Upheld, recommendations

Summary

C complained about the standard of medical care and treatment provided by the practice. C attended the practice with a lesion on their back which was diagnosed as a seborrhoeic wart (a harmless growth on the skin). C underwent cryotherapy treatment (the use of extreme cold to freeze and remove abnormal tissue) but this was unsuccessful. Therefore, the practice made a a routine referral for an outpatient hospital appointment to have the lesion removed surgically. C opted to be see a private consultant dermatologist (skin specialist) and was diagnosed with cancer. C felt that the practice misdiagnosed their skin cancer which led to a delay in receiving appropriate treatment.

We took independent advice from a GP. We found that the care and treatment C received when they first attended the practice was reasonable. However, the practice failed to record a clear description of the lesion in the medical records. This is essential to ensure that subsequent viewers of the lesion can assess whether there has been any significant change. Therefore, we could not say that subsequent care and treatment had been reasonable and upheld C’s complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failing 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:

• When managing and treating skin lesions, the medical records should contain all relevant information to ensure that subsequent viewers of the lesion can assess whether there has been any significant change in the lesion.

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 their child (A) received from a dentist. A injured their front tooth and attended their dental practice for an emergency appointment. The dentist noted there was a 1mm extrusion (tooth displacement) but decided that no treatment was needed. C complained that the tooth wasn’t treated with a splint.

The dentist said that dentists are able to use their own clinical judgement to decide whether or not to follow the guidelines in each case. In this case, the dentist decided that the tooth would recover on its own and made the decision not to splint the tooth.

We took independent advice from a dentist. We noted that there are standards a dentist should follow. This includes providing patients with treatment that is in their best interests and keeping up-to-date with current evidence and best practices. If a dentist chooses to deviate from established practice and guidance, the reason why should be recorded. We found that the dentist did not record the reasons why they decided not to follow the guidelines and they did not inform C that there were guidelines that applied in this case. We also considered that the decision not to follow the guidelines in this case was unreasonable. Therefore, we upheld C’s complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to inform them that the treatment recommended was not in line with the trauma guidelines, failing to inform them of the reasons why the guidelines were not followed, including the decision not to splint the tooth, and failing to appropriately record the reasons why in the clinical records. 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 dentist should be aware of and familiar with the guidelines on how to manage traumatic dental injuries (https://iadt-dentaltrauma.org/guidelines-and-resources/guidelines). Dentists should follow the guidelines when managing traumatic dental injuries unless there is a specific reason to take a different approach. Dentists should be aware of how and when to record their reasoning should treatment offered deviate from the approach recommended in the guidelines.
• The dentist should be familiar, and act in line with the Standards for Dental Team (particularly standards 1.4.2, 7.1.1, and 7.1.2) as well as, the Professional Duty of Candour.

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 delays in the care and treatment provided to their spouse (A) who was diagnosed with lung cancer following an abnormal chest X-ray. C said that there was a delay in A being provided with a CT scan result by the respiratory consultant, and a further wait to be seen by the oncologist (cancer specialist) following A’s biopsy (a medical procedure that involves taking a small sample of body tissue so it can be examined under a microscope). C asked whether A’s diagnostic pathway influenced their treatment, in that patients with more curable grades of cancer were treated sooner.

We took independent advice from a consultant oncologist. We found that there was no formal pathway for lung cancer patients in place at the time. We also found that the diagnostic pathway being used, was inadequate for all patients, not just for A or other patients with high grade cancer.

We found that due to a shortage of respiratory physicians at the time, there was a delay in arranging a review with the respiratory consultant. This resulted in delays to the biopsy which delayed a treatment plan. The board have accepted that the pathway for A was delayed and have made improvements to enable patients to follow the optimal lung cancer pathway. We found that there was an unreasonable delay in carrying out a respiratory review and that this, and a lack of formal pathway, had a significant impact on A’s overall treatment plan and experience. Therefore, we upheld C’s complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C 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.

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 on behalf of their elderly parent (A). A had a known history of high blood pressure and white coat syndrome (when a patient’s blood pressure rises in response to a stressful situation, such as, a doctor’s appointment or visit to the hospital). A had been prescribed a combination of two diuretic medications (types of drug that cause the kidneys to make more urine) to treat this. During an appointment with a locum GP, it was noted that A’s blood pressure was high so they prescribed a third diuretic medication. A became unwell and attended the practice a few days later. They were then admitted to hospital and diagnosed with hyponatraemia (a lower than normal level of sodium in the blood). C was concerned that the practice prescribed an unnecessary third diuretic that led to A’s admission to hospital and that they did not perform checks on A’s bloods before prescribing this medication.

The practice said that the medications were safe to be prescribed together with close blood monitoring. They explained that they have a system in place to monitor patients who are prescribed ‘triple whammy’ drugs (a combination of drugs of different types: non-steriodal inflammatories, diuretic, and ACE inhibitors). They also highlighted that they took bloods during the consultation before A’s admission to hospital.

We took independent advice from a GP. We found that the decision to prescribe the third diuretic was unreasonable and unsafe. The consultation that took place before the admission to hospital was reasonable and bloods were gathered. However, the practice’s procedure to monitor triple whammy drugs does not apply in this case as A was prescribed three diuretics and none of the other drug types. Therefore, A’s case would not be picked up by this monitoring programme. We found that the practice should have carried out a Significant Adverse Event Review and did not acknowledge any failings in their complaint response. Therefore, we upheld C’s complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C and A for failing to carry out a reasonable consultation on their first visit, failing to ensure that the medication prescribed was necessary and safe, failing to acknowledge any mistakes and failing to carry out a Significant Adverse Event Review, when they should have done. 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:

• When serious significant adverse events occur that could have caused or did result in harm, reviews should be carried out in line with the national guidance: Learning from adverse events through reporting and review – a national framework for Scotland.
• Clinicians should ensure that medication prescribed is required and is safe to be prescribed in combination with other medications before a new medication is issued. If required, blood monitoring should be carried out before commencing a patient on new medication.
• Temporary staff such as locum GPs should be aware of relevant practice procedures and working practices so that they may act in line with them.

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 parent (A) spent two months in hospital due to extensive bruising on their arms and legs with no obvious cause. A suffered acute hip pain while in hospital and became dependent on oxygen. C complained about concerns that they had regarding many aspects of A’s experiences, including A’s discharge after a few weeks and readmission just over a week later. On the day of readmission, A had been visited by district nurses who had administered morphine to A. A died on readmission.

We took independent advice from an adviser specialising in medicine for the elderly. C complained that A was unreasonably discharged. We found that steps had not been taken to ensure that A and C had been provided with reasonable information about the medication that A had been prescribed. Therefore we upheld this aspect of the complaint. Additionally, C complained that district nurses unreasonably failed to administer an appropriate amount of morphine to A. We found that the district nurses’ should have administered an additional dose after the initial dose of morphine did not take effect. Therefore, we upheld this aspect of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise for the failures in this case. 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 reflective reviews undertaken to reduce the risk of similar issues emerging in future should have included specific discussion of information about medication being provided to patients and, where appropriate, their carers/families or other support.

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 received by their young child (A). A had a complex congenital (from birth) heart condition. C complained to the board after A received heart surgery, which had been part of the treatment planned for A. C complained that the board did not reasonably respond to C’s concerns prior to A’s operation. C also complained about the timing of A’s admission to hospital and the timing of the operation.

We took independent advice from a consultant paediatric cardiologist (specialist in children’s heart problems). We found that, overall, the board provided excellent care to A and a successful outcome was achieved through A’s surgery. We found that the timing of A’s operation was reasonable considering A’s age. However, we also found that A was not provided with appropriate follow-up plans in relation to care provided before A’s surgery and that A should have been admitted to hospital three days earlier. On balance, we upheld C’s complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failings identified in this case. 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:

• Patients should receive timely admission to hospital and follow-up appointments, based on their clinical needs and presentation.

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 board failed to reasonably respond to their complaint about the way a form was completed by the GP at their GP Practice.

We found that while the board provided regular updates, apologised for the delay and reasonably managed C’s contact, the length of time responding to the complaint and the inaccuracies of the updates provided to C, were unreasonable. The response to the complaint was unclear and did not answer all of the points raised by C. As such, we upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failures in this case. 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:

• Complaint responses are issued as soon as possible, with the response responding to the main points raised and agreed with the complainant, and any required updates accurately reflect the reasons for the delay.

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 process around a Looked After and Accommodated Child (LAAC) review meeting for their child (A) and the decision taken to end A’s residential placement.

We took independent advice from a social worker. We found that the decision making was based on an appropriate needs assessment and that it was reasonable for the council to consider Self-Directed Support (SDS) options for respite, rather than continuing to fund a full time residential placement that A did not need. However, neither the assessment nor the LAAC review specified what form of respite was considered appropriate for A and why. It should have been made clear to A and C that overnight residential support was no longer required and why external agency respite options were not appropriate.

We also found no evidence that the draft assessment was shared with A and C for their comments, and no record of discussion with the parents about the respite options prior to or at the LAAC review meeting. It was not clear how the council concluded SDS was in A’s best interests, or that this had been properly communicated to or discussed with C.

We upheld C’s complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the shortcomings identified in this investigation. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.
• Provide C with an explanation in respect of external respite options, and why they were considered unsuitable for A.

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

• Key decisions and changes need to be properly documented, explained and communicated. In complex cases such as A’s, case supervision sessions should go over in some detail communication with parents – what information has been shared, what explanations given about actions taken / decisions or recommendations made. LAAC meetings and minutes should detail how best interest decisions were made.

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 and school staff failed to reasonably respond or act when C told them about domestic violence witnessed by their child (A). C said that the council had breached their duty of care and Child Protection obligations in respect of A by ignoring C’s concerns about the domestic abuse that they were suffering and failed to provide A with appropriate support.

The council did not uphold C’s complaint. They considered that C and their family had received an appropriate level of support in line with the council’s policies and procedures.

We took independent advice from a social worker. We found that there was a failure by school staff to reasonably respond to, or act upon, C’s reports of domestic violence witnessed by A. We found that staff should have contacted the council’s Joint Child Protection Team for advice and guidance following C’s initial disclosure of domestic abuse. Therefore, we upheld C’s complaint.

We also identified a concern that council staff may not fully recognise what constitutes domestic violence. It encompasses more than just physical violence and includes a range of behaviour as outlined in relevant legislation. We provided the council with feedback on this point.

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.

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 way that the partnership handled their complaint about the care and treatment provided to C’s late sibling. C said that the complaint process had been long and difficult to follow and it had been hard to obtain a clear and final complaint response from the partnership. C stated that they had to make their own enquiries to determine whether the complaint had been closed and they had been inappropriately referred to another internal complaint process. C also complained about staff conduct during complaint meetings, specifically citing instances of rude and defensive behaviour, as well as a failure to keep meeting notes.

The partnership considered that they had reasonably handled C’s complaint in line with the correct complaint handling procedure (CHP).

We found that it had been unclear which CHP had been followed (the council or NHS) and that there was a failure to comply with timescales. The partnership’s complaint handling did not consider the separate significant adverse event review undertaken by the partnership. Additionally, inaccurate information was provided about the stages of the CHP and the point at which C could escalate the complaint to the SPSO. Finally, we found that the partnership failed to apologise to C for the failings identified in their own complaint investigation. While we could not reach a decision on the behaviour of staff during meetings, we found that they failed to keep written records of complaint meetings. We upheld C’s complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to reasonably handle their complaint and for the failings identified following their own investigation of the complaint. 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:

• Complaint investigations should be managed in accordance with the appropriate complaint handling procedure. The complaint response letter should be clear and fully address all of the points of concern raised, and an apology should be offered when failings have been identified. A written record of complaint meetings should be kept and timeously shared with the complainant. The organisation should have good oversight of how a complaint is progressing, which ensures correspondence with the complainant is clear, consistent and concise.

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.