Upheld, recommendations

Summary

Mr and Mrs C were foster parents for a young child (Child A) with additional needs. Child A was moved to a residential care home by the council. During their time there, Mr and Mrs C raised concerns about Child A's care and treatment. The council investigated the concerns and concluded there was no evidence of criminality and that the marks founds on Child A were consistent with the reports that they had injured themself through play.

Mr and Mrs C disagreed with the conclusions of the investigation. We investigated whether the council responded appropriately to the child protection concerns that they raised.

We took independent advice from a social worker. We found that the council responded promptly to the concerns raised by undertaking a high volume of visits and adopting a multi-disciplinary approach to the investigation. However, we found that there was a significant delay in obtaining the incident reports from the residential care home. These were required to be provided within 24 hours, and they were not provided until five weeks after the original request. We considered this delay to be unreasonable as the reports were required to inform important decision-making regarding the child protection investigation. We upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr and Mrs C for failing to appropriately respond to the child protection concerns raised by failing to obtain the incident reports within a reasonable timeframe. 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 remind care home staff and social work staff of the importance of recording incidents promptly and of obtaining the reports within a reasonable timescale.
• To enable further learning from the complaint, the council should identify the reason for the delay and advise SPSO of the outcome. This should include information about whether the reports were written retrospectively.

Summary

Ms C runs a hostel and complained about noise coming from a nearby road depot. Ms C complained to the council but felt they did not undertake an appropriate assessment of the noise from the depot. She wanted the council to investigate and take enforcement action.

The council said that they had taken reasonable steps to investigate the complaint, stating that this was carried out in accordance with their enforcement policy. The council's position was that the site visits carried out by the environmental health officer, and subsequent interviews with staff, represented an appropriate response. They concluded there was no statutory nuisance and therefore said it was not appropriate to undertake enforcement action.

We noted that the council's website sets out the type of actions they will take upon receipt of a noise complaint. This includes asking for a noise diary to be maintained for one to two weeks, then assessing the written evidence to determine the scale and extent of the problem. Ms C had not been asked to keep a noise diary, and when the environmental health manager reviewed the actions of the investigating officer they stated it could not be judged whether the noise at the depot would constitute a nuisance without a noise diary to assist in identifying the times, duration and frequency of noise issues.

We found that there was a lack of clear evidence of the investigation which was undertaken by the council. We also found there was a lack of evidence to support the decision that the noise was not a statutory nuisance. We therefore upheld this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apololgise to Ms C for failing to take reasonable steps to investigate the complaints about noise. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.
• Contact Ms C to enquire whether the noise is an ongoing problem. If it is, liaise with her regarding the use of a noise diary, in line with council policy, and thereafter determine whether the noise constitutes a statutory nuisance.

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

• Staff should be clear about how to apply council policy and procedures when complaints about noise are made.

Summary

Ms C complained about the council's actions when she reported concerns about her child (Child A) to the social work department on several occasions.

We took independent advice from a social worker. We found that in relation to the first time Ms C raised concerns, the records were inadequate to determine whether the decisions made by the council were reasonable or not. We found that in relation to the second time Ms C raised concerns, the council should have carried out further investigation and it was unreasonable that they did not. We found that when the council was contacted by a health board in relation to concerns about Child A, they failed to assess the matter in full and therefore failed to follow national guidance on 'Getting it right for every child' (GIRFEC). We considered that it unclear from the records why the council took no further action at this point. Overall, we found that there had been a failure to properly record what happened, assessments, and follow-up. We upheld this aspect of Ms C's complaint.

Ms C also complained about the council's communication with her and their handling of her complaint. We found that the complaint responses to Ms C lacked empathy and understanding. We were also critical that the council's complaint process did not identify the failings in social work practice and failed to acknowledge the significance of poor record-keeping in this case. We considered this to be unreasonable and 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 failing to take reasonable action on the concerns raised about Child A; and that the communication with Ms C and handling of her complaint was unreasonable. 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:

• Record-keeping should be clear and accurate. Details of interviews and assessments should be recorded, and reasons for any decisions should be clear.
• Reports of concern about children and young people should be acted upon appropriately and in line with guidance.
• National Guidance for Child Protection in Scotland and the National Framework for Risk Assessment should be followed in relation to assessing risk and linking this with GIRFEC framework.

In relation to complaints handling, we recommended:

• Complaint responses should be appropriately empathetic and understanding.
• The council's complaints handling system should ensure that failings (and good practice) are identified and the significance of these failings acknowledged, in order to enable learning from complaints to inform service development and improvement.

Summary

Mr C complained about the treatment which he had received at Ninewells Hospital. Mr C said that he had problems with a left-side perianal abscess (a local accumulation of pus that forms next to the anus, causing tenderness and swelling) and that he was taken to theatre for surgery. When Mr C recovered from the surgery he noted that there was a dressing on the right side of the anus and that the abscess on the left side was still present. Staff assured Mr C that the surgery had gone ahead as planned. Mr C attended his GP a few days later and the GP confirmed the abscess on the left side was still present. Mr C felt that the board staff had operated on the wrong side of his anus.

We took independent advice from a colorectal (bowel) surgeon and a consultant radiologist (a specialist in the analysis of images of the body) and found that Mr C's records showed there was some confusion over the position of the abscess. Examination prior to surgery showed the problem area was identified on the left side and although the doctor who conducted the examination was present at the operation, surgery was carried out on the right side. The doctor did not raise their concerns with the operating consultant. We also found that international guidance states that to reduce the possibility of surgery being performed at the wrong site then the planned site should be marked. This did not happen in Mr C's case and although there was an area of concern on the right side, the area complained about by Mr C was on the left side. Therefore, we upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for performing perianal surgery on the wrong side of the anal canal. 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:

• Staff should ensure that prior to surgery the appropriate site is marked to reduce the possibility of carrying out surgery on the wrong site.
• Staff should be reminded that if they feel that surgery is about to be performed at the wrong site that they inform a senior clinician.

Summary

Mr and Mrs C complained that the board unreasonably failed to maintain the air system at the neonatal unit at a hospital in their area. They said that the air system failed and their baby, who was born prematurely and was dependent on air/oxygen, had to be moved to a hospital in a second board's area and died there instead of the hospital in the board's area. Mr and Mrs C raised various concerns, including questioning the board's account that there had been no similar failures with the air system previously.

The hospital's air system includes two dryers (dryer 1 and dryer 2) which remove contaminants and moisture from the compressed air. When one dryer is in use, the other is set as a back-up dryer. The treated air is sent to the medical and surgical terminals within the hospital.

We found that at the time of events in question, services within the hospital began experiencing intermittent drops in air pressure. The problems were caused by the failure of dryer 2. The hospital activated contingency plans and began using air cylinders. The fault with dryer 2 was repaired five hours later, but recurred after seven hours and neonatal services took the decision to transfer babies to other hospitals. The fault was subsequently repaired.

We found that there was an incident 14 months before the events in Mr and Mrs C's case, in which dryer 1 failed, but there was nothing to suggest this previous fault itself was connected with the issues with dryer 2. However, it was clear that the board were not able to carry out all of the works needed to dryer 1, which meant that the air system was less resilient at the time the fault in dryer 2 occurred (and had been so for approximately 14 months).

The board offered an explanation for the time period taken to finalise the repairs to dryer 1, and the steps that they took to stock additional air cylinders during this time (increasing their supply fivefold) to mitigate the risk of a fault. However, given that the air system supplied air to the whole of the hospital, including the neonatal unit, we were concerned that it took such an extensive period of time to repair the fault to dryer 1; and that the board did not undertake any formal written risk assessment for having a dryer with an intermittent fault as the backup dryer, after the decision was made to operate the system this way.

Therefore, we upheld the complaint. In addition, we considered that in their response to Mr and Mrs C's complaint, the board did not fully address Mr and Mrs C's concerns and that they should have provided more information on the events in this case and the action that the board was taking in response to these.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr and Mrs C for failing to undertake a formal written risk assessment for their air system and for failing to respond to the complaint appropriately. 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:

• Any potential threats to a hospital wide operational system such as the hospital's air system should be formally risk assessed and documented. There should also be a clear process for reporting and signing off the risk assessment.

In relation to complaints handling, we recommended:

• Complaint responses should fully address the concerns raised and provide the complainant with all the relevant information held on the matters complained about.

Summary

Mr C complained that the board had failed to provide a reasonable standard of psychiatric (the branch of medicine that deals with mental illness) care and treatment to his wife (Mrs A) before her death. Mrs A had been diagnosed with a brain tumour. The psychiatrist responsible for her care considered that she had a depressive illness, but Mrs A's family disagreed with this. Mr C also complained about the comments the psychiatrist made at a consultation.

We took independent advice from a consultant psychiatrist. We found that the psychiatric care and treatment provided to Mrs A had been reasonable. However, we considered that some of the language the psychiatrist used was unhelpful and left the family feeling criticised. We considered this had been unreasonable and upheld this aspect of Mr C's complaint.

Mr C also complained that the board failed to handle his complaint reasonably. We found that although Mr C had clearly expressed dissatisfaction in an email, the board had failed to record this as a complaint or to contact Mr C for clarification. When Mr C subsequently made a further complaint, the board then delayed in responding to this. Therefore, we also upheld this aspect of Mr C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C and his family for the shortcomings in the psychiatrist's approach to the assessment. 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:

• Medical staff should communicate with patients and their families appropriately. They should use appropriate language and ensure that families have adequate support where difficult discussions are necessary.

In relation to complaints handling, we recommended:

• Complaints should be dealt with promptly and in line with the board's complaints handling procedure.

Summary

Mrs C complained about the care and treatment her daughter (Miss A) received when she presented to the board with unexplained weight loss and upper abdomen pain. In particular, Mrs C complained about the investigations carried out to try and diagnose Miss A and the delay in diagnosing her with stomach cancer.

We took independent advice from a consultant general surgeon. We found that the majority of the investigations and tests carried out to try and diagnose Miss A were reasonable. However, we also found that:

a request for an endoscopic ultrasound (procedure that allows a doctor to obtain images and information about the digestive tract and the surrounding tissue and organs) should have been marked as urgent;

that the board did not enquire about the status of the endoscopic ultrasound request with the other hospital when it had not been scheduled within a certain period of time;

a lesion on Miss A's skin was not excised urgently; and

that the board should have considered requesting another urgent endoscopic ultrasound or a repeat scan when Miss A's symptoms were ongoing.

We also found that the interim discharge summaries did not contain sufficient information about the treatment provided, investigations carried out or any

follow-up treatment/recommendations and that the formal discharge letters were not sent within a reasonable period of time.

In light of the above, we upheld Mrs C's complaints, though we found that Miss A's prognosis would have remained poor even if an earlier diagnosis had been made.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C for failing to mark the requested endoscopic ultrasound as urgent; enquire about the status of the endoscopic ultrasound request; urgently excise the lesion on Miss A's skin; consider requesting an urgent endoscopic ultrasound or a repeat CT scan; ensure interim discharge summaries contained sufficient information; and send formal discharge letters within a reasonable amount of time. 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:

• Patients in a similar situation, who present with an abnormal mass in the upper stomach and persistent symptoms of pain, anaemia and weight loss, should have endoscopic ultrasounds requested on an urgent basis.
• Where an endoscopic ultrasound has been requested but not carried out within a reasonable time frame, this should be followed up.
• Where the board considers that a lesion should be urgently removed, the procedure should be carried out urgently.
• A request for an urgent endoscopic ultrasound or a repeat CT scan should be considered for patients in a similar situation with suspected stomach cancer who have normal gastric emptying studies and ongoing symptoms four months after presenting to the board.
• Interim discharge summaries should contain sufficient information to plan a transfer of care, including the treatment provided, investigations carried out and any follow-up treatment/recommendations.

Summary

Ms C complained about the care and treatment her mother (Ms A) received from the board following a referral for the suspicion of cancer.

We took independent advice from a consultant respiratory physician and a consultant radiologist (a specialist in the analysis of the body). We found that the scan guided biopsies (tissue samples) were not carried out by the radiology department within a reasonable length of time and that there was an unreasonable delay in arranging surgical treatment. We also found that it was unreasonable that the report of a scan did not mention the bony lesions (areas of bone that are changed or damaged) and the pulmonary embolism (a clot in the blood vessel that transports blood from the heart to the lungs). Therefore, we upheld Ms C's complaints.

Ms C also complained that the board failed to handle her complaint reasonably. We found that the board's complaint response commented on Ms A's financial difficulty when this was not raised in Ms C's complaint. 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 failing to carry out the CT guided biopsies within a reasonable length of time; report the bony lesions and the pulmonary embolus in the report of the CT pulmonary angiogram scan; and to ensure that the complaint response only contained information that was relevant to the complaint Ms C raised. 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:

• The radiology department should carry out CT guided biopsies within a reasonable length of time.

In relation to complaints handling, we recommended:

• Complaint responses should only contain information that is relevant to the complaint raised.

Summary

Ms C complained about the care she received from Queen Elizabeth University Hospital's maternity assessment unit (MAU) when she called for advice with heavy bleeding at 33 weeks of her pregnancy. She also complained about the treatment she received ten days later following her admission to the hospital, at which time her baby was stillborn.

In responding to the complaint, the board apologised that they could not account for Ms C's phone contact with the MAU because there was no record of the phone call.

We took independent advice from a consultant obstetrician (a specialist in pregnancy and childbirth) and gynaecologist (specialist in the female genital tract and its disorders). We considered that the record-keeping practice was of an unacceptable standard and that the advice Ms C had received was incorrect because she should have been asked to attend hospital to have a clinical assessment of her pregnancy, in line with national guidance. We also considered that it was likely that Ms C would have been admitted to hospital for monitoring but given her bleeding stopped, it was also likely she would have been discharged. Whilst we found that it was possible that follow-up with Ms C could have been earlier than when she was seen 10 days later, we considered that the large placental abruption (separation of the placenta from the inner wall of the uterus), which she had no obvious risk factors of, could not have been prevented or predicted. We upheld the complaint.

In terms of the treatment Ms C received at the hospital when she attended by emergency ambulance with heavy bleeding 10 days later, we considered that her initial management of her abruption was inadequate and not in accordance with national guidelines. However, we also considered that these failings were unlikely to have altered the outcome for Ms C's baby. We upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms C for failing to fully assess and treat her on arrival to the maternity unit. 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:

• The Maternity Assessment Service should maintain adequate records of phone consultations and advice given. Staff responding to patient phone queries should be aware of guidance on the management of significant antepartum haemorrhage.
• All staff attending patients with life threatening complications such as antepartum haemorrhage should be aware of national/local guidelines on emergency management of patient collapse.
• Staff handling complaints should ensure that the issues are fully investigated with action taken to address any failings identified.

Summary

Ms C complained that the practice unreasonably failed to assess her child (Child A) before prescribing antidepressants; unreasonably failed to assess Child A before referring her to child and adolescent mental health services; unreasonably failed to include relevant information in the referral to child and adolescent mental health services; and unreasonably failed to give Ms C the appropriate information when she raised concerns about Child A.

In investigating Ms C's complaints, we took independent advice from a GP. We found that in relation to the prescription of antidepressants, this was a repeat prescription that should not have been issued. We found that Child A should have had a face-to-face assessment prior to antidepressants being re-prescribed. We found that this was an administration error as it should have been noted by the administrative staff who printed the repeat prescription that there had been a lengthy period of time since the last repeat prescription. We upheld this aspect of Ms C's complaint, however we considered that the actions already taken by the practice would address this issue.

In relation to the referral to child and adolescent mental health services, we found that this should not have been made without Child A's consent, and without a face-to-face assessment of Child A. Therefore, we upheld the complaints that there was an unreasonable failure to assess Child A and that the referral was unreasonable. However, in relation to the information that was included in the referral, we considered this to be reasonable. We found that appropriate action had been taken by the practice to address the failure to assess Child A in person prior to the referral being made, however, we made a recommendation to the practice in relation to consent.

We found that when Ms C raised concerns about Child A with the practice, they failed to tell her that Child A would need to be assessed in person. We upheld this aspect of Ms C's complaint.

Finally, we found that the practice's significant event review of the matters relating to this complaint was of a poor standard and lacked reflection. We made a recommendation to the practice to address this.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms C for; failing to assess Child A before prescribing antidepressants; failing to assess Child A before referring them to the Young People's Department at Child and Adolescent Mental Health; making an unreasonable referral to the Young People's Department; failing to give Ms C the appropriate information when she raised concerns about Child A. 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:

• Patients should be informed of referrals and given the opportunity to object to any disclosure of information. This should be in line with General Medical Council guidance relating to consent and sharing information about young people, and ethical practice.
• Information should be given to parents/carers about the need to assess young people prior to referral where appropriate.

In relation to complaints handling, we recommended:

• Significant event reviews should be robust and reflective.