Upheld, recommendations

Summary

C complained that the council unreasonably failed to investigate and respond appropriately to incidents of bullying behaviour towards their child (A). C raised concerns about an incident where A’s private information was accessed by other pupils, and about the school’s implementation of a plan to help support A. C also complained about the way the school had handled previous concerns of bullying behaviour directed towards A.

The council noted that A’s information had been accessed and investigated the circumstances, but acknowledged that C did not accept the most likely explanation. However, the council recognised that the school had not supported A as they would have wished and upheld parts of the complaint regarding the support offered to A and the failure to implement an agreed support plan.

C was unhappy with the council’s response and brought their complaint to our office. We found that, whilst the school had reasonably investigated incidents relating to the accessing of A’s private information, the record keeping of the investigation and response to the incident was unreasonable. In addition, we found that the school had failed to record behaviours A experienced as bullying, failed to record incidents on the appropriate systems and did not appropriately record actions taken in response to bullying behaviour.

We found that the council could not adequately evidence the supports in place for A, or actions taken in response to bullying concerns. Therefore, we upheld C's complaint.

Under our general powers to investigate and consider complaints handling we determined that the council’s investigation of C’s complaint was unreasonable given that it had not identified the issues of unreasonable record keeping during the investigation. We made a recommendation to address this.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C and A for the failures we have found. 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:

• Individuals investigating complaints should be aware of the complaints handling process together with the importance of assessing the quality of the evidence available, the impact this has on the ability to respond to a complaint and the learning and improvements which should be identified.

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 that they received from the board. C underwent a left total hip replacement but returned to the consultant orthopaedic surgeon for follow-up three months later as they were continuing to experience pain and mobility problems. C complained that they were told there was nothing the surgeon could do for them. C sought a second opinion and learned that they had impingement (pinching or rubbing together inside a joint) which would require further surgery. C said that they had been significantly impacted by the initial surgery, both mentally and physically.

In their original complaint response, the board acknowledged the poor outcome of the surgery. Following our formal enquiry the board acknowledged that a different choice of acetabular (socket) implant would have been appropriate. The surgeon acknowledged that this case was one where they would have benefited from advice from a more experienced surgeon. They accepted that they had failed to discuss with C that a poor outcome from surgery was a risk, and failed to document decision making and consent discussions in C’s clinical records. They apologised for failings in communication with C during their post-operative consultation. They also apologised for record-keeping failings. The board said they should have discussed this case at a departmental Morbidity and Mortality meeting once it became clear that there were ongoing problems requiring further surgery. They considered that not doing so represented a failure of process, prompting them to review their relevant structures and processes. The board confirmed comprehensive measures to address what had gone wrong in C's case.

We took independent advice from a consultant orthopaedic surgeon (specialists in the musculoskeletal system). We concluded that the board had now appropriately acknowledged the multiple failings in this case, apologising and confirming extensive learning and improvement. Taking all of this into account, we upheld C's complaint and asked the board to apologise but did not make further recommendations for learning and improvement.

Recommendations

What we asked the organisation to do in this case:

• Apologise to 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.

In relation to complaints handling, we recommended:

• Complaints are investigated with sufficient rigour to identify failings where appropriate. Complaints handling procedure timescales are met.

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 nursing care and treatment provided to their late parent (A). A had a fall during an admission to hospital. Their condition deteriorated and a large intracranial (brain) bleed was identified. A died shortly after. C complained that the nursing staff provided unreasonable care and treatment as they did not put the correct safety measures in place, given A's frailty and instability on their feet.

The board said that A was reviewed by physiotherapy who assessed A as being safe and able to mobilise independently with a walking stick. The board said that nursing staff carried out care rounding and that A was checked 30 minutes prior to their fall. Following the fall, it was noted that A was able to get up with assistance and an assessment was completed by nursing staff. When checked later, it was found A had become unconscious. The board carried out a scan of A’s head and found a large intracranial bleed.

We took independent advice from a registered nurse. We found that there was a lack of documentation and documented evidence of action taken by staff in response to cognition and mobility. Care rounding documentation was not completed to a reasonable standard or carried out to the prescribed frequency. When A’s needs changed, the care rounding was not increased. We found that the nursing staff failed to complete the mobility risk assessment, consider the use of bedrails and identify A required more help when their condition changed. We noted that the care provided by nursing staff when the fall happened and after the fall was reasonable.

We also found that the Significant Adverse Event Review that was carried out after the fall was not carried out in line with national guidance. The Duty of Candour process should have been followed in this case and it was unclear from the documentation whether this had been activated or not. We upheld C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failures identified by the 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:

• SAERs should be completed in line with the national framework and the board’s own protocols.
• Assessments, evaluations, and intervention bundles should be completed in line with guidance. Nursing documentation should include evidence of action taken due to changes observed, such as, change in cognition, change in mobility, use of oxygen, and factors that may impact safety such as the ability to use a call bell.
• The frequency of care rounding required for a patient should be prescribed and recorded accurately in the care rounding documentation. Once prescribed, the care rounding should be completed within the frequency identified. This should be recorded in the documentation to demonstrate care rounding has happened. Frequency of care rounding should be reflective of need. When there are changes in need, the frequency prescribed should change to meet the patients needs.

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 delay in the practice diagnosing their parent (A)'s cancer. C said that A was seen by a GP with recurring chest infections but was sent away with antibiotics and their initial requests for a chest x-ray were denied. When the x-ray was arranged and the results received by the practice, the GP did not contact A directly to discuss the results. Instead, A received a copy of the report from the reception staff, which was not easy to understand. C said the communication issues regarding the x-ray also led to a delay in an urgent prescription for antibiotics being passed to a pharmacy. C said that the delays in diagnosis limited the treatment options available to A.

C complained that the practice failed to reasonably investigate A’s respiratory symptoms. We took independent advice from a GP. We found that while the majority of the care provided to A was reasonable, there was a missed opportunity to refer A for an x-ray, given their symptoms and the lack of success with previous treatments. Therefore, we upheld this part of C's complaint.

C also complained that the practice failed to inform A of the results of the x-ray in a reasonable manner. We found that the x-ray report should not have been provided to A by reception staff and the findings should have been shared in person or over the phone with the GP, including all relevant information. Therefore, we upheld this part of C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to A for failing to consider a referral for a chest x-ray sooner and for failing to provide the findings from the x-ray in a reasonable manner. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

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

• Clinical staff should communicate with patients in line with GMC guidance in relation to sharing the findings of investigations.
• Patients are referred for further investigations in a timely manner, in line with NICE guidance on suspected cancer: recognition and referral.

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 parent (A) when A was admitted to hospital with ongoing pain and mobility issues following a fall. A suffered from significant leg ulcers and had received a package of care while at home. While in hospital, A developed sepsis and did not respond to treatment. A died a few months after admission.

C complained of failings in how A’s leg ulcers had been managed, stating that A’s dressings were being changed less frequently than when A was in the community. C highlighted times when family members had raised the need for A’s wounds to be dressed with nursing staff who repeatedly failed to respond to these requests. C also complained of similar failures to provide catheter care and stated their belief that these were contributing factors in A’s deterioration.

We took independent advice from a nurse. We found significant failings had occurred with regards to washing and dressing the wounds, and a failure to adhere to the standard of monitoring, risk assessment and record keeping as per the relevant professional Nursing and Midwifery Council (NMC) code. We considered that the nursing care provided was unreasonable and upheld this part of C's complaint.

The adviser also highlighted concerns about the medical care and treatment provided and on this basis we took additional advice from a geriatrician (specialist in medicine of the elderly). We found that the wound care provided lacked a coherent and consistent approach, and in particular, that A’s legs were not examined until a number weeks after admission. We also found insufficient attention was given to wound swab results and blood tests, as well as A’s level of pain and overall condition. We found that the medical care and treatment provided to A was unreasonable and upheld this part of C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to 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:

• Nursing staff should act in line with the NMC Code of Conduct, in particular Section 10 relating to documentation.
• Where there is concern about possible infection, such as in a patient with a raised CRP, any wounds should be examined within 48 hours of admission. If there is urgent concern, wounds should be examined immediately.

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

Summary

C complained about the care and treatment provided to their late parent (A) during two admissions to hospital. C complained that during their first admission A was given insulin that was for another patient and C was not timeously informed. C complained that during the second admission, A was initially diagnosed and treated for sepsis but when a CT scan was later performed a major stroke was discovered. C considered that stroke should have been considered and a CT scan should have been carried out earlier. A was given an infusion of both insulin and glucose to manage diabetes. C complained that A was inappropriately given intravenous (IV) glucose for 38 hours after IV insulin had stopped, noting that A became hyperglycaemic (when the level of sugar in the blood is too high) and then developed seizures. C also complained that nursing records were incomplete and that the board’s incident management and review process did not go far enough to recognise or rectify failings.

We took independent advice from a registered nurse and a consultant specialising in medicine of the elderly. We found that the insulin error should not have happened. In relation to sepsis treatment, it was reasonable to treat the infection in the first instance but when C informed medical staff of A slumping to one side a medical assessment for stroke should have been carried out and a CT scan should have been booked. We also found that it was unreasonable to continue IV glucose after insulin had been stopped, record keeping was inconsistent and incomplete such that it could not be said that nursing care was reasonable and that incident management and review was also unreasonable. Therefore, we upheld C's complaints.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the unreasonable care and treatment provided to A. In particular in relation to the treatment of A’s constipation, the incorrect administration of insulin, the failure to undertake a detailed stroke assessment and book a CT scan, and the fact that fluids were not reviewed or considered on after A’s insulin infusion was stopped and their blood glucose increased. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.
• Apologise to C for the unreasonable incident management of the insulin error, for not recording a Datix incident for the glucose error, that the SAER report was not sufficiently detailed to provide reassurance in regards to the quality of incident management and review and that learning and action in relation to medical care during the second admission was not appropriately considered in the SAER. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.
• Apologise to C for unreasonable record keeping. 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:

• Errors in relation to the management of a patient’s care should be appropriately recorded e.g. using Datix. Adverse event reviews should be thorough and should appropriately identify the failings, learning and improvement from the event.
• Patients should receive appropriate treatment including any relevant checks and scans booked in accordance with their symptoms.

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 parent (A) over two admissions to hospital. A attended the emergency department following a fall at home and was treated with painkillers for a pain in their neck. They were admitted to the ward for further monitoring of their fast and irregular heartbeat. A was reviewed the next morning and discharged that day. However, A returned to hospital later that day after another fall. A was reviewed and admitted to the ward where they were later diagnosed with a fracture of a bone in their neck.

C complained that the board failed to diagnose the fracture on the first admission to hospital and about the decision to discharge A. In response to the complaint, the board did not identify any failings with respect to assessment of A, but acknowledged that the communication of their diagnosis and discharge could have been better. With respect to the second admission, the board explained that symptoms of neck fracture are not straight forward and the examinations carried out within the emergency department were appropriate. C was dissatisfied with the response and brought their complaint to our office.

We took independent advice from an emergency medicine consultant and a consultant geriatrician (specialist in medicine of the elderly). In relation to A’s first admission, we found that the initial assessment of A’s condition in the emergency department was reasonable, although there was a missed opportunity for further assessment before A went to the ward. However, the examination and assessment of A’s neck pain on the ward was unreasonable, as was the assessment of A’s suitability for discharge, given the failure to properly assess A’s neck injury, mobility, and cognitive function. We found that the board failed to provide A with appropriate care and treatment during their first admission and upheld this part of C's complaint.

In relation to A's second admission, we found that A’s neurological examination did not include a cervical spine assessment. The board acknowledged in their correspondence with our office that the care provided at this time was not to an acceptable standard. Therefore, we determined that the care provided in the emergency department was unreasonable. We found that the care and assessment provided during A's admission to the ward was reasonable, and there was no delay in arranging further investigations. Given our findings in respect to the care provided in the emergency department, we upheld C's complaint regarding A’s second admission to hospital.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C and A for the failures 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:

• Clinical staff should be familiar with relevant NICE guidelines on the management of suspected cervical fractures. Relevant departments concerned should review their practices regarding the assessment of pain and investigation of potential head/neck injury.
• Patients should only be discharged following appropriate review and assessment of all clinical factors relevant to the decision to discharge a patient from hospital.

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, the complainant, is a tenant of the council. They complained about the council’s refusal of an application for mutual exchange with another council tenant. C found out through the other tenant that the council had told them the application was refused because of ‘management concern for C’. C contacted the council to enquire about the decision and they were advised that they would receive a written response detailing their right to appeal. C heard nothing further and submitted a complaint.

In their complaint response the council apologised that C had not received a letter confirming that the application had been refused. The council said that their officers had worked within the relevant legislation and policies/procedures to refuse an exchange, on the basis that complaints had been made to the Safer Neighbourhood Team in connection with C’s tenancy.

In response to our enquiries, the council provided us with their Mutual Exchange Policy, Mutual Exchange Process Map and Mutual Exchange Guidance Note. The council said that they had followed their policy and provided more detail about alleged anti-social behaviour on the part of the tenant.

We found that the council had failed to follow their policy when considering C’s application. They should have carried out a home visit, sent out a letter with their decision, and given adequate reasons for the decision. The council’s failure to issue their decision on time also prevented C from being able to appeal the decision. Taking all of this into account, we upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to 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.
• The council should reconsider the application. In the event that the mutual exchange is no longer an option, the council should consider whether any alternative remedy is available to C. If, after an assessment in line with their policy, the council decide to refuse the mutual exchange, their decision must clearly explain why they have taken this decision.

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

• The council’s staff understand the steps that they require to follow when a mutual exchange application is received.

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 approved an application for non-material variation (NMV) to a planning consent, despite the variation significantly altering the originally agreed plot levels and having major effects on existing properties that bordered onto the new development. We took independent planning advice, which highlighted that it is it is ultimately a matter for the planning authority to determine whether or not a proposed change to a planning application is material. However, there should be clear and transparent records to support the council’s decision making and justify their decision. The council accepted that was lacking in this case, in terms of the content of the worksheet for the NMV.

We found that the NMV worksheet did not contain sufficient information to explain why the council concluded that the change was non-material. The records did not adequately demonstrate that the council considered the potential impact on neighbouring properties, and continued compliance with the relevant Development Plan in this regard. It was not demonstrated e.g. via adequate / relevant cross sections through the site, how the council concluded that there was sufficient separation distances between new and existing properties. It would also have been good practice for the council to keep a record of any site visit carried out, recognising that there is no statutory requirement to visit the site.

While we found that the council failed to keep adequate records to justify their decision, it was not possible for us to determine that the decision to approve the changes as a NMV was incorrect. That remained a discretionary matter for the council. However, on the basis of poor record keeping, we concluded that the council’s handling of the NMV application was unreasonable, and we upheld this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the issues identified in this decision notice. 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:

• Worksheets for future applications for NMVs should provide sufficient detail to make it clear why a particular conclusion has been reached, including continued compliance with all relevant Development Plan policies. When a site visit is carried out in respect of an application, a record should be kept of that visit. The council should ensure that they have sufficient information to determine the application e.g. adequate / relevant cross sections.

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 elderly, visually impaired and partially deaf parent (A) was in receipt of social care from the partnership. C raised concerns with the partnership about a number of matters related to A’s care, including the arrangement of an Adult Support and Protection (ASP) conference, that the partnership did not reasonably adhere to the Code of Practice in relation to A’s care and action around referring A to other appropriate services. A had been referred to ASP by their social worker. An ASP case conference was scheduled and held and invitations for A and their family to the conference were not received until after the meeting date. C considered that the Adult Support and Protection (Scotland) Act 2007 Code of Practice had not been reasonably adhered to in relation to actions around A’s care.

In their responses, the partnership accepted that there were some areas where their practice had fallen short of the standard that A and their family could expect and provided some apologies for these. As they remained dissatisfied, C raised their complaints with SPSO.

We took independent advice from a social work adviser. We found that elements of the partnership’s record keeping, provision of information, advice and support to A and their family regarding the ASP conference were unreasonable. We also found that the partnership had not reasonably considered aspects of the format of the conference and had not reasonably provided a written care package for A. The effect of this was that A’s voice was not heard in the conference. Given the close connection between this and the contents of the Code of Practice, we upheld this aspect of the complaint.

In relation to the partnership’s handling of C’s complaints, the partnership had provided a response to C in relation to some of these matters and that response addressed some of those issues and identified some areas for improvement. However, we found that the partnership had not directly addressed C’s concern that the social workers assurances had been accepted without evidence or verification.

We also found that the partnership did not indicate that they had taken, or intended to take, any action to address the areas for improvement that they had identified. We found that it was unreasonable that the partnership did not consider what action was necessary as a result of their findings on C’s complaints, and that they did not advise C, as part of the complaint response, of these. We upheld this aspect of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to A and their family that they did not reasonably arrange or conduct the Adult Support and Protection case conference in relation to A. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.
• Apologise to C that they did not respond reasonably to C’s complaints. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.
• A written care plan is provided to A.

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

• Adult Support and Protection case conferences are arranged and conducted reasonably, and service users and, where appropriate, their families are reasonably advised of, and facilitated to be properly involved in, the process, and their wishes reasonably taken into account.

In relation to complaints handling, we recommended:

• Complaints are properly investigated and responded to in line with the partnership’s 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.