Upheld, recommendations

Summary

Mrs C complained about the care and treatment provided to her late brother (Mr A), who had chronic obstructive pulmonary disease (COPD) (a disease of the lungs in which the airways become narrowed) and a mental health condition.

Mrs C complained that the practice failed to admit Mr A to hospital in the months leading to his death. Mrs C had contacted the practice to raise concern about Mr A's physical health. Shortly following this, the GP attempted to carry out a home visit, but found no response on attendance at Mr A's property. A week later, Mr A was examined during a home visit by one of the board's out-of-hours doctors who initiated treatment for his COPD. At this time, Mr A had very low oxygen saturation and potential signs and symptoms of heart failure. A report of the out-of-hours consultation was sent to the practice. The practice arranged to visit Mr C again approximately ten days later, but when the GP attended Mr A refused an examination. The GP felt that the symptoms were likely due to COPD and treatment was commenced with a plan to review Mr A in ten days time. Mr A died on the date of the planned review, with the cause of death unknown.

We took independent advice from a GP adviser. We were unable to conclude that the practice reviewed the details of the out-of-hours report, which contained details of concerning symptoms, and used this to determine a working diagnosis and management plan at the penultimate home visit attempt. We considered that the practice's decision that that there was no clinical indication for hospital admission following the home visit was unreasonable. We upheld this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C for failing to consider the details of the out-of-hours report and use this to determine a working diagnosis and management plan; and for the unreasonable decision that there was no clinical indication for hospital admission following a home visit. 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:

• When an acutely unwell patient refuses examination, a GP should consider what other evidence is available – including details of recent examinations and clinical history for background information – to assist clinical decision making and the management plan.

Summary

Mrs C complained about the care and treatment provided to her late brother (Mr A), who had chronic obstructive pulmonary disease (a disease of the lungs in which the airways become narrowed) and a mental ill health condition.

Mrs C firstly raised concern about a home visit by an out-of-hours doctor a number of weeks before Mr A's death. We took independent advice from a GP adviser. We found that the doctor who visited Mr A performed a reasonable assessment of him and we noted that the record-keeping was of a high standard. The records showed that Mr A had very low oxygen intake and potential signs and symptoms of heart failure. In view of the symptoms and the presentation described by the out-of-hours doctor, we considered that immediate hospital admission should have been arranged. We did not find evidence that this happened and we considered that this was unreasonable. We upheld this complaint.

Mrs C also raised concern about the input of the Community Mental Health Team (CMHT) in the months leading up to Mr A's death and also felt that the board had reached inconsistent conclusions about whether Mr A was refusing assistance for his physical health in their respective adverse event review and complaint investigation. We took independent advice from a mental health nursing adviser. We found that the level of liaison between the CMHT and Mr A's GP was limited and ineffective, whilst we also identified shortcomings in the documentation. We did not consider that the board reached inconsistent conclusions in the adverse event review and complaint investigation; however, we considered that the board's investigations failed to give adequate consideration to the judgement that Mr A had capacity to make decisions about his physical health. We upheld this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C for failing to offer and arrange hospital admission for Mr A following an assessment during a home visit; not giving adequate consideration to the judgement that he had capacity to make decisions about his physical health; and the limited CMHT liaison with the GP and the poor documentation of this. 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 presenting with symptoms and signs of heart failure should receive investigations and treatment in line with national clinical guidelines.
• Where a member of a CMHT identifies concerns about a patient's physical health, they should liaise with the patient's GP in a systematic and effective way and this should be documented in the mental health records.

In relation to complaints handling, we recommended:

• Investigations should objectively evaluate the merits of clinical decisions made.

Summary

Mrs C complained about the care and treatment given to her late husband (Mr A) while he was a patient at Forth Valley Royal Hospital. Mr A had a history of cancer and his condition was investigated. His results were in keeping with alcoholic hepatitis. Mr C had abnormal liver function results and changes had occurred in his brain as a consequence of his liver disease. He had lost a lot of weight and went on to develop influenza A (a highly contagious viral infection of the respiratory passages).

Mrs C complained that when she visited Mr A in hospital he was often unkempt and dirty. He also experienced an unwitnessed fall but Mrs C said that he was not properly assessed after this. Mrs C felt that Mr A's condition was allowed to deteriorate, and after developing sepsis he died.

We took independent nursing and gastroenterology (medicine of the digestive system and its disorders) advice. We found that on admission, nursing staff failed to complete a Malnutrition Universal Screening Tool (MUST) which, had they done so, would have alerted staff to his malnutrition and prompted further steps (for example referral to a dietician). A falls assessment should also have been carried out earlier in his admission and then regularly after that, particularly after his fall. However, while we found no evidence that he had not been nursed in a dignified way, we found that there had been failures in Mr A's medical care, there was poor documentation and monitoring of his liver disease, insufficient investigation of his fall, and a full sepsis screen had not been carried out. We upheld Mrs C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C for failing to properly carry out a MUST and falls assessments and for failings in medical care.

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

• A MUST assessments should be carried out on admission.
• Falls assessments for patients similar to Mr A should be carried out on admission and thereafter at least on a weekly basis.
• Patients admitted with moderate liver impairment who have a mortality of over one in four should be treated in the correct ward by the correct team as a matter of priority.
• All relevant documentation should be completed appropriately and as required.
• Full assessment and investigation should be made after a fall, particularly when the fall occurs in a patient with liver failure, into the possible reasons for the fall.
• Medical teams should be aware of the high risk of mortality of patients admitted with decompensated liver disease, including the risk of sepsis.

Summary

Miss C, a student advisor, complained on behalf of a student (Ms A) about how Ms A's academic appeals were handled. Ms A was enrolled on a masters course at the university. Ms A was given an alternative exit award of a postgraduate diploma. Ms A submitted a Stage 1 and a Stage 2 academic appeal.

We found that the university failed to check the date that Ms A received her result before issuing their Stage 1 academic appeal response and that the university failed to consider the reason why Ms A's Stage 1 academic appeal was late. We also found that they failed to acknowledge Ms A's Stage 2 academic appeal within ten days and failed to keep Ms A updated on the progress of her Stage 2 academic appeal contrary to the university's policy. The assessor appeal response form also was not completed for Ms A's Stage 2 academic appeal. We upheld Miss C's complaints.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms A for failing to check the date that she received her result prior to issuing the Stage 1 Academic Appeal response; failing to consider the reason why Ms A's Stage 1 Academic Appeal was late; failing to acknowledge Ms A's Stage 2 Academic Appeal within ten days and for failing to keep her updated on the progress of her appeal; and failing to complete an Assessor Appeal Response Form for her Stage 2 Academic Appeal. 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 university should check the date that results have been received before responding to academic appeals.
• The reasons why an academic appeal has been submitted late should be considered.
• In accordance with the relevant policy and procedures, academic appeals should be acknowledged within the timescales and students should be kept updated on the progress of their appeals.
• In accordance with the relevant policy and procedures, the assessor appeal response form should be completed for all Stage 2 academic appeals.

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 Scottish Prison Service (SPS) did not reasonably investigate and respond to his report of lost property. Mr C's property went missing and the SPS acknowledged that the door to his cell was left open accidentally by one of their officers.

We found that the SPS had carried out investigations into what happened to Mr C's property and offered compensation. However, we noted that there were gaps in the investigation and the offers of compensation did not clearly state what they were for, or why some items were not being compensated. Therefore, we upheld Mr C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for failing to carry out a robust investigation into his report of lost property. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/leaflets-and-guidance.
• Reconsider Mr C's compensation claim, taking into account the failings identified.

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

• Reflect on the findings of this decision and share this with the relevant staff. The SPS should ensure investigations are robust and reasoning for compensation claims are clear.

Summary

Mrs C complained that the Crown Office and Procurator Fiscal Service (COPFS) unreasonably delayed in investigating the death of her daughter (Miss A) and that their communication with her had been unreasonable.

We found that COPFS have no fixed timescales within which investigations should take place; the reasons for this are clear given the range of complexities of investigations and the involvement of various external authorities. We accepted their position that they have no power to compel individuals and authorities to respond to them, but we considered that they must be proactive in driving investigations forward. We considered it would be reasonable for this to include giving timescales within which a response is expected, and escalation where deadlines are not met. We saw no consistent evidence of timescales being given, and we noted that often it took communication from Mrs C before authority responses were chased up. We therefore upheld this complaint.

In relation to unreasonable communication, COPFS acknowledged failings in the period leading up to Mrs C's complaint. We upheld this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C for the length of time this investigation has taken, with an acknowledgement of the personal impact. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/leaflets-and-guidance.
• Apologise to Mrs C for the failings in communication. The apology should meet the standards set out in the SPSO guidelines referred to above.

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

• Where responses to COPFS from external individuals or organisations are awaited, timescales for response should be given and proactive steps taken to escalate matters in the event that deadlines are not met.

Summary

Mr C complained that the council failed to take action within a reasonable timeframe to investigate the concerns he reported about his child, including the delay in the council speaking to his child about the concerns.

We took independent advice from a social worker. We found that, as Mr C's concern was not dealt with as a child protection investigation, there are not specific timescales that are required to be met. In light of this, the actions taken by the council and the timescales for the actions taken were not unreasonable in the circumstances. However, we found that there were delays in recording the referral Mr C made to the council and the action taken by them in response to Mr C's referral. We also found that there was no contemporaneous record of the decision not to progress Mr C's referral while the allocated social worker was on leave. We upheld this aspect of Mr C's complaint.

Mr C also complained that the council failed to handle his complaint reasonably. We found that the council's response did not address a particular aspect of Mr C's complaint. We upheld Mr C's complaint that the council failed to handle his complaint reasonably.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for failing to address all the points of his complaint. 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:

• Decisions not to progress referrals when an allocated social worker is on leave should be recorded clearer.

In relation to complaints handling, we recommended:

• Complaint responses should address all the issues raised. This is in accordance with the model complaints handling procedure: www.valuingcomplaints.org.uk/sites/valuingcomplaints/files/resources/SW-Model-CHP.pdf  

Summary

Ms C complained about the failure of the partnership to follow their own complaints process. Ms C raised concerns about the service provided by social work to her child on at least two occasions.

We found that the partnership did not recognise that Ms C's concerns were complaints and that the receipt of these complaints should have instigated the documented complaints process. As a result Ms C's concerns were not being formally assessed and responded to under the complaints process. Therefore, there was a delay in Ms C being signposted to our office and we upheld the complaint. However, when the complaint was eventually investigated by the board this was generally handled well.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms C for the failure to recognise what a complaint was within the organisation and instigate the complaint process. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/leaflets-and-guidance.

In relation to complaints handling, we recommended:

• To ensure all members of staff are able to recognise a complaint and are aware of the documented complaints process that requires to be instigated when a complaint is received.

Summary

Mrs C complained on behalf of her husband (Mr A). Mrs C said Mr A had undergone an operation on his heart, which they had believed would be routine and uncomplicated. Mr A suffered serious complications during the surgery, resulting in a long period of recuperation and life altering consequences. Mrs C said they accepted that what had happened was a recognised risk of the surgery, however, she complained that Mr A had not been provided with adequate information during the consent process. Mrs C felt her complaint had been poorly handled, and although the board had apologised to Mr A, Mrs C was unhappy with this response.

We took independent medical advice. We found that Mr A was not provided with sufficient information during the complaints process. The advice also stated that the board needed to ensure that consent was taken early enough to allow patients to consider properly the potential complications and risks associate with their surgery. We found that the board's response to the complaint was reasonable in terms of practical solutions to the failings identified, but that they had not fully accepted responsibility for the failings, which devalued the apologies they offered. We upheld both aspects of Mrs C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr A for failing to obtain his informed consent. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/leaflets-and-guidance.

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

• Ensure the boards consent process allows (where practical) for a reasonable period of time between consent being given and a surgical procedure being undertaken.

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

Mrs C complained that the Scottish Ambulance Service (SAS) delayed in sending an ambulance for her husband (Mr A). Mr A's GP requested an ambulance within two hours as Mr A was experiencing vomiting and diarrhoea and was delirious. The ambulance did not arrive until almost eight hours later. SAS explained that there was an unexpected increase in the volume of calls that day, and that there was no missed opportunity to allocate an ambulance. SAS acknowledged that their delay in sending an ambulance was unreasonable.

We took independent advice from a consultant paramedic. We found that there was no missed opportunity to send an ambulance. However, we found that on one occasion the SAS call handler failed to use the correct interrogation system. We also found that SAS failed to carry out a clinical triage which would have involved Mrs C receiving a call from a clinical adviser who would have assessed Mr A's symptoms in more detail. This failing was acknowledged by SAS and was due to the high demand on the service. We upheld Mrs C's complaint and made a recommendation for learning and improvement.

Recommendations

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

• SAS should ensure that call handlers have absolute clarity on 999 call made by/on behalf of urgent patients to ensure correct interrogation system is used consistently.