Upheld, recommendations

Summary

Mrs C complained about the care she received at St John's Hospital. In particular, Mrs C was unhappy with delays in the identification, monitoring and diagnosis of an abnormality in her pancreas. Mrs C had a number of hospital admissions and underwent four scans. The scans showed that the abnormality had increased in size. By the time of the final scan, it was identified that the abnormality was likely to be cancer. Mrs C was subsequently diagnosed with cancer and had surgery to have part of her pancreas removed as well as chemotherapy.

We took independent advice from a radiologist (a specialist in the analysis of images of the body) and a general surgeon. We found that the management of the abnormality was reasonable until the point of the third scan. The report of this scan identified a definite increase in size of the abnormality, although inconsistently referred to it as unchanged. We considered that a referral should have been made to the surgical team to follow up the abnormality and concluded that the failure to do this was unreasonable. We upheld the complaint. However, we concluded that if follow-up had been appropriately planned, it was unlikely that the course of events would have been different in this case. This is because Mrs C received a scan to investigate abdominal pain around the same time that a scan would have been planned in line with the recommended timescales for follow-up of abnormalities.

Mrs C also had concerns about the way the board handled her complaint. We noted that the board had acknowledged and apologised to Mrs C that there had been a significant delay in responding to the complaint. We were critical that the board did not seem to have identified the cause of the delay. We also found that the board had failed to provide updates to Mrs C about the delay. We upheld this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C for the failure to make a pancreatic surgical referral after a CT scan identified a definite change in the size of a pancreatic lesion. 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 definite increase in size of a pancreatic lesion should prompt a pancreatic surgical referral.

In relation to complaints handling, we recommended:

• Where there has been a significant failure follow the Complaints Handling Procedure, the board should consider whether they need to take any actions as a result of learning from this case.

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 time taken by the practice to refer them to the breast clinic. C initially attended at the practice with pain in their breast, which was diagnosed as musculoskeletal pain. C later returned to the practice with ongoing pain and a new lump in their breast. The practice referred them urgently to the breast clinic and a scan found a large breast cancer.

We took independent advice from a GP and from a breast surgeon. We found that the treatment provided at the initial appointment was, for the most part, reasonable, and we did not find sufficient evidence to conclude that the practice missed the breast cancer in that appointment. However, we considered that the practice should have advised C, at their initial appointment, to return within three months (in keeping with guidelines). Ideally, the practice should also have sent the referral to the breast clinic as 'urgent – suspected cancer' rather than simply 'urgent', although we accepted that, on balance, this was not unreasonable. Based on the failings identified, we upheld C's complaint. We noted that the practice accepted both these points and considered the action taken was appropriate for reflection and learning .

Under section 16G of the SPSO Act, SPSO has a responsibility to monitor and promote good practice in complaint handling by organisations under our jurisdiction. We found that the practice failed to fully reflect on and learn from C's complaint until prompted by this office. We therefore made recommendations to address the failings we identified.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for not advising them to return within three months, and for failing to fully reflect on their complaint until prompted by our 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:

• The practice should be willing to reflect on and learn from complaints (without being prompted by an investigation from this office).

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 A received at Raigmore Hospital. C was concerned that A was told by the hospital, following a CT scan, that they had a brain tumour (and likely metastases due to their lung cancer) when it later became apparent after an MRI scan that A had a stroke rather than a brain tumour.

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 in acute medicine. We found many aspects of A's care and treatment to be reasonable. However, the CT scan report stated there was uncertainty over a diagnosis of metastases and that an MRI scan should be carried out. Over a 24-hour period, a diagnostic momentum increased. This meant whilst there was uncertainty around this diagnosis it was not picked up by successive clinicians and the working diagnosis became more certain despite a confirmatory MRI having yet to be carried out. A and their family were led to believe by successive clinicians over a 7-day period that A had a brain tumour when this was not certain. Therefore, we upheld C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failure of successive clinicians to pick up on the fact the CT brain scan was uncertain around the diagnosis of a metastasis which led them to convey to A and their relatives that it was definitive. 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 CT scans commenting on diagnostic uncertainty should not be taken as definitive in their diagnostic conclusion.

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

Mr C complained that the board failed to follow relevant procedures for moving his mother-in-law (Mrs A) from a hospital in Scotland to a residential care home in England. We took independent advice from a social worker. We found that there are three contractual routes available and that the board entered into a Route 2 contract without giving Mr C a choice about the contractual route he wished to take. This was contrary to the guidance that was in place at the time of events and we upheld this aspect of Mr C's complaint.

Mr C also complained that the board failed to communicate reasonably with him about the process of moving Mrs A to a residential care home in England. We found that there was no clear communication with Mr C about the process for a cross-border placement, the contractual requirements, or transport arrangements. We upheld this aspect of Mr C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for failing to clearly communicate the process for a cross border placement, the contractual requirements, and transport arrangements and for entering into a Route 2 contract without giving him a choice about the contractual route he wished to take. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/leaflets-and-guidance.
• Consider whether it would be possible to offer Mr C other contractual options, including the Route 3 option.

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

• Individuals should be given relevant information about the different contractual arrangements, which they can fully understand and then act upon in accordance with the Guidance on Charging for Residential Accommodation (CCD2/2019).
• There should be clear communication with family members at the earliest opportunity about the process for a cross-border placement, the contractual requirements, and transport arrangements.

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 when the Driver & Vehicle Licensing Agency (DVLA) contacted the practice about C's fitness to drive, the practice incorrectly advised the DVLA that they had attended detoxification for alcohol in the past 12 months.

We took independent advice from a GP. We found that the treatment C had received from the practice was not to treat alcohol withdrawal and would not be classed as a detoxification programme. We found that there was no evidence that C had attended a detoxification programme in the past 12 months. Therefore, we upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failing 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 practice should ensure their knowledge of detoxification programmes is up to date - who delivers them and what a programme entails. Also the practice should ensure the information held by the DVLA in relation to this issue provides details of the treatment given to C.

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

Ms C complained that the care she received from the board when she attended A&E at Queen Elizabeth University Hospital and a surgical hot clinic (the hot clinic provides assessment and management of patients referred by A&E that need further investigations and assessment but that do not require to be admitted) the following day was unreasonable. We took independent advice from a consultant in emergency medicine. We found that while the majority of the care and treatment Ms C received in A&E was reasonable, the wait for triage and the wait for pain relief was unreasonable and there was no evidence of pain scores being recorded in Ms C's notes. With regard to Ms C's attendance at the hot clinic, there was an issue with her appointment, and the way the hot clinic operated did not appear to have been communicated to Ms C in advance to manage her expectations. As a result, we upheld this aspect of Ms C's complaint.

Ms C further complained that there was an undue delay in the board providing her with an endoscopy (a medical procedure where a tube-like instrument is put into the body to look inside). We found that Ms C had to wait 15 weeks for an endoscopy which was outwith the 6 week national standard waiting time and as a result, we upheld this aspect of the complaint.

Ms C also complained that the board's handling of her complaint was unreasonable. We found that the board's handling of Ms C's complaint was not in line with the NHS Complaints Handling Procedure and as a result, we upheld this aspect of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms C for the unreasonable care and treatment, the unreasonable delay in receiving her endoscopy and the unreasonable handling of her complaint. 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 triaged timeously, in line with relevant guidelines. Pain scores should be recorded regularly and acted upon timeously in line with relevant guidelines.

In relation to complaints handling, we recommended:

• Complaints should be handled in line with the NHS Scotland 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

Mr C complained that Clear Business Water (CBW) unreasonably charged his business premises for water on the basis of estimated meter readings. He said these estimated readings were based on the usage of the previous owner who operated a different type of business and for many more hours per week than Mr C’s business. He said the last time CBW read the meter at the premises was nearly a year before he had taken it over. He said that had CBW read the meter when they should have, they would have noted that it had been removed and he could have been charged on an ‘unmetered’ basis and his bills would have been considerably smaller.

CBW received a query from a meter reader who had attended to read the meter at Mr C’s premises for the first time since Mr C had taken over the lease. The reader thought the meter may have been removed as they were unable to locate it. There followed a lengthy dispute during which several attempts were made by Scottish Water on behalf of CBW to attend and try to locate a meter. Mr C was advised he would need to remove boxing behind a cistern to allow for inspection and would need to cover the costs of this. He was unwilling to bear the cost himself and declined to have the boxing removed.

We found that had CBW read the meter every six months as they should, in terms of the Market Code for Licensed Providers, they may have identified an issue with the meter sooner and Mr C may not have been billed for so long based on the consumption of a previous tenant. We also found that Mr C’s refusal to uncover the pipework at his own expense meant that CBW could not have carried out a full inspection. Mr C had a contractual responsibility to allow CBW access to the pipework even if that meant that he had to incur costs in doing so. However, we saw no evidence to show that CBW told Mr C of his contractual responsibilities. Had they done so, Mr C may have agreed to carry out the necessary works.

As CBW may have missed an opportunity to determine whether or not the meter was present prior to Mr C taking on the tenancy by failing to read the meter every six months as they are required to do, and as they failed to make clear to Mr C his contractual obligations to expose the pipework, at his own cost, we upheld this complaint.

While reviewing the complaint correspondence, we found aspects of the complaint handling to be poor and made a recommendation to address these failings.

Recommendations

What we asked the organisation to do in this case:

• Apologise for their failure to read the meter and for the impact this may have had on Mr C. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets
• Carry out a review of Mr C’s outstanding account, taking into consideration the findings detailed in this decision, and make a reasonable offer of settlement to Mr C in order to bring this matter to a conclusion as quickly as possible.

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

• CBW should ensure that they arrange for meter readings on a six-monthly basis.

In relation to complaints handling, we recommended:

• CBW should adhere to the principles of good complaints handling. They should consider ensuring that final decisions submitted in response to complaints clearly detail the complaint which was investigated, explain the steps which have been taken to investigate the complaint and provide a full, evidenced decision clearly explaining whether or not the complaint is supported or rejected.

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

Ms C complained that the Council had unreasonably failed to assess her needs as a carer. She said that she had suffered considerable stress for over a year as a result of her caring role for her son (Mr A) who has a number of disabilities.

We took independent advice from a social worker. We found that the council’s delay in completing a carers assessment was unreasonable. In addition, the report lacked any analysis of need and recommendations. It was clear that over this period Ms C was finding the situation extremely challenging and was under considerable stress. In view of these failings, we upheld this complaint. The council had accepted there was a delay in completing the carers assessment and had apologised for this.

Ms C also complained that the council had failed to provide reasonable care to Mr A. In relation to this aspect of the complaint, we found that there were failings in relation to communication and a lack of evidence to show the reasoning around decision-making. We upheld this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms 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 .
• Review Ms C’s carers assessment report in light of the findings of this investigation.

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

• There should be a clear summary of the council’s involvement and why a case is being closed to ensure that there is transparency and a clear understanding of the reasons for this action.
• Account should be taken of someone’s preferred means of communicating, unless there is a reason this is unreasonable or inappropriate.
• Assessments of this nature should set out the kind and/or level of support recommended or required.
• While there is no specific time frame for carrying out assessments, the progress of one should be monitored and addressed if it appears to be drifting and taking longer than anticipated, and action should be taken to correct this.

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

Ms C complained about the council's handling of a planning application for a housing development adjacent to her property. Ms C complained that the council did not tell her about changes that had been made to the site plan and that she was not given a further opportunity to provide representations. Ms C also complained that when the building work started, the nearest house was significantly closer to her boundary than what the council had told her the separation distances would be.

We took independent planning advice. We found that the council was not required to invite Ms C to make further representations on the planning application, as they did not consider the changes to the site plan had been significant. We noted that in their response to Ms C's complaint, the council acknowledged that they had told her the wrong separation distances. However, we also found that the council had relied upon these inaccurate separation distances in their assessment of the planning application. We considered the council's response to Ms C did not adequately acknowledge or address this. We also considered that their assessment did not contain enough detail about how they assessed the impact on Ms C's amenity. We upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms C for the issues identified in the council's handling and assessment of the planning application. 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 ensure that any representations they receive about amenity are appropriately taken into account and addressed in their assessment.
• The council should ensure they have adequate checks in place to ensure that planning applications are accurately assessed and to avoid these types of factual errors in relation to the separation distances.

In relation to complaints handling, we recommended:

• The council's complaints handling system should ensure that failings (and good practice) are clearly acknowledged and addressed, and that they are using focused learning from complaints to inform service developments and improvements (where appropriate).

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 actions in response to a child protection concern about their child (A) particularly about information shared with the Police and the conduct of specific social workers. After C received a copy of the report relating to the child protection concern, they submitted a complaint. Remaining dissatisfied with the council’s response, C brought the complaint to our office.

We took independent advice from a social worker. We found that, while the initial actions by the council in response to the child concern were reasonable, the council failed to reasonably gather and record information throughout the investigation, and in so doing failing to follow national guidance. There was no evidence that appropriate checks were made before A’s family member (B) became temporarily responsible for A’s welfare or that appropriate action was taken after C advised the council that A’s health was being impacted by the arrangement. There was no evidence that the council provided a reasonable rationale behind their decisions for this case or that relevant legislation was appropriately utilised, and records kept of the same. This was unreasonable and we upheld C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to B for failing to undertake reasonable action in relation to their role for caring for C’s child.
• Apologise to C for failing to reasonably respond to the child protection concern. 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:

• Child protection concerns are reasonably responded to.
• Decisions affecting the rights and responsibilities of parents are clearly recorded, and reasons given why any particular legislation has been utilised, with the decision appropriately reviewed.
• Decisions relating to investigations of child protection concerns are supported by a reasonable rationale which is recorded appropriately.
• National guidance is followed when gathering and recording information in relation to child protection concerns.

In relation to complaints handling, we recommended:

• Complaints investigations should be thorough and identify any key failings that occurred.

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.