Upheld, recommendations

Summary

Mrs C complained that the council failed to provide a reasonable response to her contact about leasing a unit. Mrs C was in contact with the council's estates and planning departments in relation to leasing a unit in an industrial estate. It was found that Mrs C required planning permission to allow her to use the unit for a business that included a take-away element. Mrs C complained that throughout her contact with the estates department that they did not voice concerns over her use of the unit. Later, after her application for Change of Use was considered, she was informed that it was likely the estates department would refuse her application.

We found that the council had not communicated reasonably with Mrs C. We considered that the estates department did not manage Mrs C's expectations with respect to the viability of the proposed use of the unit, despite having sufficient information. The council were correct to advise Mrs C to seek planning advice on the use of the unit. However, we were of the view that the council could have alerted Mrs C earlier to the possible issues with the takeaway element. Therefore, we upheld Mrs C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C for failing to communicate concerns about the proposed use of the 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:

• Estates should include in advertisement particulars which type of class uses are acceptable for a property, if applicable.

Summary

Mrs C complained that the partnership's assessment of her father's (Mr A) care needs was unreasonable and that subsequent care package offered was inadequate. Mrs C contacted the partnership to request that Mr A be assessed for residential care as she considered his health had deteriorated significantly. An assessment was carried out and it was deemed that Mr A's needs could be met in the community. The partnership offered home care, day care and befriending services. Mrs C declined this offer as she felt that the support offered was not adequate and that Mr A required to be in a care home.

We took independent advice from a social work adviser. We found that the partnership's assessment of the risks to Mr A were underestimated and that the risks should have been categorised as substantial rather than moderate or low. We also found that the partnership underestimated the opinion of Mr A's GP and that his needs and risks should have been assessed as substantial. We considered that the assessment of need and subsequent care and support offered was unreasonable. Therefore, we upheld both of Mrs C's complaints.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C for the distress caused to her and her family. 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 partnership should ensure that staff reflect and learn from the findings of this investigation. In particular, staff should ensure that the family and service user's view are adequately weighted.

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, a solicitor, complained on behalf of his client (Mrs A) and her power of attorney that the partnership failed to act reasonably in relation to the assessment of capital. Mrs A and her late husband (Mr B) purchased a property, the title of which was subject to a survivorship destination (a property that is jointly owned and on death of one of the owners, their share will pass to the survivor). Mrs A was diagnosed with dementia and moved into residential care. Mr B was diagnosed with terminal cancer and shortly before his death, he evacuated the destination meaning his share of the property would no longer go to Mrs A on his death. The partnership considered that Mr B's actions were a deliberate attempt to deprive Mrs A of capital due to the timing and circumstances of it, and began charging Mrs A for residential care from the date of Mr B's death. Mr C argued that as a survivor destination the property only ever potentially belonged to Mrs  A, and it was possible for Mr B to change his intentions on inheritance at anytime.

We took independent legal advice in our consideration of this complaint. We concluded that the partnership did not fully consider the relevant guidance in relation to their financial assessment of Mrs A's capital, nor did they properly assess the value of that capital. We upheld Mr C's complaint.

Recommendations

What we asked the organisation to do in this case:

• The council should carry out a new financial assessment on the basis of our findings.

Summary

Mrs C, an advocacy and support worker, complained on behalf of her client (Mr  A) that the partnership unreasonably failed to carry out a full or formal kinship care assessment. Mr A became the legal guardian of his two younger siblings following his mother (Ms B)'s death. Before and after Ms B's death, the partnership indicated that Mr A would receive kinship allowances after he assumed caring responsibilities for his siblings. However, the partnership later advised Mr A that they would not pay kinship allowances, stating that as the caring arrangements were made before Ms B died, the partnership did not have a responsibility to do so.

Mrs C challenged this decision, stating that Mr A is an informal kinship carer and his siblings could be considered to be at risk of becoming looked after (a looked after child is a child under the care of the council). This would mean that his siblings could be classed as eligible children, which would allow kinship allowances to be paid. However, the partnerships's view was that Mr A's siblings were not at risk of becoming looked after and were therefore not eligible children.

We took independent advice from an adviser with a background in social work and children and family services. We found that the partnership had not carried out an appropriate assessment to determine whether Mr A's siblings were at risk of becoming looked after. The partnership had largely based their decision-making on statements made by Mr A. We considered that these statements were not adequate evidence that the siblings were not at risk of becoming looked after. We noted a number of entries in the partnership's records that indicated that Mr  A and his family were struggling and that Mr A and Ms B's decision-making appeared to have been influenced by the understanding that kinship allowances would be paid. Therefore, we upheld Mrs C's complaint.

We noted that the partnership had apologised for indicating that Mr A would receive kinship allowance and then changing their position on this. However, we were concerned that the partnership had not explained why this was their position for so long and that they had not appeared to have reflected on the significant impact this had on the choices made by Mr A and the connection to the subsequent difficulties his family experienced.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr A for not carrying out a kinship care assessment which would have clearly identified whether or not he was eligible to receive kinship allowances in respect of his siblings. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/leaflets-and-guidance.
• Complete a full kinship care assessment, in line with any relevant guidance, should Mr A still want one to be carried out. As far as possible, consideration should be given to the circumstances of the household when the assessment was originally due to take place, not just the current circumstances. If, following the assessment, the children are deemed to be eligible, any kinship allowance should be backdated to when they would have commenced had the original assessment taken place. However, it is reasonable for the partnership to deduct any financial support that has already been provided through section 22 payments from the backdated amount.

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

• Ensure that all partnership staff are aware of what assessment should be carried out in order to determine whether a child is at risk of becoming looked after.
• Reflect on the circumstances that led to Mr A being wrongly advised about kinship allowance eligibility for around five months before being told that this position was incorrect. Identify why Mr A was given this incorrect advice for so long, with a view to putting in place learning and improvement where appropriate. Reflect on the impact this advice and subsequent change of position had on Mr A and give consideration to whether any further redress is appropriate

Summary

Mrs C complained that certain risks associated with knee replacement surgery she underwent at Ninewells Hospital had not been explained to her when she consented to the operation. She also complained that the wrong size of implant was used and that cement had leaked and caused nerve injury. Mrs C underwent additional surgery a couple of days later to remove the cement.

We took independent advice from a consultant orthopaedic surgeon (a specialist in the treatment of diseases and injuries of the musculoskeletal system). We found that the recognised risk of some complications were not documented as having been explained to Mrs C in line with the General Medical Council's consent guidance. We considered this was unreasonable and upheld this aspect of Mrs C's complaint.

Whilst we could not say for certain what caused Mrs C's nerve damage (a recognised risk of surgery that was explained to her during the consent process), we considered it was unlikely to be related to the cement leakage. However, we were concerned about actions of staff in relation to the sizing of the implants and the lack of experienced staff present in the theatre at the time of implantation. Therefore, we upheld this aspect of Mrs C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C for failing to inform her of all the recognised risks of the surgery, for the inappropriate circumstances around component sizing, lack of experienced staff in theatre and record-keeping failures. 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 receive full information on the risks of surgery in accordance with recognised guidance such as the General Medical Council.
• Implant sizing is the operating surgeon's responsibility; and all relevant staff should ensure they are present in the theatre.
• Staff should ensure thorough and contemporaneous record-keeping of all relevant events during surgery.

Summary

Mrs C complained that the board unreasonably failed to make appropriate arrangements to deliver her baby by cesarean section (c-section) in line with her birth plan. Mrs C's waters broke two days before she was due to have her c- section at Wishaw General Hospital and she contacted the hospital for advice. Mrs C was told to return that evening and confirmed she still wished to have a c- section. After her arrival at hospital, Mrs C waited almost three hours before being clinically assessed. By the time she was examined she was 8cm dilated, and although staff started to prepare her for a c-section there was no theatre available and she progressed through labour, with her child eventually being delivered by forceps.

The board said that the department had been particularly busy, and that they had prioritised patients according to clinical need. Mrs C was unhappy with this response and brought her complaint to us.

We took independent advice from a consultant obstetrician (a doctor who specialises in pregnancy and childbirth). We found that there was no medical need to open a second theatre and that Mrs C and her baby has been appropriately monitored throughout the labour. However, Mrs C was on the 'red pathway' for her maternity care which highlights significant/obstetric risks and we found that there had been a delay in assessing her after her arrival at hospital. We considered that Mrs C should not have been left without adequate triage on her arrival at hospital. We upheld this aspect of Mrs C's complaint. However, we noted that the outcome may not have been different even if Mrs C had been examined sooner.

Mrs C also complained that the board's handling of her complaint was unreasonable. When Mrs C first raised her concerns with the board, she was offered a meeting with the consultant whose care she was under. At the end of the meeting the consultant suggested that Mrs C prepare a note setting out her account of what had happened. Mrs C understood she was making a formal complaint, but the consultant had actually asked for the account so that the Obstetric Risk Management Group could consider if a review of the case was required and identify any areas for learning. The misunderstanding came to light several months later, at which stage Mrs C was appropriately directed to the complaints process. Although we considered that the consultant had been acting in good faith, we were critical of the board's failure to identify Mrs C's concerns as a formal complaint. We upheld this aspect of Mrs C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C for the delay in assessing her. The apology should recognise the impact of her birth experience on her daily life.
• Apologise to Mrs C for failing to identify her concerns about her treatment as a formal complaint. The apologies should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/leafletsand-guidance.

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

• Relevant staff should take a pro-active approach to triage, ensuring clinical questions are asked and documented.

In relation to complaints handling, we recommended:

• Staff should be confident in recognising complaints. In cases where there is any lack of clarity over whether concerns should be treated as a formal complaint, steps should be taken to ascertain and clearly record the wishes of the patient.

Summary

Mr C complained on behalf of his mother-in-law (Mrs B) about the care and treatment provided to her husband (Mr A) at Raigmore Hospital. Mr C complained that the board failed to manage Mr A's falls risk appropriately and failed to provide a reasonable standard of oral and nutritional care to Mr A.

We took independent advice from a nursing adviser. We found that Mr A sustained seven falls during his admission, with the last fall resulting in him suffering a serious injury. The board had apologised for this and the lack of communication by their nursing team on some occasions, and we acknowledged the action that the board said they had taken to address this. However, we found that there were additional failings and an unreasonable level of care provided to Mr A not identified by the board. We noted that there appeared to have been a lack of action and a failure in record-keeping in relation to the management of Mr  A's falls risk. We considered that the supervision provided was unreasonable and highlighted that there was no person-centred care plan provided to record the management of Mr A's falls risk and interventions in place to reduce the risk of falls, or the level of observation he required. In addition, communication with Mr A's family was unreasonable. Therefore, we upheld this aspect of Mr C's complaint.

In relation to Mr A's oral and nutritional care, the board accepted that this was not of an acceptable standard and apologised. We found that there were shortcomings in the assessment and management of Mr A's nutritional needs and in record-keeping. Although staff made urgent referrals to the dietician, Mr A did not appear to have been treated as a priority. We also found no evidence that Mr A's oral care needs were met. Therefore, we upheld this aspect of Mr C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs B and her family for the unreasonable level of care provided to Mr A in relation to falls sustained by Mr A, his nutritional and oral care, record-keeping and communication with Mrs B and her family. 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 at high risk of falls should have their falls risk appropriately managed.
• Nursing records should be maintained in accordance with the nursing and midwifery code of practice.
• Patients should have their nutritional and oral care appropriately assessed and managed.
• There should be adequate communication with a patient's family and this should be appropriately documented.

Summary

Ms C complained about the care and treatment provided to her late husband (Mr  A) by the board in relation to treatment of his cancer. Ms C raised concerns that after a scan which showed progression of Mr A's cancer, neither the 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) nor oncologist (a doctor who specialises in the treatment and management of cancer) involved in his care contacted him to discuss this with him. Ms C said that Mr A did not discover that his cancer had progressed until he contacted his GP several month later. Ms C also complained that when Mr A was having palliative chemotherapy (a treatment for terminal cancer to prolong survival and minimise suffering, but which cannot cure the disease) the oncologist failed to identify or investigate his low haemoglobin (a protein in the blood that carries oxygen).

We took independent advice from a consultant oncologist. We found that it was reasonable that Mr A's low haemoglobin was not identified as he had not been reporting unusual symptoms. However, we found that the failure to contact Mr A to discuss his scan results was unreasonable. We determined that this was due to a miscommunication between the oncologist and radiologist and that the radiologist had changed their practices as a result of this complaint. However, we upheld Ms C's complaint and made a further recommendation to the board regarding this failing.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms C for the breakdown in communication which resulted in neither the oncologist nor radiologist contacting Mr A to discuss the scan results. 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 two or more specialists are involved in a patient's care, it should be clear who is going to contact them to discuss their ongoing treatment, and this contact should be made in a timely manner.

Summary

Ms C, a support and advocacy worker, complained on behalf of her client (Ms A) about the care and treatment Ms A received at Queen Elizabeth University Hospital following an operation. Ms A also considered that she had not received a transparent account of events of her post-operative care.

We took independent advice from a nurse. We found that Ms A had issues with urine retention after surgery. Ms A reported not feeling well and this was responded to by nursing staff; however, no attempt was made to catheterise (a  process that involves inserting a tube to the patient's urethra to allow urine to drain freely from the bladder for collection) Ms A, prompt her to self-catheterise or to take a bladder scan. We also noted there were inadequate records of Ms A's fluid balance.

Ms A also had issues with the surgical stockings she was required to wear after her operation, as she found these to be too tight. We noted that according to the Scottish Intercollegiate Guidelines Network (SIGN) guideline 122 a lack of mobility after surgery put a patient at risk of venous thromboembolism (a blood clot that starts in a vein) and devices such as surgical stockings should be worn unless there are specific reasons why these should not be used. We noted that there was no record of an assessment being carried out and we considered this should have been documented. However, as there was no evidence in the notes to raise concerns about the fit of the stockings, it was reasonable that these were worn.

In relation to the board's response to Ms A's complaint, we found that the board did not provide a full, objective and proportionate response.

We upheld both of Ms C's complaints.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms A for failing to perform a bladder scan and/or prompt Ms A to self-catheterise, failing to keep adequate records and for failing to provide Ms A with a full and objective response to her complaint. The apology should meet the standards set out in theSPSO guidelines on apology available at www.spso.org.uk/leaflets-and-guidance.

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

• Nurses should have clear guidelines to ensure a consistent approach to the indicators patients should achieve during an assessment period or a trial of voiding post catheter removal.
• Assessment of the suitability of surgical socks recorded prior to application and regular review of these should be documented as part of ongoing care planning.

In relation to complaints handling, we recommended:

• The board should follow their complaints handling procedure and issue appropriate responses.

Summary

Ms C complained about the care and treatment provided to her mother (Mrs A) when she attended Queen Elizabeth University Hospital for a graft repair of a brain aneurysm (a procedure in which a catheter is passed through a small cut in the groin area to an artery and then to the blood vessel in the brain where the aneurysm (a bulge in the blood vessel wall) is located in order to repair it using coils (spirals of wire) which stabilise the aneurysm). Ms C complained that there had been complications and that there was a delay in the vascular team (specialists in the treatment of diseases affecting the vascular system including diseases of the arteries, veins and lymphatic vessels) coming to assist with the repair. Ms C also said that during Mrs A's recovery, the vascular team had not reviewed Mrs A.

We took advice from a consultant in interventional neuroradiology (a specialist in minimally invasive image-based technologies and procedures used in diagnosis and treatment of diseases of the head, neck, and spine) and a vascular surgeon. We found that the graft repair of brain aneurysm procedure was carried out reasonably, and the leakage of blood where the blood vessel had been closed is a well recognised complication of this procedure. We found that the complication had been managed in a timely and appropriate way, and that the care provided to Mrs A after her surgery was reasonable. However, we found that consent for the graft repair of brain aneurysm had only been taken on the day of surgery. We considered that this should have occurred earlier in order to allow Mrs A to fully understand the procedure and risks. We also found that there was no evidence that Mrs A had been provided with an information leaflet prior to the surgery. Finally, we found that the management plan after the procedure was not adequately communicated to the relevant team. Therefore, we upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs A that the consent process was not initiated at an earlier point than on the day of the procedure, that she was not provided with an information leaflet prior to the procedure, and that the management plan after the procedure was not adequately communicated to the relevant team. 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 consent process for graft repair of a brain aneurysm should be initiated at an earlier point than on the day of the procedure (unless there is an emergency situation) and information leaflets should be provided at the appropriate time.
• The plan regarding which team are responsible for the patient should be clear.