Upheld, recommendations

Summary

Ms C complained about the care and treatment her late father (Mr A) received at Queen Elizabeth University Hospital. Mr A was admitted to hospital with a broken hip after falling at home and underwent an operation. Ms C complained about both the medical and nursing care Mr A received. The board acknowledged that there was an unreasonable delay in transferring Mr A to the orthopaedics (the specialty of medicine regardingconditions involving the musculoskeletal system) ward and identified failings in nursing care, which they apologised to Ms C for. Ms C was unhappy with this response and brought her complaint to us.

We took independent advice from a consultant orthopaedic and trauma surgeon (a specialist in diagnosing and treating a wide range of conditions of the musculoskeletal system) and from a registered nurse. We found that there was no unreasonable delay in carrying out Mr A's hip operation, as he needed treatment for other health issues to ensure he was fit for the operation. However, we considered that there was an unreasonable delay in transferring Mr A to the orthopaedic ward, which the board had accepted. Therefore, we upheld this aspect of Ms C's complaint.

In relation to the nursing care, we found that there was an unreasonable failure to communicate with Mr A's family about the risk of him developing delirium and that there was a delay in obtaining information about his likes/dislikes but we considered that reasonable steps were taken to minimise Mr A's risk of a fall. We also found that there was a failure to transfer all of his belongings with him when he moved to another ward but the board had subsequently found his belongings and returned them to Mr A's family. Finally, we noted that his bowel movements were not monitored and/or recorded appropriately. Therefore, we upheld this aspect of Ms C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms C for the failure to properly monitor and/or record Mr A's bowel movements. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/leaflets-and-guidance.

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

• Nursing staff should appropriately monitor and record patients' bowel movements, particularly after they have an operation.

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 care and treatment provided to her late husband (Mr A) at the Queen Elizabeth University Hospital. Mr A had liver cancer and was admitted to hospital to have a procedure to deliver chemotherapy directly into the tumour. This is known as transarterial chemoembolization (TACE). Mr A become unwell following the procedure and died. The cause of death was linked to some of the chemotherapy drug entering the pancreas and part of the bowel, causing them to become damaged. Mrs C complained about the care and treatment Mr A received in relation to this procedure.

We took independent advice from a consultant interventional radiologist (the type of clinician who carries out TACE procedures) and a consultant heptologist (a liver specialist). We found that the treatment Mr A received was reasonable, however, the adviser highlighted concerns that the consent process was inadequate. The complication that Mr A experienced is a rare but recognised risk of the TACE procedure. We found that there was no documentary evidence that the risks of the chemotherapy drug affecting another area of the body or death were appropriately covered during the consent process. Obtaining appropriate informed consent is an important part of a patient's care pathway. Therefore, we upheld Mrs C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C that the consent process did not adequately document the risks of the procedure. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/leaflets-and-guidance.

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

• Patients should be appropriately informed of the risks and benefits of transarterial chemoembolization procedures in line with national guidance on consent.

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 take appropriate steps for her child's (Child A) plagiocephaly (asymmetry of the skull). Mrs C received several visits at home from the health visitor team following the birth of Child A and raised concerns about the shape of Child A's head when they were three months old. Mrs C later attended her GP and was referred to a paediatrician (a doctor who deals with the medical care of infants, children and young people) who diagnosed them with plagiocephaly. Mrs C considered that if the health visitors had identified problems with head shape sooner, it could have been prevented.

We took independent advice from a health visitor. We found that when the health visitor who visited Mrs C was advised of her concerns, they gave appropriate advice regarding positional changes to maintain Child A's natural head shape. However, no record was taken of the circumference of Child A's head or the shape. Therefore, there was no baseline information and we considered that it would have been reasonable to document this for later comparison. We also noted that there was no recorded plan to review the situation. We found that Mrs C was visited by several members of the same staff team but her concerns had not been shared between staff. It would have been appropriate to share this information to ensure continuity of care. We considered that if these steps had been put in place then Child A may have obtained physiotherapy support sooner. Therefore, we upheld Mrs C complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C for the failure to follow up on her concerns about Chid A's head shape. 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:

• All members of health visiting teams should have up-to-date guidance on the identification, assessment and management of plagiocephaly in young children.
• There should be a structured approach to care planning so that concerns and plans to review those concerns are documented.
• There should be effective communication within teams where several members of the team are providing care for the same family.
• There should be a review of their compliance with the Universal Health Visiting Pathway and a timeline provided for this review.

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 on behalf of her late mother (Mrs A) who was admitted to Aberdeen Royal Infirmary after complaining of severe back pain. On admission to hospital, Mrs A was also suffering from vomiting, constipation and had an infection. Ms C considered Mrs A did not receive reasonable care and treatment during her admission. In particular, that the board should have performed an MRI scan on Mrs A's back as she had previously had surgery for a spinal fracture.

We took independent advice from a consultant in geriatric medicine (specialist in care of the elderly) and a nurse. We found that the actions of staff following Mrs A's admission to treat the cause of her dehydration and to determine why she was unwell and in pain were reasonable. We considered that all the relevant tests had been carried out and action taken by medical staff was reasonable. We also considered that the pain relief medication prescribed for Mrs A during her admission was appropriate. However, we noted that on one occasion Mrs A did not receive a dose of paracetamol when she should have and it was possible she may have suffered an increase in her pain as a result. The adviser noted that Mrs A's pain relief medication was an important part of her treatment. This incident was referred to by the board as an adverse event and was recorded on their Datix system (a system for tracking and reporting incidents). It was also noted that Ms C had not been made aware of this incident at the time. Therefore, we upheld Ms C's complaint.

Ms C also complained that the board did not respond reasonably to her complaint. The board acknowledged that there were factual errors in their complaint correspondence and we considered that they had appropriately apologised to Ms C for this. We found, however, that there was an unreasonable delay by the board in informing Ms C that an adverse event had been recorded and this was compounded by their failure to tell Ms C the specific details of this event, despite her asking for them. We considered that the board had not provided Ms C with a full and reasoned response to her complaint and, therefore, we upheld this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms C for failing to provide Mrs A with reasonable care. Also apologise for the unreasonable delay in informing Ms C that an adverse event had been recorded on the Datix system, and for not providing her with an appropriate explanation of the adverse event and what, if any, harm had been caused to Mrs A. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/leaflets-and-guidance.

In relation to complaints handling, we recommended:

• Identify any training needs to ensure staff fully and appropriately respond to complaints.

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

Summary

Mr C complained on behalf of his late wife (Mrs A) about the care and treatment she received at Forth Valley Royal Hospital. Mrs A had been experiencing tingling in her fingers, which continued to worsen. Mr C complained there was an unreasonable delay in carrying out a scan to investigate Mrs A's condition. He also considered that there was an unreasonable delay in giving Mrs A the results of the scan. After Mrs A was referred for surgery, her mobility declined. Mr C felt that, with earlier surgery, she may have been walking normally.

We took independent medical advice from a consultant orthopaedic surgeon (a doctor who specialises in conditions involving the musculoskeletal system). We found that Mrs A was appropriately referred for an urgent scan and that it was carried out within a reasonable timescale. However, we considered that there was a delay in reporting the results and in giving Mrs A the results, which was unreasonable as there were significant clinical findings that required urgent surgical intervention. The adviser considered that earlier surgery was likely to have improved Mrs A's outcome and mobility. However, they explained that a good outcome was not guaranteed, as her condition was degenerate and it was unlikely she could have been walking normally. In light of these delays identified, we upheld Mr C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for the delay in reporting Mrs A's scan and in telling her the results. 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:

• Urgent scans should be reported promptly.
• A process should be in place so that significant findings in scans and x-rays are immediately flagged up to the referring clinician (this could, for example, be through a generic phone number or email address that is checked and acted on daily).

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 care and treatment she received at Borders General Hospital. Ms C suffered from lower abdominal pain and appeared to have diverticular disease (disease of the colon). Ms C attended the emergency department at hospital on six occasions over a number of months. She complained that over this period of time the board did not treat her reasonably and failed to carry out suitable investigations. As a consequence, she said her diagnosis was delayed and her treatment options were reduced. Ms C also complained about the actions of nursing staff and about the way the board dealt with her complaint.

We took independent advice from a consultant general and colorectal surgeon (a specialist in the medical and surgical treatment of conditions that affect the lower digestive tract) and from a registered nurse. We found that Ms C's initial investigations had been satisfactory. However, she continued to present with similar symptoms and persistent pain which, therefore, should have indicated that her diverticular disease had progressed and she should have received a scan earlier. Had this been the case, her distress and symptoms could have been managed earlier, although her surgery options were unlikely to have been different. We upheld this aspect of Ms C's complaint.

In relation to the actions of the nursing staff, we found that there was a great deal of confusion about where Ms C's future treatment was to take place; an appointment had been cancelled at extremely short notice and she was incorrectly advised that treatment would be given in England. Therefore, we upheld this aspect of Ms C's complaint.

Finally, we also found that this incorrect information about Ms C's future care was included in the board's complaint response. We considered this to be unreasonable and upheld this aspect of Ms C's complaint. However, we noted that the board has already taken remedial action in relation to the issuing of the incorrect information and we made no further recommendations in light of this.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms C for failing to consider further investigations despite the persistance of pain. 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:

• In circumstances similar to Ms C, consideration should be given to making further investigations.

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 care her late son (Mr A) received from the board's mental health team. Mr A was discharged home on a community based compulsory treatment order but completed suicide around 18 weeks later. Specifically, Mrs C complained that the conditions of the compulsory treatment order were not adhered to by staff, that there was insufficient communication with Mrs C as Mr A's named person, and the board's review of Mr A's death did not include certain information which Mrs C considered relevant.

The board carried out a significant adverse event review (SAER, a structured approach to learning from an adverse event) and in their response to Mrs C, they concluded that the care Mr A received was person-centred. The board also identified some learning points in relation to managing the expectations of the named person. Mrs C was unhappy with this response and brought her complaint to us.

We took independent advice from a mental health nurse and a consultant psychiatrist (a specialist in the diagnosis and treatment of mental illness). We found that there were significant gaps and numerous retrospective entries in Mr A's medical records which were unreasonable and not in line with national guidance on record-keeping. We considered that this likely impacted on the team's ability to fully understand Mr A's health and wellbeing. There was evidence to show that Mr A did not receive the planned number of weekly visits from the team, either because he missed appointments or because the visits were not carried out. Given Mr A's complex care package, we also considered that escalation to the responsible medical officer should have taken place when there had been a nine day gap in contact or when there was a significant deviation from his care plan (only one visit a week instead of three). Therefore, we upheld this aspect of Mrs C's complaint.

In relation to communication with Mrs C, we noted that the rights of the named person are limited and there was no requirement for the team to have shared all aspects of Mr A's care with her. However, we considered it is generally good practice to communicate with the named person/family which had been part of Mr A's care plan. We found that the mental health team did not communicate reasonably with Mrs C and upheld this aspect of her complaint. However, we noted that the board had acknowledged these failings.

In relation the the SAER, we did not have significant concerns about the information Mrs C felt was missing. However, we were critical that she had not been provided with the opportunity to raise such concerns. We were also concerned that the SAER should have identified the failings in record-keeping as part of the review of Mr A's care. We 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 failings in Mr A's agreed care plan and poor record-keeping. 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 significant deviation from an agreed care plans occurs, this should be escalated to the responsible medical officer for discussion and a record made of what the response to this should be.

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

Summary

Miss C complained about the college's handling of her complaints about being abused on a college-created social media page by another student, and about plagiarism of her work by other students. Miss C also raised concerns about the way the college handled her complaint about their complaints handling.

In relation to Miss C's complaints about online abuse and plagiarism, we found that the college failed to provide her with clear explanations at the outset about exactly what policies were being used to deal with her complaints; how long they might take to investigate; and what information, if any, she would be able to receive about the outcomes, given the need to protect other students' personal data. The college did not proactively keep Miss C updated about the progress of their investigations, and did not tell her the outcomes. Miss C was only told the outcomes by the college after we became involved. In responding to our investigation, the college failed to provide us with a copy of evidence, even heavily redacted, to show that investigations into online abuse and plagiarism took place.

Regarding Miss C's complaint about the college's complaints handling, we found that the college failed to follow their complaints handling procedure, for example in relation to contacting Miss C after she submitted her formal complaint to ensure everyone involved was clear from the start about exactly what was being investigated. The college said they did not provide the social media service and had no control over its operation; we concluded this statement was unreasonable, as the social media page was created by a member of college staff for a college course, it was self-moderated by students, also moderated by staff, and staff were able to remove the abusive posts Miss C complained about.

We upheld Miss C's complaints and made a number of recommendations, including asking them for evidence of actions they said they had taken already.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Miss C for the college's communication with Miss C at the outset not being clearer; the unreasonable delay in the college providing Miss C with information about the outcome of their investigations into her complaints of online abuse and plagiarism; and the college's handling of her complaint, under the complaints handling procedure, being unreasonable.

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

• The college should consider adding sections on the use by students and staff of such college-created social media pages to their existing policies.

In relation to complaints handling, we recommended:

• College staff need to know what information can be given to students, who have complained about other students, for example with regards to other students' behaviour or plagiarism of work.
• College staff should explain to students when they first submit their complaint: what procedure is being used to deal with their complaint (in particular if it is not a CHP complaint); the mandatory, guideline or likely timescales for their complaint being dealt with; and what information, if any, the student will receive about the outcome.

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 was found guilty of a breach of discipline for refusing an order to return to his cell. He submitted a disciplinary appeal, claiming that he had refused to return to his cell as he was being bullied and victimised by other prisoners in the residential hall. He also submitted a complaint that his bullying allegation had not been adequately investigated. His appeal was barred by the Scottish Prison Service (SPS) as it was not submitted within 14 days of the decision, as per prison rule 118. The SPS responded to Mr C's complaint, noting that their investigation had found no evidence to substantiate his bullying allegation. Mr C was unhappy with this response and brought his complaint to us.

Mr C complained that the SPS failed to appropriately investigate his complaint. The SPS were unable to provide us with evidence that an appropriate investigation had been carried out. They said that the investigating officer had not produced a written report and had since left the organisation. They told us that they had since improved their process and it is now compulsory for investigating officers to provide a written investigation report. We upheld Mr C's complaint and asked the SPS to provide evidence of their new process.

Mr C also complained about the decision to time limit his disciplinary appeal. The SPS confirmed that they have no discretion to consider an appeal submitted later than 14 days from the date of the decision. They acknowledged that existing guidance and forms do not make this clear and confirmed plans were in place to revise these. As an interim measure, they proposed to issue a Governors  &  Managers Action Notice (GMA) and amend prisoner notices to highlight the 14 day time limit. While the SPS had made it clear to Mr C that they had time limited his appeal as it was outwith the 14 days, they subsequently entered into discussion with him regarding the circumstances he put forward for the late submission. This gave the impression that his late appeal could potentially have been considered had the SPS deemed his circumstances exceptional, when that was not the case. Therefore, we upheld Mr C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for the lack of evidence of an appropriate investigation of his complaint having been carried out. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/leaflets-and-guidance.
• Re-investigate Mr C's complaint, ensuring that the findings are appropriately documented.

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

• Until the SPS are able to complete their review of the disciplinary appeal guidance and planned review of the relevant forms, the SPS should raise a GMA highlighting to staff the time limit set out in rule 118, and reminding them of the importance of making prisoners aware of this; and update the prisoner notices on disciplinary appeals to highlight the time limit set out in rule 118. In both instances, it should be made clear that appeals will not be considered outwith this time limit, irrespective of circumstances.

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 lives near a recycling centre, and complained about the way the Scottish  Environment Protection Agency (SEPA) dealt with complaints of noise and dust coming from there. He complained that SEPA had failed to take appropriate sanctions against the site operators, saying they had been responsible for increased pollution coming from the site for the last few years. SEPA said that they had engaged with Mr C through a number of processes in seeking to address his complaints and concerns. They said that they were actively working to modify the existing licence to include prescriptive noise limits and operator monitoring to demonstrate this.

We took independent advice from an environmental health adviser. They confirmed SEPA's obligations in the circumstances of this case, both as a regulator and a waste management licensing authority. The adviser noted that SEPA had not taken the opportunity to put prescriptive noise levels in the waste management licence at the outset, but had now taken steps to rectify this.

In terms of SEPA's role as regulator, we considered that they generally complied with their obligations in relation to having a policy and framework for enforcement. However, we noted that noise monitoring was not carried out sufficiently and promptly by the regulator. With regard to enforcement, the adviser said that regulators have a duty to act when breaches of regulations or licence conditions are found. We considered that SEPA had met many of their obligations, however, noted that SEPA did not take the opportunity to serve notice for repeated non-compliance. We also found that SEPA took enforcement action of providing advice and guidance to limit noise and dust emissions from the centre; however, they did not serve an enforcement notice to limit noise and dust emissions to an acceptable level. Therefore, we upheld Mr C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for failing to take appropriate steps following notifications of noise and dust arising from the recycling centre. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/leaflets-and-guidance.
• SEPA should reconsider the appropriateness of the enforcement action they have taken following notifications of noise and dust arising from the recycling centre, having regard to their policy and procedures, and all the circumstances of this case. Consideration should be given to the current situation, when deciding on what further action to take (if any).

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

• Staff should be clear on the principles underpinning their enforcement policy, and should be confident in identifying instances of non-compliance in which formal enforcement action would be proportionate.

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.