Upheld, recommendations

Summary

Mr C, an advocacy and support worker, complained on behalf of Mrs B about the care and treatment provided to her late husband (Mr A) at Inverclyde Royal Hospital. Mr A was referred to the hospital for a scan of his urinary tract. A  blockage was found and subsequent investigations identified an inoperable bladder tumour. Palliative treatment was planned for Mr A and he had a number of scans carried out over the following months. Mr C complained about the reporting of Mr A's scans, palliative care support and communication between staff and with Mr A and Mrs B.

We took independent advice from a consultant 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), a palliative care nurse and a consultant urologist (a doctor who specialises in the male and female urinary tract, and the male reproductive organs). We found that there had been errors in reporting the extent/spread of Mr A's cancer and also in relation to a possible bowel perforation. We upheld this aspect of Mr C's complaint, however, the errors were unlikely to have affected the clinical treatment that Mr A received.

In relation to the palliative care support provided to Mr A, we found that there had been reasonable palliative care whilst Mr A was in hospital. However, there were issues with the referral process and access to community palliative care support. The board had already identified failings in palliative care support and apologised following their own consideration of the case. We upheld this aspect of Mr C's complaint.

Finally, we found that the board had acknowledged there were failings in relation to communication when Mr A was referred to another treatment centre and that they had offered apologies. We were also concerned that it was unclear from the case notes that the situation regarding prognosis and palliative care had been communicated and understood by Mr A and Mrs B. Therefore, we upheld this aspect of Mr C's complaint.

Recommendations

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

• Consideration should be given to issuing a report addendum when additional significant features are identified after review of medical imaging by the multidisciplinary team.
• Consideration should be given to issuing a report addendum if the interpretation of a medical image alters significantly from the previously issued report, following discussion with the referring clinician.
• Reporting errors should be discussed at imaging discrepancy meetings.
• There should be clearly defined referral criteria and process in place for discharge home from hospital for palliative care patients. Consideration should be given to using a discharge/transfer of care checklist.

Summary

Mrs C was admitted to Queen Elizabeth University Hospital with severe abdominal pain. She was pregnant at that time and had been referred to the hospital with suspected appendicitis (a serious medical condition in which the appendix becomes inflamed and painful). The hospital carried out an ultrasound scan and considered it was likely that Mrs C had gastroenteritis (inflammation of the stomach and intestines). Her condition deteriorated over the next few days and it was found that her unborn baby had died. Mrs C was taken to theatre where it was identified she had appendicitis and her appendix was removed. She was then admitted to the intensive care unit at the hospital with sepsis (blood infection) and organ failure. Mrs C recovered but later had two further admissions with infections in her abdominal muscles. Mrs C complained that there was an unreasonable failure to diagnose appendicitis and sepsis.

We took independent advice from a consultant general and colorectal surgeon (a  surgeon who specialises in conditions in the colon, rectum or anus). We found that there had been a number of failings in Mrs C's care and treatment, including:

• a failure to adequately consider an alternative diagnosis to gastroenteritis in view of rising CRP (C-reactive protein - a blood test marker for inflammation in the body),

• a failure to give adequate consideration to carrying out a CT scan or diagnostic laparoscopy (a surgical procedure in which a fibre-optic instrument is inserted through the abdominal wall to view the organs in the abdomen or permit small-scale surgery),

• the national early warning scoring (NEWS - an aggregate of a patient's 'vital  signs' such as temperature, oxygen level, blood pressure, respiratory rate and heart rate which helps alert clinicians to acute illness and deterioration) that was carried out was not done appropriately,

• a failure to interpret and actively pursue signs of sepsis on the NEWS scores,

• staff should have used maternity early warning score (MEWS) observation charts,

• there was no review by an experienced obstetrician (a doctor who specialises in pregnancy and childbirth),

• the lack of physical examination by experienced doctors,

• there was a delay in carrying out a repeat ultrasound scan and

• the delay in considering a diagnostic laparoscopy or surgery was unreasonable.

We considered that there was an unreasonable failure to diagnose Mrs C with both appendicitis and sepsis and, therefore, upheld Mrs C's complaints. A number of failings had been identified by the board, but we made some additional recommendations for learning and improvement.

Mrs C also complained that the board's investigation into her care and treatment was inadequate. We found that there had been a delay in starting a critical incident review and that there were some failings in the report. We also 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 starting the significant clinical incident investigation. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/leafletsandguidance.

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

• In relevant cases, NEWS scoring should be carried out appropriately.
• Deteriorating patients should be escalated to a senior clinician especially in the presence of sepsis. Where appropriate in these cases, a senior doctor should carry out a physical examination.
• Significant clinical incident investigations should be started promptly in appropriate cases.

Summary

Mr C complained about the care and treatment he received at Woodend Hospital. Mr C had suffered knee problems for a number of years and had been refused surgery as his Body Mass Index (BMI - weight health calculation) was too high. Mr C lost a substantial amount of weight and reduced his BMI. Mr C was then reviewed by a consultant who said that they would not consider surgery unless he lost at least a further three and a half stone in weight.

We took independent advice from an orthopaedic consultant (a specialist in the treatment of diseases and injuries of the musculoskeletal system). We found that Mr C had previously been given a target BMI which he reached. However, when Mr C was reviewed by the consultant, they felt that Mr C needed to achieve an even lower BMI before they would consider surgery. We considered that Mr C had persevered with his weight loss attempts and that it was then unreasonable for the consultant to have decided that Mr C continue to lose a further substantial amount of weight. Therefore, we upheld Mr C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for asking him to lose a further three stones in weight before staff would consider surgery. The apology should meet the standards set out in the SPSO guidelines on apology available at https://www.spso.org.uk/leaflets-and-guidance.

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

• Staff should review the decision as Mr C had reached the target BMI for consideration of surgery.

Summary

Mr C complained about the care and treatment that his wife (Mrs A) received from the board's gastroenterology department (the branch of medicine which deals with disorders of the stomach and intestines) at Aberdeen Royal Infirmary for her abdominal problems. A number of tests were carried out and it was considered that she had probable small bowel Crohn's disease (a long-term condition that causes inflammation of the lining of the digestive system).

We took independent advice from a consultant gastroenterologist. We found that Mrs A's case was complex. Whilst there had been a short delay in her seeing a consultant, this was not unreasonable. That said, we found that there had then been an unreasonable delay in carrying out an urgent colonoscopy (examination of the bowel with a camera on a flexible tube) that had been requested for her. However, in their response to Mr C's complaint, the board said that this had been reviewed and action had already been taken to prevent similar delays. We also found that given staff were aware of Mrs A being atypical for a Crohn's disease patient, alternative / additional diagnoses, including a psychological diagnosis, should have been considered, documented, discussed and treated earlier in the course of her assessment. Staff should have concentrated more on controlling Mrs A's symptoms and considered more active treatment for irritable bowel syndrome type symptoms. In view of these failings, we upheld this aspect of Mr  C's complaint.

Mr C also complained that the board's response to his complaint was unreasonable. Given the symptoms Mr C had described in his complaint to the board, we found that the board should have explored what further treatment should be provided to Mrs A and referred to this in their response. Given the failure to do so, we also upheld this aspect of Mr C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs A for the delay in carrying out an urgent colonoscopy, failing to concentrate on controlling Mrs A's symptoms and failing to explore what further treatment could be provided to Mrs A. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/leafletsand-guidance.
• Review Mrs A's treatment to ensure it is appropriate.

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

• In cases similar to Mrs A's where a patient's presentation with Crohn's disease is atypical, staff should consider alternative/additional diagnoses.

In relation to complaints handling, we recommended:

• In complaints, where complainants have raised concerns about the lack of treatment being provided, the board should explore what further treatment should be provided and refer to this in their response.

Summary

Mrs C complained about the care and treatment that was provided to her at University Hospital Crosshouse for a melanoma in situ (an early stage of skin cancer where the cancer cells are in the top layer of skin) on her face. Mrs C was concerned that the consent process for the procedure to remove the melanoma was inadequate, as she had been unaware that she would be left with a scar far larger than the area of skin removed. Mrs C complained about the procedure that was carried out and considered that the overall handling of her complaint was unreasonable.

We took independent advice from a consultant maxillofacial surgeon (a doctor who specialises in treating diseases and injuries to the mouth, jaws, face and neck). We found that the procedure carried out to remove the melanoma in situ was appropriate for Mrs C and there were no concerns about the standard of the surgery itself. However, we found that the consent process had been inadequate and that the operation note was not sufficiently detailed. Neither of these records included a diagram to aid understanding of the procedure, and there was no evidence that the extent of the wound Mrs C would be left with had been discussed before the surgery. The advice also highlighted that, despite the fact that the melanoma in situ was in a cosmetically sensitive area on Mrs C's face, no photographs were taken prior to initial investigations. We upheld Mrs C's complaint about care and treatment.

In relation to complaints handling, we found that the board had not responded within the 20 working day target and that Mrs C had not been kept timeously updated. We upheld this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C for the inadequate consent process, the quality of the operation note and the complaints handling failing identified. 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:

• There should be effective communication with patients to ensure they have sufficient information to understand their treatment. The consent process should be in line with national guidance on consent.
• Consideration should be given to photographing all pigmented lesions or lesions of cosmetic significance prior to biopsy.
• Operation notes should be of an appropriate standard.

In relation to complaints handling, we recommended:

• Complaints should be handled within the prescribed timescale and where this is not possible, complainants should receive a timeous update.

Summary

Mr C complained about the way the Scottish Prison Service (SPS) handled his claim for lost property compensation. Mr C said that several items sent from his cell to the laundry had not been returned.

We were not satisfied that the SPS had undertaken a thorough investigation when Mr C first reported his laundry as missing. Given that prisoners have no control over their property in laundry bags between submitting them and receiving them again, we considered that the prison should have a robust tracking process to show that the laundry bags have been delivered back to the relevant prisoner. We also found that the subsequent review of Mr C's claim was unreasonable. The SPS claimed that the items in question were handed out. However, the only evidence identifying items handed out was the property card, which was not fully completed as Mr C had not signed out the items (although this is required on the card). We also noted that the SPS had provided inconsistent explanations about what happened to Mr C's property. We considered that they failed to handle Mr  C's claim reasonably and upheld this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for failing to fully investigate Mr C's claim of lost laundry. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/leaflets-and-guidance.
• Reconsider the claim for lost property, taking into account the points contained in our decision.

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

• The SPS should have a system in place to adequately track prisoner's laundry, so that any claim for missing laundry can be fully investigated.

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 a prisoner officer made inappropriate comments about him in an email sent to another officer. The officer did not accept that their comments were inappropriate, and noted that they were informed by a psychological risk assessment given to the Scottish Prison Service (SPS) in relation to managing Mr C. Mr C was unhappy with this response and brought his complaint to us. He believed the comments were unnecessary in the context of his query, and that they did not adhere to the terms of a Staff Notice previously issued to staff advising the use of appropriate and non-biased language in communications.

While we noted that it was appropriate for the SPS to give regard to the psychological risk assessment in managing Mr C, we did not consider that the comments were appropriate in the individual circumstances of the particular query. Therefore, we upheld Mr C's complaint.

Mr C also complained about the handling of his subsequent complaint. Mr C felt it was inappropriate that his complaint was handled at the first stage of the process by the officer it was about and then was not properly addressed at the second stage. We found that having the officer complained about respond to his complaint was not a direct breach of prison rules. However, we considered that it would be best practice to avoid this situation. We also found that the second stage of the complaints process failed to give due regard to all relevant factors and evidence. On balance, we upheld this complaint.

Recommendations

Sector: Scottish Government and devolved administration

Subject: communication

Decision: upheld, recommendations

• Summary
• Mr C complained that a prisoner officer made inappropriate comments about him in an email sent to another officer. The officer did not accept that their comments were inappropriate, and noted that they were informed by a psychological risk assessment given to the Scottish Prison Service (SPS) in relation to managing Mr C. Mr C was unhappy with this response and brought his complaint to us. He believed the comments were unnecessary in the context of his query, and that they did not adhere to the terms of a Staff Notice previously issued to staff advising the use of appropriate and non-biased language in communications.
• While we noted that it was appropriate for the SPS to give regard to the psychological risk assessment in managing Mr C, we did not consider that the comments were appropriate in the individual circumstances of the particular query. Therefore, we upheld Mr C's complaint.
• Mr C also complained about the handling of his subsequent complaint. Mr C felt it was inappropriate that his complaint was handled at the first stage of the process by the officer it was about and then was not properly addressed at the second stage. We found that having the officer complained about respond to his complaint was not a direct breach of prison rules. However, we considered that it would be best practice to avoid this situation. We also found that the second stage of the complaints process failed to give due regard to all relevant factors and evidence. On balance, we upheld this complaint.
• Recommendations [3]

What we asked the organisation to do in this case:

• Apologise to Mr C that due regard was not given to all relevant factors and evidence in responding to his query, and for comments having been made about him that were not justified by the individual circumstances of the situation. 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 they use appropriate and non-biased language in communications, avoiding any unnecessary statements that are not justified by the circumstances of the situation. The SPS should reiterate to staff the terms of the Staff Notice.

In relation to complaints handling, we recommended:

• Each complaint or query should be considered on its own merits, and due regard should be given to all relevant factors and evidence, avoiding narrow focus that could lead to perceived or actual bias. The SPS should feed this requirement back to staff in a supportive manner.

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 progress work on his management plan during his temporary transfer to another establishment. He was being held out of association with other prisoners (under Rule 95 of the Prisons and Young Offenders Institutions (Scotland) Rules 2011) due to difficulties managing him and finding a suitable location for him. He was temporarily transferred to another establishment for operational reasons, and to give the SPS time to formulate a plan for his future management and location.

In responding to the complaint, the SPS said attempts had been made during Mr  C's temporary transfer to relocate him to another establishment. They said that options for his future management had consistently been pursued. However, they could not find evidence to support this and they acknowledged that the Rule  95 paperwork had not been fully completed to record all action taken. We acknowledged that there appeared to be difficulties for the SPS in managing Mr  C. However, as they were unable to demonstrate that steps had been taken to implement or explore agreed actions during his temporary transfer, we upheld this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for not being able to clearly demonstrate that steps were taken to plan for his future management and location during his temporary transfer. 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 SPS should tell us what they will do to ensure future adherence to the Rule 95 process, particularly in relation to being able to demonstrate that steps have been taken to implement or explore agreed actions.

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 service provided by the Crown Office and Procurator Service (COPFS) when they were dealing with the investigation into the circumstances around her relative's death and the Victims Right of Review of that investigation. Ms C considered there was a lack of compassion when dealing with her family and that they were always having to chase for information and updates. Ms C also complained about the response she received to her complaint. Ms C considered it was not clear which part of the organisation was dealing with it. She also felt that no specific improvements were addressed as a result of her feedback about her experience.

We upheld all aspects of Ms C's complaint. We found that there was a failure to instigate communication with the family and provide updates, even if the details of those investigations could not be disclosed. There was also a failure to take reasonable care when deciding the route to a meeting room where discussions were held with the family. We considered that the organisation failed to confirm which part of the organisation was dealing with the Victims Right to Review or which part of the organisation was dealing with Ms C's complaint . We also found that when responding to Ms C's complaint there was a failure to clarify what specific steps would be taken to ensure communication with other families would be improved in the future.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms C for failing to instigate communication with her and her family providing updates on the investigation and review; failing to take reasonable care when deciding on the route to the meeting room where discussions were held with Ms C's family; failing to confirm what branch of the organisation was dealing with her request for a Victims Right to Review or complaint; and failing to clarify what specific steps could be taken to improve communication with other victim's families in the future. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/leafelts-and-guidance.

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

• Members of staff should agree a contact point with victims' families at different stages of investigation and/or review and set prompts to provide regular updates. COPFS should consider what can improve the experience for victims' families.

In relation to complaints handling, we recommended:

• There should be better coordination and communication within the organisation regarding who is dealing with a complaint where different streams of communication are being used.
• COPFS should demonstrate that improvements have been made as a result of Ms C's experience.

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 council failed to provide a reasonable response to his correspondence about planning and enforcement and other issues in relation to land near his home.

We took independent advice from a planning adviser. We found that, in general, the council had tried to address the issues Mr C raised in his correspondence. However, we identified a number of failings:

• the council did not provide an adequate explanation to Mr C about their delay in progressing matters in relation to a planning breach

• they did not advise him that he should notify them of a planning breach through their electronic enforcement system

• their response could have been clearer in relation to whether action that was being taken would resolve the enforcement issues

• their response incorrectly stated that the enforcement case must be suspended until planning applications had been determined

• they did not provide an adequate response to his comments about aggregation in relation to procurement

• they should have taken further action in relation to comments made in advertising by one of their contractors

• they failed to keep him updated on the delay in responding to his complaint.

In view of these failings, we upheld Mr C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for the failings in relation to the handling of his correspondence to them. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/leafletsand-guidance.
• Investigate and provide a response to Mr C's comments about aggregation.

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

• It should be clear from the Council's Enforcement Charter that anyone who did not make the initial complaint regarding a breach of consent, will not be kept informed of actions taken by the council to address that breach or of the outcomes. The Charter should provide a link to the enforcement register so that customers can track progress of any enforcement action themselves.

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.