Upheld, recommendations

Summary

Mr C complained about the board's treatment of his Basal Cell Carcinoma (BCC, a type of skin cancer). Having undergone three initial operations to remove a BCC, he required a further operation to remove a recurrence around nine years later. Mr C complained that the board failed to treat him properly when they initially carried out the surgery.

We took independent advice from a consultant dermatologist (a doctor who specialises in the diagnosis and treatment of skin disorders).

We found that the pathology report of the third procedure should have raised concerns that the tumour may recur. We noted that Mr C had been offered a follow-up appointment, but did not seem to have been warned of the possibility of recurrence. We considered that reasonable treatment options following the pathology from the third procedure would have included consideration for Moh's surgery (surgery where thin layers of cancer-containing skin are progressively removed and examined until only cancer-free tissue remains) and/or follow-up in one to two years with the warning that the tumour could return.

The board confirmed that following the third procedure, Mr C was reviewed then discharged to his GP two months later. We found that there was no record on file that he was advised the tumour may return. There was also no record of the board having considered treatment with Moh's microsurgery, although they confirmed that it was available at the time in question. Therefore, we upheld Mr  C's complaint.

Although we upheld the complaint, we noted the board's comments that had they provided a longer follow-up over two years, this would not have detected or prevented the later occurrence of the BCC. We accepted that it was unlikely this would have detected the recurrence. We also noted that there was no evidence that the surgeries were carried out incorrectly or that they contributed to the recurrence.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for the failure to consider possible Moh's microsurgery treatment, to arrange an appropriate timeframe for follow-up and to advise of the risk of recurrence of the tumour. The apology should meet the standards set out inthe SPSO guidelines on apology available at www.spso.org.uk/leaflets-and-guidance.

Summary

Mrs C complained about the care and treatment that her child (Child A) received from the orthopaedic department (the branch of medicine that deals with diseases and injuries of the musculoskeletal system) and the rheumatology department (the branch of medicine that deals with rheumatism, arthritis, and other disorders of the joints, muscles, and ligaments) at the Royal Hospital for Sick Children, Yorkhill.

We took independent advice from a consultant spinal surgeon and a rheumatologist. We found that:

Mrs C was not informed that the possibility of a spinal x-ray had been discussed following Child A's appointment with the orthopaedic department.

there was no record of the referral that the orthopaedic department made to physiotherapy.

there was no record of the discussions within the orthopaedic department about the risk of doing an x-ray on Child A's spine.

there was no record of the referral that physiotherapy made to rheumatology.

the plan to watch Child A's back for changes did not happen.

We upheld Mrs C's complaints about the care and treatment provided following Child A's referral to the orthopaedic department and the rheumatology department.

Mrs C also complained about the way the board handled her complaint. We found that the board failed to acknowledge Mrs C's complaints in writing within three working days and failed to keep Mrs C updated about the reason for the delay in responding to her complaints and provide a revised timescale for a response. We upheld this aspect of Mrs C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C and Child A for failing to provide Child A with reasonable care and treatment following their referral to the orthopaedic department and the rheumatology department, for failing to communicate reasonably with Mrs C and for failing to handle Mrs C's complaint reasonably. 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 and/or their parent/guardian should be informed when an x-ray is being considered following the identification of scoliosis (abnormal lateral curvature of the spine).
• Clear records of inter-disciplinary referrals and discussions should be kept.
• Clear records should be kept of discussions about the risk of performing an x-ray on a child's spine.
• Clear records of inter-disciplinary referrals and discussions should be kept.

In relation to complaints handling, we recommended:

• Complaints should be handled in line with the model complaints handling procedure. The model complaints handling procedure and guidance can be found here: www.valuingcomplaints.org.uk/handling-complaints/complaints-procedures/nhs.

Summary

Mr C complained about the medical care and treatment that his wife (Mrs A) received from the board. Mrs A had a diagnosis of cancer and had a number of admissions to Aberdeen Royal Infirmary over a two month period. We took independent advice from a consultant clinical oncologist (a doctor who specialises in the diagnosis and treatment of cancer). We found that:

• Mrs A was discharged from hospital before the results of a stool sample were obtained and while she was experiencing diarrhoea
• there are no written records of the phone calls that the doctor had with Mrs  A or her GP following a positive result for Clostridium difficile (a bacterium that causes diarrhoea and more serious intestinal conditions)
• Mrs A was not readmitted to hospital as soon as the Clostridium difficile result became available.

We considered the medical care and treatment to be unreasonable and upheld this aspect of Mr C's complaint.

Mr C also complained about the nursing care and treatment that Mrs A received. We took independent advice from a nursing adviser. We found that:

• the board's response in relation to hand gels was inaccurate in that hand gels are ineffective when caring for patients with Clostridium difficile
• Mrs A's personal hygiene requirements were not recorded consistently and daily records were not kept to indicate what personal hygiene assistance Mrs A had received or had been offered
• nursing staff did not appear to adhere to the Infection Control Policy.
• nursing staff did not record how they knew about Mrs A's shingles (a viral infection that causes a painful rash) diagnosis or whether this information had been passed on to the admitting doctor.

We considered the nursing care and treatment to be unreasonable and upheld this aspect of Mr C's complaint.

Mr C also complained that the board did not handle his complaint reasonably. We found that the board failed to keep Mr C updated about the reason for the delay in responding to his complaint and to provide a revised timescale for completion. We also found that the board's complaint response did not address all the points that Mr C raised. We upheld this aspect of Mr C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for the failure to provide Mrs A with reasonable medical and nursing care and treatment and for failing to handle his complaint reasonably. 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:

• Nursing staff should be aware that alcohol based hand rubs or hand gels are ineffective in removing Clostridium difficile spores and that hand-washing is an important aspect of preventing the spread of Clostridium difficile.
• Personal hygiene requirements should be recorded clearly and consistently. There should be daily recordings to indicate what personal hygiene assistance patients have received or have been offered.

In relation to complaints handling, we recommended:

• Complaints should be handled in line with the model complaints handling procedure. The model complaints handling procedure and guidance can be found here: www.valuingcomplaints.org.uk/handling-complaints/complaints-procedures/nhs.

Summary

Mr C had been in contact with mental health services for a number of years and was informed by his current psychiatrist (a medical practitioner who specialises in the diagnosis and treatment of mental illness) that he had a diagnosis of borderline personality disorder. Mr C complained that his previous psychiatrist had failed unreasonably to diagnose him with this and provide the appropriate treatment.

We took independent advice from a medical adviser. We found that the standard of communication in relation to the diagnosis was unreasonable and that this led to uncertainty and distress for Mr C. While, we did not find this had an adverse effect on his management or treatment, we recognised that not learning of his diagnosis until recently lead to a great deal of uncertainty and distress. On balance, we upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for the failings in record-keeping and communication. 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 clinician involved should reflect on this complaint and findings at their next appraisal.
• The board should ensure that clinicians follow the relevant guidance when diagnosing and discussing personality disorders with patients.

Summary

Ms C underwent abdominal surgery at Dumfries and Galloway Royal Infirmary and complained about the way in which it was carried out. Ms C also complained that the follow-up care and treatment was unreasonable.

We took independent advice from a consultant surgeon. We found that the board failed to explain all the recognised risks and complications of the surgery to Ms  C prior to the surgery. We considered that this was not in line with the General Medical Council guidance on consent. We also found that the board were unable to confirm the operating consultant surgeon's experience in this type of surgery. We concluded that there was a lack of evidence to demonstrate that the operating consultant surgeon was appropriately trained, experienced and had conducted a sufficient number of cases to perform the surgery without the direct involvement of a plastic surgeon. Therefore, we upheld this aspect of Ms C's complaint.

In relation to follow-up care and treatment, the board acknowledged and apologised for failings highlighted in their own complaint investigation. They found that Ms C's symptoms and pain were not fully considered in order to identify and prompt the removal of stitches sooner and that communication around this had been unreasonable. Following our investigation, we also found that an urgent GP referral and ultrasound scan should have prompted urgent surgical review. We also noted that there was no planned review following earlier treatment and that there were no post-operative instructions on operation records. Therefore, 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 inform her of all the recognised risks of the surgery and for not involving the appropriate clinicians in her surgery. 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:

• Operation records should be legible and give sufficient detail to enable continuity of care by another doctor as set out in Good Surgical Practice.
• Surgeons should obtain the patient's consent in the pre-operative clinic in accordance with the Royal College of Surgeons' guidance.
• Surgeons should be appropriately trained, experienced and have conducted a sufficient number of cases to perform this type of surgery.

Summary

Mr C was removed from his cell to a different part of his prison temporarily and when he was returned to his usual cell, he said that some of his property was missing. Mr C put in a lost property claim to the prison, but they did not pay it. Mr C complained to the prison about this, and the Internal Complaints Committee (ICC) agreed with the decision not to pay his claim. Mr C claimed that the ICC's handling of his complaint was unreasonable.

We found that the form for clearing Mr C's cell was not completed properly and was not dated, so it was not known how long it took to secure Mr C's property. The ICC did not take this into account. They also did not consider that the property claim panel stated that Mr C's cell was cleared on a specific date, while there was no record of when the cell was cleared.

The ICC referred to a disclaimer that Mr C signed, stating that he was to be responsible for his own property when it was in his care; this was part of the reason for not paying Mr C's claim. We found that it was unreasonable to say that property was described as being in Mr C's care when he had been removed to another part of the prison, and his property was in his cell for an unknown period of time before it was secured. In addition, the ICC failed to ask the property claim panel what evidence, if any, they considered and how they had come to their view about Mr C's claim.

We upheld Mr C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for the failure to properly investigate and respond to his concerns. 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 claim, given the failings identified, taking account of the prison's statement that if the ICC had upheld Mr C's complaint, they would have recommended that the property claim panel pay him in full for his claim.

In relation to complaints handling, we recommended:

• ICC members should be sufficiently trained in good investigative practice, and apply that practice in dealing with prisoner complaints.

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

Summary

Ms C complained about the time taken to remedy problems with her heating system. Ms C had experienced a number of problems with her heating system over a period of several months.

We found that some issues, while related to the heating system, were new and distinct from earlier problems and that a number of issues were responded to promptly. However, we also found occasions where engineers failed to attend and repairs took too long. On balance, we upheld Ms C's complaint.

Recommendations

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

• The association should consider if there is anything further they can do, or put in place, to minimise the risk of these problems recurring.

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

Summary

Ms C complained that the association took an unreasonable amount of time to fix problems she reported about her windows. After Ms C reported an issue, the association attended a number of times, with the contractor, over the next 11  months.

We found that there was poor communication with Ms C about what progress was being made to remedy problems with the windows. Ms C had to chase up responses and at the point of reaching a decision on her complaint, there was still disagreement about whether the windows had been fixed properly. Therefore, we upheld Ms C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms C for taking an unreasonable amount of time to remedy problems she reported with her windows. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/leaflets-and-guidance.
• Arrange for a suitably qualified person (independent of the contractor) to attend to assess the windows and for any remedial action required to be promptly taken.

Summary

Ms C complained that the partnership unreasonably managed her foster child's (Child A) transition to their new home.

We took independent advice from a social worker. We found that Child A's views were not sought even though, given their age, there was an opportunity to understand how they felt. We considered that Child A could have been better supported to help them understand what was happening. Child A was also not given an opportunity to say goodbye to their foster family in a way that was sensitive to their needs.

We also found that a Looked After Child (LAC) review did not take place after the Children's Hearing made their decision to move Child A. This would have provided the best opportunity to ensure that all relevant areas were assessed, to safeguard Child A. Relevant agencies were also not aware of Child A's move, meaning gaps in information could have occurred and potentially have an adverse effect on the protections in place for Child A. Therefore, we upheld Ms  C's complaint.

Recommendations

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

• Children's views should be sought in an age appropriate manner to understand how they are feeling and have a more informed assessment of their behaviour.
• Future review dates should be set at LAC meetings and be incorporated into the decisions and action to be taken as per LAC procedures.
• Actions identified in LAC reviews which impact on child safety should be followed up with the actions/outcomes recorded at the subsequent LAC review.
• The partnership should follow LAC procedures regarding permanent substitute care with management systems in place to ensure that this is happening.

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

Miss C complained about the partnership's decision to move her father (Mr A) to sheltered accommodation. Miss C had Power of Attorney for her father and was of the view he required a care home setting to meet his needs. Mr A moved into his new tenancy but shortly after was involved in an incident which left him detained in hospital. Mr A was then discharged to a care home setting. Miss C complained that her views had not been considered and questioned the decision to move her father to sheltered accommodation.

The partnership responded by explaining that there is no specific guidance on whether someone's care would be best met in supported housing or 24 hour care. They said that their normal practice would always be to use the least restrictive option that was suitable. They advised the decision to try housing with care was a multi-disciplinary decision which included Miss C and was approved by the housing committee. The partnership also advised that a social worker only became involved toward the end of the process when Mr A's needs increased and the assessment became more complex. Miss C was unhappy with this response and brought her complaint to us.

We found that the quality of information provided by the partnership was poor and limited with no clear explanation about why the decision was made to move Mr A into sheltered accommodation rather than a care home. We noted that the partnership did not have any procedures which guide when it is appropriate for a social worker to become involved in the decision-making process. We took independent advice from a social worker who found that the council failed to involve a social worker at the appropriate time in the assessment process as they only became involved after Mr A was admitted to hospital. Given this and the poor quality of assessment, we upheld Miss C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Miss C for failing to involve a social worker in the assessment process and for failing to communicate all options to her in a reasonable manner. 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 there is clarity about staff roles to ensure they complete assessments for care appropriately.
• The partnership should reflect on the failings identified and actions for learning and improvement should be proposed to prevent similar issues occurring in the future.