Upheld, recommendations

Summary

Miss C complained on behalf of her late mother (Mrs A) that the practice unreasonably admitted Mrs A to hospital when it was her wish to remain at home. Mrs A had terminal cancer and was being cared for at home. A GP from the practice visited her at home and was concerned about the ability to meet her care needs there. Therefore, the GP arranged for Mrs A to be admitted to hospital where she died two days later. Miss C was concerned that this was against Mrs A's wishes as she had wanted to remain at home.

We took independent advice from a GP. The adviser considered that the initial decision to have Mrs A admitted to hospital was reasonable. However, by the time that the ambulance crew had arrived, she had lost consciousness. We found that, at that point, the GP should have consulted the family about having Mrs A admitted to hospital. We considered that Mrs A should have been allowed to remain at home if that was what her family wanted. Therefore, we upheld Miss C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C for not clarifying and acting in line with her family's wishes about Mrs A's admission to hospital. The apology should meet the standards set out in the SPSO guidelines on apology available at: www.spso.org.uk/leaflets-and-guidance.

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

• When someone is in the final days of their life, there should be shared decision making with them and with their family, as appropriate, about their care.

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

Mrs C complained that the board failed to process an autism spectrum disorder (ASD) assessment for her child (child A). Mrs C said there were a range of administrative errors in the process, which led to significant delays. Mrs C also said that the board unreasonably tried to transfer child A's care to a different health board, based on child A attending a new school outwith the board area.

The board upheld Mrs C's complaint and apologised for some administrative errors in the process. They acknowledged that they were responsible for the assessment (rather than the other health board) and that their current wait times for assessment were unacceptable. The board said that they were introducing a new assessment pathway to improve this, including a new central point of contact for processing referrals. Mrs C remained dissatisfied and brought her complaint to us.

We took independent paediatric and nursing advice. We found that the board failed to process child A's referral in line with their own guidance, including failing to follow-up the paperwork sent to Mrs C. The board also failed to arrange a planned follow-up appointment with a paediatrician. We also found that it was unreasonable that the board tried to transfer child A outwith the board area, as staff should have been aware that they were responsible for all children resident in the board area, regardless of schooling. We upheld Mrs C's complaint.

While the board had acknowledged some failings, we found that their response to Mrs C did not give a clear and full apology for all the failings we identified. We considered that the action taken by the board to improve waiting times and communication was appropriate. However, we were concerned that, in 2014, we made similar findings about a delay in an ASD assessment (case 201401014) and, while the board took action following that case to reduce waiting times, these appeared to have extended again significantly. The board said that they had implemented a new pathway for ASD assessments, and we asked to see evidence of this and other actions the board is taking to reduce waiting times. We also made a number of recommendations.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C's family for the unreasonable delay in the ASD assessment, their error in attempting to refer child A outwith the board area, the administrative failings in their handling of the assessment pathway, and the failure to provide a follow-up paediatric review. 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:

• Information about patients within the board's area of responsibility should be easily accessible to all staff.
• Requests for consent to ASD assessment should be followed up, in line with the relevant guidance, when there is no response.
• Planned follow-up reviews should take place. If this is subsequently considered not necessary, clear explanations should be provided to the patient.

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 about the care and treatment he received at University Hospital Crosshouse following a referral made by his GP. He was suffering from chest pain and was seen by a consultant cardiologist (a doctor who specialises in finding, treating and preventing diseases of the heart and blood vessels) at the hospital. Mr C complained that the examination he received was poor and that the consultant failed to take into account all the information provided by his GP. At a later appointment, Mr C underwent an echocardiogram (echo - a heart scan that uses sound waves to create images) and was fitted with a Holter monitor (a device that measures and records the heart's activity). Mr C considered that the results were not properly reported and no follow-up appointment was made. He complained to the board who confirmed that there had been errors in the consultant's note taking but that they did not impact upon his care. Mr C was unhappy with this response and brought his complaint to us.

We took independent advice from a consultant cardiologist. We found that some records contained inaccuracies and that there had been no reference made to Mr C's chest pain which was the reason for his attendance. We also found that no investigations were made at his initial referral and the adviser noted that they would have expected an electrocardiogram (ECG - a test that records the electrical activity of the heart) to be carried out. We found that the subsequent echo was reported as normal although there were some abnormalities. We considered that the board failed to provide reasonable care and treatment and upheld Mr C's complaint. However, we noted that although some information was not recorded correctly, this would not have affected Mr C's treatment.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for failing to provide a reasonable level of cardiology care and treatment. 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 cardiology department should consider whether all new cardiology patients should have an ECG on arrival and consider whether or not provision should be made to arrange other tests prior to, or very soon after, consultation.
• In their clinical records, the named consultant in cardiology should consider and offer opinion about their patients' presenting symptoms.

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 pornographic magazines stocked by the prion's supplier were aimed at heterosexual men. Mr C asked for access to equivalent homosexual pornographic magazines. The prison said that magazines were subject to the stock held by the supplier and that the supplier could not accommodate one-off requests. Mr C then submitted an Equality and Diversity Form and complained that this was not acknowledged by the prison.

We found that the prison had recently changed its policy to now allow prisoners to purchase pornographic magazines through the sundry purchases process. This decision was a matter of discretion for the Governor. Our office has no role in determining what policy the prison should have on this issue.

However, we were concerned that the prison had not carried out an Equality Impact Assessment before changing their policy on access to pornographic magazines. The prison did not have an objection to Mr C receiving homosexual pornographic magazines, however, their suggested possible solutions would not give Mr C the same access privileges that prisoners purchasing heterosexual pornographic magazines had.

We also found that the prison had failed to progress Mr C's Equality and Diversity Form. We noted that the purpose of these forms and who is responsible for processing them is not clear. Therefore, we upheld Mr C's complaints.

Recommendations

What we asked the organisation to do in this case:

• Following the review of the policy (recommended below) the prison service should review Mr C's specific situation.

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

• The prison service should now carry out an Equality Impact Assessment. Following that, they should review their policy in light of the Equality Impact Assessment.
• The prison service should review the use and purpose of the Equality and Diversity Form.

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

Mrs C complained about the council's decision not to offer her daughter a funded place at a private nursery. She had a number of concerns about the way her funding application had been handled. When she submitted the application, two out of three of her choices were unavailable but the council did not communicate that to Mrs C in their acknowledgement letter. A few months later Mrs C received a letter from the council advising that her daughter had been granted an afternoon place at the nursery class identified as first choice on the application form. When Mrs C contacted the council to let them know this was not suitable because of her working hours, she was not given advice on how to apply for funding at a nursery with suitable provision, despite requesting it.

We did not find any evidence that the council had failed to follow their policy when allocating places at the nursery, but we did consider that their handling of the application at the initial stage was poor and that their communication could have been clearer. We, therefore, upheld this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise for the shortcomings in their communication.

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

• Staff handling nursery funding applications should provide the opportunity for alternative choices to be made, in the event that they cannot offer the applicant's choices.

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 about reinstatement works at the site of a former opencast mine. Mr C accesses his home via a road that runs adjacent to the site and he complained that the council unreasonably considered a development to be permitted when it did not satisfy the correct requirements. When Mr C first raised his concerns, the council maintained their position about the planning status of the land, until the council reversed their view two years later. Mr C also complained that they failed to consider the risk of flooding when granting the works permitted development status. He said that access to his home was sometimes impossible as flood water remained on his access road and did not drain away as previously. Finally, Mr C felt that the council's handling of his complaint was unreasonable.

We took independent advice from a chartered town planner. We found that the council had been presented with sufficient information around the time of Mr C's initial concerns to determine that planning consent was required. Instead they determined that the proposed works constituted permitted development. It was only two years later after protracted correspondence that they accepted there had been an error. Therefore, a number of processes and consultations, which should have occurred, did not. We considered the fact that, had the works been properly assessed, the council should have explicitly considered the use of their powers in relation to flooding. We also found that Mr C had been given incorrect information regarding the role of the Scottish Environment Protection Agency (SEPA).

In dealing with Mr C's complaint we found that there was very extensive correspondence; however, there had been some delays in the council responding and Mr C and he was not always kept updated. For these reasons, we upheld all of Mr C's complaints.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for failing to correctly assess the development; providing incorrect advice regarding SEPA's role; and failing to explicitly consider the use of their powers in relation to flooding. 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:

• Proposed development should be assessed in line with applicable planning legislation, guidance, circulars and policy.
• Potential flood issues should be properly assessed.

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 about the care and treatment his late father (Mr A) received at the Royal Alexandra Hospital. In particular, Mr C complained about an unreasonable delay in diagnosing and treating Mr A's metastatic melanoma (skin cancer that has spread). Mr C also complained about a failure to communicate clearly from the outset to Mr A that he was suspected to have cancer.

We took independent advice from a plastic surgeon. We found that appropriate investigations were carried out into Mr A's condition. However, we found that Mr A's treatment plan should have been discussed by the multi-disciplinary team when there were concerning findings from his full body scan. We also found that it would have been appropriate for Mr A to have been offered a scan. We upheld this aspect of the complaint.

We found that discussions with Mr A about his condition were not recorded. The board acknowledged failings in their record-keeping and outlined steps that they had taken to address this. We upheld the complaint and we have asked the board to provide evidence of the action that they said they have taken to address this.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for the delay in referring Mr A to the regional multi-disciplinary team to discuss his treatment plan; for not offering a scan and for the failure to properly document discussions with Mr A in which he was told he might have cancer.

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

• High risk cases of melanoma should be discussed by the regional multi-disciplinary team before surgical treatment is carried out.

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 dentist failed to provide her with a reasonable standard of dental care and treatment. Ms C attended the dentist over a number of months, concerned about a number of issues. Ms C had experienced pain in one of her teeth which she subsequently discovered had a crack in it. She said that the dentist failed to investigate this appropriately. As a result, Ms C said an adjoining tooth was extracted, and she was unreasonably prescribed three courses of antibiotics before the cracked tooth was extracted. Ms C also had to receive root canal treatment on another tooth which had an infection Ms C said that as a result of the failings, she was in pain for months and needed to get veneers or implants to close the gap at the front of her mouth because she could not eat or smile.

We took independent advice from two dentists. We found that there were significant failings around record-keeping, the prescription of antibiotics, and the management of two teeth. We also found that the dentist was not in a position to appropriately monitor any potential decay progression, which was unreasonable. However, we did not find that the extractions were unnecessary. On balance, we found that the care and treatment Ms C received was unreasonable and therefore. we upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms C for failing to follow relevant guidelines and standards. The apology should comply with the SPSO guidelines on making an apology, available at https://www.spso.org.uk/leaflets-and-guidance.

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

• Records should meet the relevant standards and the dentist should become fully aware of and comply with the requirements of these standards.
• Ensure that the approach to patient care is in line with professional guidance (including key skills in primary dental care and management of acute dental problems) and complies with the new guidance due in 2018 in relation to x-rays (Ionising Radiation (Medical Exposure) Regulations).

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 board unreasonably failed to identify her hip fracture. Following a referral to Ninewells hospital, Ms C was reviewed by a consultant orthopaedic and trauma surgeon who considered that she had strained a ligament in her knee. She was then referred for physiotherapy for mobilisation and rehabilitation. Ms C was reviewed over the following months and developed progressively worsening pain. A subsequent x-ray identified a hip fracture.

We took independent advice from a consultant orthopaedic surgeon and a physiotherapist. Ms C noted that no x-ray was performed at the consultation with the surgeon. The board said that an appropriate examination was carried out, and that this examination gave no indication that an x-ray was required. The orthopaedic surgeon adviser said that the examination was not recorded in sufficient detail in Ms C's medical record, and that it provided inadequate evidence that a hip fracture was excluded.

Ms C also raised concern about the subsequent physiotherapy appointments. The physiotherapist adviser considered that, throughout the physiotherapy sessions, there were indications that the initial diagnosis of ligament strain of the knee may have been incorrect. We found that there was a failure to re-evaluate the situation in light of Ms C's increasing pain and deteriorating mobility. We considered that this contributed to the delay in identifying the hip fracture. Finally, we found that there was failings in recording of assessments and pain scores during these appointments. However, we noted that the board had acknowledged this failing and had taken steps to address this.

Overall, we found that the board unreasonably failed to identify Ms C's hip fracture and upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms C for unreasonably failing to identify her hip fracture and for the failings in record-keeping.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 carry out full and appropriate examinations and assessments, and record these in contemporary records.

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 about the care and treatment that his father (Mr A) received at Perth Royal Infirmary following a fall. Mr C was concerned that a fracture was not identified until Mr A had been in hospital for eight days. Whilst in hospital, Mr A also suffered a period of delirium. Mr C complained about communication issues and the way that Mr A had been transferred between wards at the hospital. Finally, Mr C also considered that the board had not handled his complaint reasonably.

We took independent advice from an emergency department consultant, an acute care consultant and a nursing adviser. We found that there was no documentation of an examination of Mr A's neck in the emergency department. As the x-rays that were taken had been difficult to interpret, further action should have been taken to rule out fracture, or clear reasons should have been recorded for not doing this. We considered that there were opportunities to diagnose the fracture at an earlier stage. In regards to Mr A's delirium, we found that the care he received was reasonable, although there was some areas where practice could be improved.

In relation to communication issues and transfers within the hospital, we found that nursing notes indicated that Mr A was in pain but that this information did not appear to have been shared with medical staff. We also found that Mr C had not been kept properly updated regarding Mr A's moves within the hospital. We noted that Mr A's moves had been reasonable however, on one occasion, he was transferred during a meal which was inappropriate.

In relation to complaints handling, we found that the board had not addressed Mr C's concerns about the delay in diagnosing Mr A's fracture in their response and that Mr C was not kept appropriately updated during the complaints process.

We upheld all of Mr C's complaints. However, we noted that the board identified some failings in their consideration of this case and had apologised for these.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for the delay in diagnosing the fracture; for not fully addressing his concerns; and for not keeping him updated during the complaint process. 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:

• Medical staff should keep comprehensive medical records.
• Where x-rays are inadequate, consideration should be given to further imaging or discussion with the on call radiologist. If this is not considered necessary, the rationale should be clearly documented in the medical records.
• There should be a mechanism in place for nursing staff to make medical staff aware of issues with continuing pain. Consideration should be given to unitary records and reviewing how nursing/medical staff communicate during formal handovers.
• Consider the adoption of Health Improvement Scotland's 'Think Delirium' as a means to try to reduce delirium in hospital and manage it appropriately, particularly liaising with relatives.

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.