Upheld, recommendations

Summary

Mr and Mrs C were kinship carers for Child A. Child A was removed from Mr and Mrs C's care and placed in foster care. Mr and Mrs C complained to us that the council failed to provide the appropriate support to them as kinship carers.

We took independent advice from a social work adviser. We found that, while at times the level of support provided was reasonable, there were occasions when the council's actions were unreasonable. In particular, we found that:

• Child A was not seen alone by their supervising social worker every four weeks, contrary to the council's own standards.

• The council failed to carry out home visits to Mr and Mrs C on two occasions.

• The council did not provide a reasonable level of support to Mr and Mrs C to ensure they had the necessary skills to meet Child A's needs, given the possible impact of Child A's experiences and the behavioural issues that could arise.

• The council instructed an external service to provide Child A with support. It was not clear from the records when the support of this service started and ended for Child A or what work the service was doing with Child A.

• A planning meeting was not carried out within 72 hours of Child A being placed with Mr and Mrs C and no kinship care assessment was completed for Mr and Mrs C, contrary to the council's own guidance and the Looked After Children (Scotland) Regulations 2009.

• Child A's social work notes were often recorded much later than set out by the Council's policy which states that they should be recorded within five days of the event.

In addition, we found that the handling of Mr and Mrs C's complaint was unreasonable.

We upheld Mr and Mrs C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr and Mrs C for failing to provide a reasonable level of support to them as kinship carers and for failing to handle their complaint in accordance with the Social Work Model Complaints Handling Procedure. 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:

• Looked After Children should be seen on their own by their allocated social worker every four weeks in accordance with Fife Council's Social Work Service Children & Families Service Duty Principles & Standards (August 2017).
• The council should visit the child and their carer on any occasion where it is considered necessary or appropriate to safeguard or promote the welfare of the child or where it is considered necessary or appropriate to provide support and assistance to the child's carer for the purpose of safeguarding or promoting the welfare of the child, in accordance with the Looked After Children (Scotland) Regulations 2009.
• Where a child has experienced neglect and/or abuse, the council should discuss the likely impact of this with the kinship carers at the earliest opportunity and provide the level of support needed to ensure the kinship carers have the necessary skills to meet the child's needs in accordance with the Getting it Right for Every Child Framework.
• Where the council instructs an external service to provide support, changes to the service provided and the reasons for those changes should be recorded clearly.
• Planning meetings should be held within 72 hours of kinship care placements beginning in accordance with Fife Council's Kinship Assessment Guidance. Kinship care assessments should be completed within 12 weeks of the kinship care placements beginning in accordance with the Looked after and Accommodated (Scotland) Regulations 2009, the Guidance on Looked After Children (Scotland) Regulations 2009 and Fife Council's Kinship Assessment Guidance. If there are legitimate and assessed reasons for not complying with the Regulations or the Council's Guidance then these should be recorded clearly and approved by a manager.
• Social work case notes should be recorded within five days of the event taking place in accordance with Social Work Service Children & Families Service Duty Principles & Standards (April 2016).

In relation to complaints handling, we recommended:

• When responding to complaints the council should follow their complaints handling procedure and all staff should be aware of this and the model complaints handling procedure for local authorities.

Summary

Mrs C complained that the council failed to follow appropriate policies and procedures after an incident involving her child in the playground at school.

We took independent advice from a social worker in relation to the council's handling of matters. We found that the council had acted appropriately immediately after the incident. However, we found that in the period that followed there had been significant failings in the way things were handled. Contrary to GIRFEC principles (Getting it Right for Every Child - the nationwide policy which puts the child at the centre of decision-making and ensures their views are heard), there was a clear failure to involve the child, or take account of their clearly stated views about what had happened to them. The child had written to the council with their concerns about what might happen next, and what would make them feel safe to return to school, and this letter went unacknowledged.

We also found failings in communication with Mrs C. In line with council policy, a Lead Professional should have been nominated when other agencies became involved. The Lead Professional would have been a single point of contact for Mrs C, and would have helped to ensure there was clearer communication and management of expectations. We found there was no clear communication or co-ordination between agencies, which would have heightened the family's anxiety.

In light of these failings, we upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C and her family for failing to follow GIRFEC policy, by failing to take the child's views into account and by failing to ensure that the child was fully involved in decisions affecting them. Also apologise for the failings in communication with Mrs C, with regard to what steps were being taken to resolve matters and what could be expected in terms of timescales. The apology should meet the standards set out in the SPSO guidelines on apology available at https://www.spso.org.uk/leaflets-and-guidance.
• An appropriate person from the council (probably the Headteacher) should respond to the child's letter, acknowledging the impact on them and providing an explanation for the original decision that they should not move class after the incident.

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

• Staff should be confident in applying GIRFEC policy to incidents such as this one. They should ensure that children are fully involved in decisions affecting them and their views taken into account. Clear records should be kept of communication between agencies, and staff should be aware of the importance of clarity in communication between agencies. Staff should be clear about the roles of Named Person and Lead Professional.
• Relevant staff should be clear about who will take the lead in situations such as this. Staff should be aware of the importance of clear and accurate communication about the steps being taken to resolve matters and what can be expected in terms of timescales.

In relation to complaints handling, we recommended:

• Complaint responses should be appropriately empathetic and include a recognition of impact.

Summary

Mrs C complained on behalf of her daughter (Miss A), who suffers from quadriplegic cerebral palsy (a condition which results in severe or complete loss of motor function in all four limbs) and other complex additional support needs. Mrs C complained that the board unreasonably withdrew Miss A's physiotherapy.

We took independent advice from a physiotherapist. We found that it could have been deemed appropriate for the board to stop Miss A's physiotherapy. However, we found that this was done without any appropriate assessment documented in the notes and without any documented consultation and discussion with Mrs C and her husband (Mr C). This is contrary to the Scottish Government Getting it Right for Every Child guidance. We upheld this aspect of Mrs C's complaint.

Mrs C also complained that, when asked, the board unreasonably failed to show her that their decision to withdraw Miss A's physiotherapy was based on clinical need. We noted that, while the board referred to the progress Miss A had made, they did not explain why improvement in Miss A's physical abilities affected her need for physiotherapy. In view of this, it was unclear why the specific physiotherapy was withdrawn. There was also a delay in the board providing this complaint response to Mrs C. We upheld this aspect of the complaint.

Mrs C also complained that the board unreasonably failed to carry out a paediatric physiotherapy review of Miss A's physiotherapy requirements, as had been agreed at a meeting with Mrs C and Mr C. We were unable to confirm if a review took place at the time the board said that it would. We upheld this aspect of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr and Mrs C and Miss A for the failings in Miss A's physiotherapy care and their response to the complaint.The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/leaflets-and-guidance.

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

• In a similar situation, parents should be consulted prior to making changes to their children's physiotherapy treatment. The clinical reasoning for making changes should be documented and explained prior to them taking place, in accordance with Scottish and UK legislation and advice.
• Actions agreed at meetings regarding physiotherapy complaints should be completed and formally documented.

In relation to complaints handling, we recommended:

• Respond to complaints within a reasonable time and provide full responses, in accordance with the board's complaints procedure.

Summary

Mrs C complained that the dental treatment she received was unreasonable. Mrs  C had been a patient of the dentist for 20 years but received a second opinion from another dentist and was told that she had extensive gum disease. Mrs C was concerned that she was never informed of this and that the treatment she had received was inappropriate. Mrs C also complained that the dentist unreasonably communicated with her about the health of her mouth and that they provided an unreasonable response to her complaint.

We took independent dental advice. We found that the patient notes recorded were very limited, with little information about the ongoing overall health of Mrs C's mouth or the investigations or treatments that occurred over the 20 year period. We also found no record of a Basic Periodontal Examination (BPE - a check on gum health that is required to take place at every six month exam).

In relation to the dentist's communication with Mrs C, we found that there was little evidence in the dental records that the dentist adequately informed Mrs C about the health of her mouth over the 20 year period. We also found that the response to Mrs C's complaint included inaccuracies and comments that were not supported by the dental record and failed to signpost Mrs C to us at the end of the complaints process.

We upheld all of Mrs C's complaints.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C for the failings in treatment and communication. 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:

• The dentist should be fully aware of the requirements for good clinical record-keeping as stipulated in 4.1 of the General Dental Council Standards and the guidance for good note taking that is available in the Clinical Examination & Record Keeping Standards (FGDP RCS (Eng)).
• The dentist should be fully aware of the Scottish Dental Clinical Effectiveness Programme guidance contained within the Prevention and Treatment of Periodontal Disease in Primary Care.
• The dentist should be fully aware of the requirements of the Statement of Dental Remuneration.
• The dentist should be fully aware of the Selection Criteria for Dental Radiography (FGDP RCS (Eng)).
• The dentist should be fully aware of the Ionising Radiation (Medical Exposure) Regulations (2000) justification and reporting requirements, and the subsequent 2018 regulations.

In relation to complaints handling, we recommended:

• The dentist should ensure responses to complaints are accurate and supported by the dental records, and should also ensure that the complainant is advised of their right to come to the SPSO.

Summary

Mrs C complained about the care and treatment she received from Ninewells Hospital regarding a delay in physiotherapy and the board's handling of her complaint concerning the matter.

We took independent advice from a consultant obstetrician and gynaecologist (a doctor who specialises in childbirth and the female reproductive system). We found that the handling of Mrs C's referral to physiotherapy was unreasonable and caused a delay of around seven months in her receiving her first appointment. We acknowledged that the board had apologised to Mrs C for the failure to action the referral to physiotherapy and for problems both Mrs C and her GP had when trying to expedite the referral through the doctor's secretarial staff. We considered that there was an unreasonable failure to amend Mrs C's management plan (regarding the decision to refer her for physiotherapy) after she was reviewed post-operatively.

We found that there was poor internal communication across two hospital sites and a missed opportunity for the problem with the referral to be addressed at an earlier stage when Mrs C and her GP contacted the doctor's support staff. We considered that the board had taken reasonable action to improve communication between hospital sites. We considered that the delay in receiving physiotherapy was unlikely to have affected the progression of Mrs C's condition. However, we upheld the complaint and made a further recommendation to ensure learning and improvement.

In terms of the board's handling of Mrs C's complaint, we acknowledged that they had apologised to Mrs C about their delay in responding. We found that the board had delayed by three weeks in updating Mrs C when they were unable to meet the 20 working day timescale for responding to complaints. Were were also critical that the board had not responded to all of the concerns Mrs C had raised in her complaint correspondence. The board accepted that they should have responded to this aspect. We upheld Mrs C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C for not responding to all aspects of her complaint.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 ensure that management plans are updated between theatre and post-operative review.

Summary

Mrs C complained about the care and treatment that her late husband (Mr A) received in A&E at the Royal Infirmary of Edinburgh. Mr A was taken to hospital after becoming unwell with chest pains and was treated for a suspected heart attack. Tests carried out showed that Mr A was not having a heart attack and he was referred for a CT scan (a scan that creates detailed images of the inside of the body) to investigate other causes. Before the scan took place, Mr A collapsed and staff were not able to resuscitate him. The cause of death was a thoracic aortic dissection (a condition where the lining of the main blood vessel from the heart is injured). Mrs C felt that a CT scan should have been ordered sooner.

We took independent advice from a consultant in emergency medicine. We found that it was appropriate to investigate and treat Mr A for a heart attack as this is what his symptoms suggested. When a heart attack was ruled out, we noted that a CT scan was ordered within a few minutes and that there was no unreasonable delay in relation to the wait for the scanner to become available. We did, however, identify an unreasonable failing in the observations of Mr A's vital signs as there was a gap in the records of over four hours. On balance, we upheld the complaint and made recommendations in this connection.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C for the gap in recording vital signs. 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:

• Vital signs should be recorded at appropriate intervals for patients in the emergency department.

Summary

Mr C complained that the practice had unreasonably stopped prescribing his Capasal (medicated shampoo) medication on NHS prescription. Mr C said that he had psoriasis (a skin condition) and had been prescribed Capasal for many years. He was suddenly told by the practice that in accordance with health board guidance, he would have to purchase Capasal over the counter at a chemist.

We took independent advice from a general practitioner. We found that Mr C's medical records contained information that Mr C had been diagnosed with psoriasis in the past and as such he did satisfy the health board criteria which would allow the practice to prescribe the medication on NHS prescription. We upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for stopping prescribing his medication shampoo. 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 review their decision on Mr C's medication based on health board guidelines and ensure that when considering medication reviews they have considered all the available clinical evidence in order to support their decision.

Summary

Ms C complained about the nursing care her mother (Mrs A) received at Raigmore Hospital. Mrs A suffered from osteoporosis (weak or fragile bones) and fell during an admission to the hospital. A number of weeks following her discharge from hospital, Mrs A's GP arranged for x-rays to be taken which showed that she had suffered two fractures to her spine. Ms C complained that nursing staff failed to appropriately care for Mrs A following her fall.

We took independent advice from a nurse who is experienced in hospital falls prevention. We found that the nurses who attended Mrs A failed to act in accordance with falls prevention guidance. There was no record that an adequate assessment had been carried out to establish if Mrs A had sustained an injury following the fall. There was also a failure to arrange a medical review for Mrs A. We were unable to find out when the fractures actually occurred as Mrs A did not report to staff that she was in pain at the time and the actual diagnosis of fractures was not made until a number of weeks following the fall. However, we considered that the failings identified were unreasonable and upheld Ms C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs A for failing to act in accordance with the guidance following her fall and failing to arrange a medical review. 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:

• Nursing staff should ensure that action is taken in accordance with guidance in relation to in-patient falls and ensure that a record is made on which examinations have taken place and that a medical review is arranged.

Summary

Ms C complained that the practice provided unreasonable treatment to her late mother (Mrs A). A GP from the practice attended Mrs A at home and prescribed an antibiotic. Mrs A was also on Warafin (a drug used to prevent blood clots) and other medication. She later became unwell and was admitted to hospital with bleeding from a peptic (stomach) ulcer and considered at risk of internal bleeding. Mrs A died a few weeks later. Mrs C complained that the prescription of the antibiotic was unreasonable and that Mrs A should have been advised to have her INR (a blood test which allows monitoring of Warafin levels) checked after she was started on the antibiotic.

We took independent advice from a GP. We found that the practice reasonably prescribed the antibiotic. However, the practice should have advised Mrs A that she should have her INR checked four to seven days after starting the antibiotic. Therefore, we upheld Ms C's complaint.

Recommendations

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

• This complaint should be discussed with the GP involved at their annual appraisal.

Summary

Mr C complained that the board delayed in providing him with surgery for his feet and knees, and that they unreasonably failed to explain the reasons for the delays.

We took independent advice from an orthopaedic surgeon (a surgon who specialises in the musculoskeletal system). We found that the Treatment Time Guarantee places a legal requirement on health boards so that, once planned treatment has been agreed with the patient, the patient must receive that treatment within 12 weeks. We found that Mr C waited around six months for the surgery on his first foot, and then ten months before being seen by a knee surgeon. We found that, whilst medically Mr C came to no harm as a result of the delays, he clearly suffered pain and functional restriction for longer than was reasonable. We upheld this aspect of the complaint.

Regarding communication, we noted that Mr C had received a letter confirming a guarantee of treatment within 12 weeks for his first surgery. The next documented communication was several months later, and was only sent in response to contact from Mr C. We considered that there should have been further communication from the board, apologising for the delay and setting out the steps being taken to minimise this. We found that Mr C had been left for many months without knowng when he might receive surgery. We upheld this aspect of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for the delays in his orthopaedic treatment.The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/leaflets-and-guidance.
• Apologise for failing to explain the reasons for delays in treatment, and for failing to keep Mr C updated with regard to when he could expect to have his surgery.

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

• In the event that the Treatment Time Guarantee is not going to be met, letters to patients should make this clear, in accordance with the Patient Rights (Scotland) Act 2011.
• Be clearer with patients about any delays, the reasons for the delay and the steps being taken to improve matters.