passed. This was unreasonable and we upheld this aspect of the complaint.

We also found that the communication relating to this complaint was poor. Wave did not make clear their position on C's dispute with the charges and on their complaint until months after the complaint was submitted. Then it was predominately follow-up contact from C which prompted Wave to respond to their queries. C's complaint was not finalised nor was C referred to our office until twelve months after they submitted their complaint. This was an unreasonable delay and, therefore, we upheld this aspect of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the communication failings and billing delays. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.
• Revise C's charges to align with what C would have paid if they had been awarded a leak allowance.
• Review the bills issued to C to ensure they are accurate. If any changes are required a cover letter should be provided explaining the changes.

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

• Have a process in place to respond to actual meter readings and notifying customers of the updated bills in a timely manner, possibly including a cover letter if there is a significant change and what steps they can take to dispute the usage.

In relation to complaints handling, we recommended:

• A clear process in place to escalate complaints/disputes, ensuring Wave makes their position clear and customers are aware of how they can escalate their complaint.

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

Summary

C complained about the university's handling of their complaint in relation to language used by an external tutor that C felt was inappropriate. C told us they were specifically concerned that the tutor was not contacted or interviewed as part of the investigation and that it was unreasonable that correspondence between the tutor and the Dean of the relevant school was not included in the appendices of the investigation report.

We found that there was no requirement for the university to contact or interview the tutor as part of the investigation or for the correspondence to be included in the investigation report but that these things would usually happen. We found that the reasons given in the report for why the university had decided not to contact or interview the tutor were inaccurate. We also found that the university did not make clear all of the reasons why the correspondence between the tutor and the Dean were not included in the report. Therefore, we considered that the university had not responded to C's complaint reasonably and upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for not responding reasonably to their complaint. The apology should meet the standards set out in the SPSO guidelines on apology, including direct reference to the specific issues highlighted in this decision. The standards are available at: www.spso.org.uk/information-leaflets

In relation to complaints handling, we recommended:

• The university should clearly record all significant decisions taken as part of an investigation and provide clear and accurate investigation reports.

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

Miss C, a student adviser, complained on behalf of a student (Miss A) regarding the university's stage 2 appeal outcome letter. She complained that the outcome letter took 20 weeks to be completed as opposed to the published timescale of four weeks; that the university did not apologise for failings they had identified through the appeal consideration; that no further reasons were given for the stage 1 appeal being turned down; and that it was not clear whether the additional evidence provided at stage 2 was taken into account.

We considered that the delay in the stage 2 outcome letter being issued was unreasonable, although we noted that the university had apologised for this and had made changes to prevent this occurring in the future. We accepted that it will not always be appropriate to put information about lessons learned in the academic appeal outcome letter; however, we considered that any failings identified in appeal should be formally apologised for, either in the outcome letter or in a separate letter. We also considered that the stage 2 appeal outcome letter could have stated more clearly that all additional evidence had been considered. We upheld Miss C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Miss A for the failings identified in their consideration of her stage 2 appeal (ie missing opportunities to support her during her studies and not providing a full response at stage 1 of the appeals process), failing to apologise for the failings identified in consideration of her stage 2 appeal, failing to state more clearly that all additional evidence provided at stage 2 of the appeals process was considered. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/leaflets-and-guidance.

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

• Ensure that, regardless of the outcome of an appeal, any failings identified are apologised for.
• The stage 2 appeal outcome letter should clearly communicate the evidence that has been 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.

Summary

C complained in their own right and on behalf of their child (A) about the Scottish Prison Service (SPS)'s handling of two complaints they made. C also complained about A being transferred to another prison, that they did not receive a reasonable explanation of why they were transferred, and about the SPS's response to a complaint made by A.

We found that the SPS's handling of C's complaints was not in line with good practice, and communication with C about their complaints were not clear. Therefore, we upheld these aspects of the complaint.

We also found that, while the SPS had the authority to transfer A, they had not recorded the reasons for doing this, in line with their own procedures, and were therefore unable to confirm the reasons for their decision. Therefore, we also upheld these aspects of C's complaints.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the unreasonable handling of their complaint and for failing to provide a reasonable response to their letter.
• Apologise to C and A for failing to record or explain the reason for A's transfer. The apologies should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.ul/information-leaflets

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

• A clear record should be made of the reasons a prisoner is being transferred, explaining, where appropriate, what behaviour has led to the decision to transfer, what evidence is available of that behaviour and, importantly, why the prison consider transfer is an appropriate way to address that behaviour. This record should then be shared with prisoners, unless there is a clearly recorded security reason not to do so.

In relation to complaints handling, we recommended:

• All complaints should be reasonably investigated, with a record made of any discussions with staff. Full explanations should be provided to all complainants.
• Complaints should be handled and responded to in line with the relevant process and the Model Complaints Handling Procedure.
• Responses to complaints should address the points raised, or explain why information cannot be provided.

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 constituent (A) about the council. A and their child had been homeless and living in temporary accommodation. They were offered permanent accommodation but turned this down, as they did not consider the property to be suitable. The council were satisfied that they had discharged their legal duty, as A had refused what was considered a reasonable offer of permanent accommodation. A requested a review of the offer of permanent accommodation. The council's appeal panel considered A's request and concluded that the offer of permanent accommodation was reasonable and stated that, as a result, they would not make a further offer of housing to A.

C complained that the council did not appropriately consider all the points raised by A in the request for review. Therefore, C did not consider the council to have handled the request for review reasonably. In addition to this, C complained about the council's communication with A in respect of housing matters.

In response to our enquiries, the council acknowledged they did not appropriately address all the points A made in their request for review in a satisfactory manner. Furthermore, the council identified that information requested from A by the appeals panel was either not relevant or was already accessible. Based on our review of the evidence, and taking into account the council's response, we concluded that the council failed to consider A's review request in a reasonable or appropriate manner. Therefore, we upheld this complaint.

In respect of communication, the council also acknowledged failings that were not identified as part of their investigation into A's complaint. We also identified further failings in respect of communication during the review process and when A's housing officer was off work for a significant period of time. In light of these failings, we upheld this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to A for failing to consider their request for a review of an offer of housing in an appropriate or reasonable manner and for the instances where there was a failure to provide a reasonable level of communication in respect of housing matters. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.
• Ensure that the process failings identified are taken into account when considering any future applications for housing made by A.

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

• Service users should receive a reasonable level of communication when contacting the council in respect of housing matters. Tenants should be informed if their housing officer is expected to be absent for a significant length of time. Communication with service users should be recorded appropriately.
• Requests for a review of a homeless decision or an offer of housing should be considered and decided in line with the relevant council guidance/policy.

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.