Upheld, recommendations

Summary

Ms C complained about the service provided by the council after her property sustained water ingress from a nearby mains water pipe. The pipe was located under a council owned footpath and fed a nearby property. Scottish Water was unable to assist in the circumstances and so the council undertook to investigate the leak. Subsequently, a contractor appointed by the council excavated the footpath and fixed the leaking pipe. Initially, the water ingress into Ms C's property ceased. However, a short time later Ms C contacted the council to advise of a reoccurrence of the water ingress. The council did not accept Ms C's position that the work carried out by their contractor had caused the further ingress and decided not to undertake further work on the pipe. Ms C was unhappy with the way the council had dealt with the leaking pipe.

We found no evidence that these repairs were inspected by the council prior to or at completion to ensure that they were carried out to a satisfactory standard. We concluded that there was a lack of appropriate oversight over the works and we upheld this aspect of Ms C's complaint.

Ms C also had concerns about the way the council handled her correspondence and complaints. The council acknowledged to Ms C that they had not responded to a number of her letters, yet we found that they did not adequately establish the reasons as to why this happened. While other aspects of the council's complaint handling were satisfactory, we upheld this aspect of Ms C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms C for the failings identified. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

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

• A clear specification of works should be provided to contractors acting on behalf of the council and, where appropriate, inspections should be performed to ensure work is carried out to an appropriate standard. Any inspection should be documented.

In relation to complaints handling, we recommended:

• Where resolution is not possible, an investigation should provide a customer with a full, objective and proportionate response that represents the council's final position.

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 agreements between them and the school their child (A) attended had been repeatedly broken. In addition, C's spouse had been initially prevented from attending a meeting about A, due to an objection from A's other parent. C believed it was unreasonable for the school to have informed A's other parent that their spouse would be attending. C was also unhappy with the council's investigation into the complaints they made about these issues. Although some of their complaints had been upheld, C felt that the council had not investigated the issues properly and noted that the recommendations made following the investigation by the council had not been carried out.

We found that the school had failed to adhere to the agreements it had reached with C about A. We considered that the council's investigation was right to uphold C's complaints, but it had unreasonably concluded that the actions taken by the school were adequate, when they were not. We also found that the recommendations made by the council's investigation had not been carried out, which undermined the value of the apology they offered to C.

We found that the investigation into the meeting which C's spouse was initially barred from attending was unreasonable. In particular, the actions of school staff did not appear to be in line with Getting It Right For Every Child procedures. We also found that the council's investigation had unreasonably restricted the information that it was considering. Consequently, important aspects of the decision were overlooked, including the legal basis for the original decision to bar C's spouse from the meeting, which was the source of the complaint. We found, however, that given the passage of time a re-investigation of the complaint would not have been reasonable or proportionate. We upheld all of C's complaints.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C, their spouse and A for the failures identified in this report. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

In relation to complaints handling, we recommended:

• Complaint investigations should identify and pursue all relevant avenues of investigation.

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 was concerned about the support they received from the Children and Families Social Work Team regarding concerns about their child (Child A), particularly following Child A running away from the family home. We took independent social work advice. We found that:

social work did not act appropriately on a Getting it Right for Every Child (GIRFEC) referral from a GP;

no call was made to a neighbouring social work office to investigate Child A's living situation;

there was no closing summary to explain why it was considered appropriate to close the case to social work;

the social worker in training did not appear to have been regularly supervised by a manager; and

the council's own investigation did not identify the failings in the support provided to Ms C and Child A.

Therefore, we upheld Ms C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms C and Child A for failing to provide reasonable support. 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:

• Closing summaries should be completed to explain why it is considered appropriate to close a case to social work.
• Social workers in training should receive regular supervision with a manager.
• When a GIRFEC referral is received, the GIRFEC practice model should be implemented and consideration should be given to holding a multi-agency meeting to assess the risk to the child and consider what level of help is required.
• Where a child refuses to return home and chooses to live elsewhere, reasonable efforts should be made to investigate the suitability of that living situation.

In relation to complaints handling, we recommended:

• The council's complaints handling system should ensure that failings (and good practice) are identified, and that it is using the learning from complaints to inform service development and improvement (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, an advocacy worker, complained on behalf of their client (A) who was a single parent who provided the majority of the care for their child (B). B had significant support needs and required 2:1 and sometimes 3:1 care. A employed an additional carer through B's Self Directed Support (SDS) allowance. A submitted a complaint to the council in relation to the support that they provided to help A care for B and for A's opportunities for respite.

We took independent advice from a social worker. We found that while the initial support provision for B was reasonable, when their hours of support were reduced there was a lack of transparency or reasonable explanation in the documentation for how the council came to the decision. This was unreasonable. There was also a lack of a Multi-Agency Action Planning Meetings (MAAPM) assessments until a considerable time after B moved into the council area. We found that the council failed to provide reasonable support to B. We upheld this aspect of the complaint.

Secondly, we found that more action should have been taken to look for appropriate respite care for B to allow A time away from their caring role. We found that it would have been reasonable for the council to have prioritised arranging further carer time. Overall, we found that the council failed to provide reasonable support to A as carer for B. We upheld this aspect of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to A for the failings identified. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.
• Decisions to change support packages should be transparent and justifiable.
• Reasonable actions should be taken to consider what options are available to allow A to receive respite away from their caring role.

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

• Information recorded should always be checked for accuracy.
• MAAPMs should be on a regular basis with specified formal review dates.
• There should be transparency in respect of the level of assessed need and changes to the package of care should be clearly explained and evidenced.

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's late parent (A) had dementia and received care services in their home from a care provider managed by the partnership. A had increasing difficulties with mobility. C complained about delays in the care provider putting appropriate measures in place to assist A to mobilise. A remained in bed while suitable equipment was being sourced. C complained that delays in putting measures in place to assist A in mobilising resulted in A's health declining.

C's complaint was responded to by the partnership. The partnership said that relevant measures were implemented at each stage of the process following a necessary assessment with relevant specialist professional input. They said it was evident that A's general health and mobility were in a downward decline during this period of time.

From the available evidence, we noted that although the care providers were liaising with appropriate professionals to put measures in place they were responsible for a number of delays which impeded this process.

We took advice from a suitably qualified adviser. We recognised that A's health and mobility were declining and variable during this period and there were clear practical difficulties in maintaining their mobility. However, we considered that there were some unreasonable and avoidable delays in putting measures in place to assist with mobilisation. We therefore upheld this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to A's family for the unreasonable delays in putting effective measures in place to help mobilise A out of bed. 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:

• Care staff should act promptly to ensure appropriate equipment is ordered following assessments.
• Care staff should use safe moving and handling techniques at all times.

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 his mother (Mrs A) was having problems with her monitored alarm system, which kept activating a carbon monoxide alarm. Mr C said the partnership had taken inadequate steps to investigate this, leaving Mrs A stuck in cycle of alarm activation, gas disconnection and reconnection, which was costing her money. It also meant that the source of the alarm was never identified. Mr C noted that the partnership's final action had been the removal of the alarm, which meant Mrs A potentially still had an unexplained source of carbon monoxide within her property.

The partnership had told Mr C that they were at a loss as to how they should investigate further. They had provided him with a third party claim form, to seek to recover the costs of the gas reconnection for Mrs A, but Mr C had opted not to do this.

We found that Mr C had provided the partnership with a reasonable suggestion for possible causes of activation for the alarm system. We considered that it was inaccurate for the partnership to say they had carried out a thorough investigation into the possible causes of the false activations of the carbon monoxide alarm. We upheld this aspect of Mr C's complaint.

Mr C also complained that the partnership failed to communicate with him reasonably or appropriately. Mr C said that he had insisted that his correspondence was not a formal complaint, although the partnership had treated it as one. We found that the partnership have the discretion to decide when correspondence would be better handled under their complaints procedure. However, the partnership did not explain to Mr C why they felt it was appropriate to take the matter forward as a complaint. They also failed to respond to the specific points Mr C raised in his subsequent correspondence. Therefore, 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 the failure to adequately investigate the issues he was raising and for the failure to acknowledge or address the issues raised by his correspondence. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.
• Investigate the possible causes of alarm activation suggested by Mr C in his complaint to the partnership.

In relation to complaints handling, we recommended:

• Complaint investigations should whenever possible be agreed with the complainant before they start.

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, an advocate, complained on behalf of his client (Mr A) about the care and treatment Mr A received from the board when he attended hospital after his GP sent for an ambulance for him. The GP sent for an ambulance after a phone consultation with Mr A's wife, as they suspected that Mr A was having a stroke.

When Mr A was admitted to A&E, he was treated for fast atrial fibrillation (an irregular heart beat) and possible alcohol related issues. Mr A was discharged from the hospital on the day after he was admitted. However, he was admitted to hospital again the following day. A CT scan was carried out and this confirmed that Mr A had suffered a stroke.

Mr C said that medical staff within A&E did not act appropriately when Mr A was originally admitted to hospital and that medical staff unreasonably failed to investigate the possibility that Mr A had suffered a stroke, despite symptoms being identified in his admittance notes.

We took independent advice from an appropriately qualified adviser. We found that there was nothing contained in Mr A records when he was originally admitted that indicated he had suffered a stroke. Based on the evidence and Mr A's presentation, we concluded that it was reasonable for medical professionals to exclude a stroke at that time. However, we noted that Mr A symptoms were suggestive of a transient ischaemic attack (TIA; a stroke lasting for a shorter period, less than 24 hours). The records suggested appropriate consideration was not given to the possibility and symptoms of a TIA. If a TIA had been diagnosed, then the management of Mr A's atrial fibrillation may have been different. This may not have prevented Mr A's readmission or stroke, but could have changed the overall clinical management.

We concluded that medical professionals did not unreasonably fail to identify a stroke when Mr A was originally admitted. However, we concluded that the board did not give appropriate consideration to whether Mr A had suffered a TIA. In light of this, our view was that the board unreasonably failed to provide appropriate care and treatment to Mr A when he was originally admitted to hospital. Therefore, we upheld Mr C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr A for failing to give appropriate consideration to the possibility he had suffered a TIA and as a result, did not include this as part of their atrial fibrillation workup and decision-making with respect to out-patient follow-up and anticoagulation. 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&E staff should be aware of the signs of a TIA and the links between TIAs and arterial fibrillation.

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 mental health care and treatment provided by the board. They also complained about the board's communication in relation to their care and treatment.

C had been referred to psychiatry by their GP because of difficulties with anxiety and depression. C was seen by a psychiatrist who referred them for cognitive behavioural therapy (CBT) and discharged them from their clinic. C was re-referred to psychiatry urgently by their GP a few months later, following a deterioration in their mental health. C saw a psychiatrist three times and was referred for community psychiatric nurse (CPN) support because of the CBT waiting list and C's deteriorating mood state.

C saw a locum psychiatrist four times over a two-month period when C was experiencing a continued deterioration in their mental health. C then saw their original psychiatrist on another two occasions. C's mental health deteriorated further and they were admitted to a psychiatric unit.

We took independent advice from a mental health adviser, who noted from C's records that their clinical presentation was complex and multifaceted. We found that there had been a significant interruption in C's psychiatric out-patient care, with a period of 17 weeks elapsing between appointments. There was a further unplanned and unexplained gap of seven weeks between out-patient appointments. We considered these interruptions to be unreasonable, although we could not conclude with certainty that the interruption to continuity of out-patient care led to the deterioration in C's mental state and subsequent hospitalisation. Although we found that the care planning was reasonable, the significant unscheduled gaps between out-patient appointments were not reasonable, causing continuity of C's care to be disrupted. We therefore upheld this aspect of the complaint.

Overall, we considered that C had been appropriately enabled to participate in decision-making related to their care, but some failings in communication were noted. C did not receive an explanation for the issues with consultant cover which appear to have contributed to the gaps in their psychiatric out-patient care. On balance, we upheld this aspect of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to clarify precisely when their CBT referral was withdrawn; for the significant unscheduled interruptions to their out-patient psychiatric care; for failing to provide an explanation for the issues with consultant cover which contributed to the gaps in their psychiatric out-patient care; and for the instances of ineffective communication between the psychiatrist and CPN, including that which resulted in a delay in referring C to another service. 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 there are unscheduled interruptions to patient care, the patient needs to be informed of this. There also needs to be clear communication between staff when decisions are made in relation to patient care, such as onward referrals or requests for intervention by other disciplines. The timescales for the action and the person responsible for the action should be made clear, and the request should be appropriately followed up to ensure the action is taken. The board should feed the above back to staff in a supportive manner.

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 underwent specialist reconstructive surgery. After the surgery, C experienced urinary incontinence. C said that they had believed the surgery would be of a routine nature and complained that they had not been not provided with adequate information about it; in particular, that a possible side effect was incontinence.

We took independent advice from a urology adviser (a doctor who specialises in the male and female urinary tract, and the male reproductive organs). We found that the board failed to provide adequate information to C about the planned procedure prior to obtaining their consent and, therefore, we upheld this complaint.

C also complained about the delay in the surgery being carried out. The board accepted that there was a delay in C accessing treatment and explained that the delay reflected the waiting list issues the department had at the time. We found that there was an unreasonable delay in C's planned procedure being carried out. We upheld this complaint.

C complained that the board failed to provide them with reasonable care and treatment. C had concerns about how the board managed their place on the waiting list for the planned procedure and about the aftercare provided. The board acknowledged that there was a breakdown in communication which resulted in C having to arrange aftercare themselves. However, they said that their waiting list was managed appropriately. We found that there was nothing to suggest that C's place on the board's waiting list was managed inappropriately. However, we upheld the complaint on the basis of the breakdown in communication which resulted in C arranging aftercare treatment themselves.

Finally, C complained that the board failed to handle their complaint reasonably. The board acknowledged that there had been a delay in responding to C's complaint and that they had not communicated about the delay with C. We found that the board did not respond to C's complaint within expected timescales or communicate with C about that delay. We upheld this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the identified failures. 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 consent process should follow national guidelines. Consent should be taken, where possible, prior to the day of surgery. As part of the consent process, there should be a clear discussion of the risks and benefits (of having the surgery and not having the surgery) and of any alternative treatment options; and those discussions should be clearly documented.
• Patients should get appropriate follow-up appointments.

In relation to complaints handling, we recommended:

• Staff should handle complaints in line with the Model Complaints Handling Procedure, which includes responding to complaints within timescales and where this is not possible, advising complainants of this and providing revised timescales.

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 advocate, complained on behalf of their client (A) about the care and treatment A received at St John's Hospital when they attended after becoming unwell with vomiting. A had also been suffering from migraines over the previous few days. C complained that there was inaccurate reporting of the CT angiogram (a specialised scan using x-rays to look at the heart) which resulted in a delay in diagnosing a stroke; there was a delay in performing a lumbar puncture; and there had been a lack of consistent communication with the family. C also complained that A was not treated fairly due to comments made by staff about their previous medical history and that they did not receive assistance with personal care.

The board accepted that there was a failing in relation to the provisional report of the CT scan and this would have initiated treatment for A's stroke at that time. The board apologised and said that they would highlight the case at their local learning meeting. The board accepted that there was no documented evidence to support that A was receiving help with personal care, for which they apologised. However, they noted that there were regular attempts to keep A and their family updated on care.

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), from a consultant in general medicine and from a registered nurse. We found that, while many aspects of the medical care provided were reasonable (including the timing of the lumbar puncture), there was an unreasonable error regarding the provisional CT scan. This meant that there was a delay between the scan being performed and it being correctly reported. We upheld this aspect of the complaint.

We considered that A would have received medication, such as aspirin, to thin their blood earlier, but the effect of this is to prevent future strokes rather than improve the one that has currently occurred. While this would have added to the distress of A's family, we were of the opinion that the impact on A's clinical outcome would not likely have been significant.

We found evidence of reasonable communication and did not consider that inappropriate comments were made about A's previous medical history. However, we were unable to establish that A received a reasonable level of assistance with personal care because the nursing documentation fell below the record-keeping standards set out in the Nursing and Midwifery Code. Therefore, we upheld this aspect of the complaint.

Recommendations

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

• Patients should receive personal nursing care where appropriate; and this should be clearly and accurately recorded in accordance with the Nursing and Midwifery Code.
• The board should minimise the contribution of any system deficiencies to radiological errors.

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.