Upheld, recommendations

Summary

Mr C, an MSP's caseworker, complained on behalf of a constituent (Mr A) that the council failed to appropriately investigate Mr A's reports of noise. Mr A said that renovation works being carried out by his next door neighbour were causing him severe disruption. The council had initially served an abatement notice, setting out legal time restrictions for the hours the works could be carried out. However, Mr A said that he had repeatedly reported that works were ongoing outwith the specified hours and that the council had been unable to attend to witness the noise and enforce the notice. By the time that the council were able to attend out-of-hours, the works were mostly complete, with remaining works taking place during the specified hours.

We took independent advice from an environmental health adviser. We found that the council had no formal policy or procedure relating to the investigation of noise and enforcement of abatement notices. The council said that a policy would not cover the complexity of noise complaints and would restrict their staff from using their professional judgement. The adviser noted that Scottish Government guidance suggests that local authorities should have clear policies and procedures in place to govern the investigation of noise nuisance. The guidance also suggested that those policies and procedures should set out clear timescales for response, along with details for out-of-hours provision. We considered that the council's reason for not having these policies and procedures was unreasonable. We also found that the council had taken too long to attend and investigate Mr A's ongoing reports of noise, both during and outwith normal working hours. Finally, we noted that the were a number of documents missing including records of phone calls made by Mr A and details of the site visits the council did carry out. For these reasons, we considered that the council failed to appropriately investigate Mr A's reports of noise and upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr A for failing to appropriately investigate his reports of noise. 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 council should have a clear procedure for noise management and investigation, in line with the Scottish Government guidance. This will include full details of out-of-hours arrangements and timescales for attendance following noise reports.
• Full records should be made of investigations, which should be made readily available for any complaint investigation.

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 on behalf of her late husband (Mr A) who had been a patient at a clinic within the partnership. Mr A was admitted to the clinic as a voluntary patient after he attempted to take his own life. A number of days later, Mr A was allowed to leave the clinic on pass and return home. Within a day of returning home, Mr A completed suicide. Mrs C complained that the partnership failed to provide Mr A with reasonable care and treatment both when and after he was admitted to the clinic. Mrs C also complained that the partnership failed to follow their complaints procedure.

We took independent advice from a consultant psychiatrist and from a mental health nurse. We found that as Mr A was admitted as a voluntary patient with capacity, he was able to leave the clinic any time he wished. However, it was noted that there was no record of Mr A undergoing a full assessment. A comprehensive mental state assessment should have been completed both on admission and before Mr A left the clinic on pass. We also found that there was no evidence of planned, structured nursing engagement in Mr A's care. Therefore, we upheld this complaint. However, we were also clear that even had these shortcomings not occurred, the outcome for Mr A would have been unlikely to have been different.

In regards to complaints handling, we found that the partnership failed to respond correctly to Mrs C in line with their complaints procedure. Therefore, we upheld Mrs C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C for failing to deal with her complaint in a timely manner in accordance with stated procedures. 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 quality of medical note-taking should be improved.
• Nursing staff must ensure that there is a daily, structured engagement with patients, and that there is a record made of this engagement.

In relation to complaints handling, we recommended:

• Complaints should be responded to in accordance with stated procedures.

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 level of communication provided by the partnership regarding the care of her father (Mr A). Mr A was moved from a rehabilitation centre to another tenancy, however, this property did not suit his needs and Mr A returned to the centre. Miss C, who has financial power of attorney, complained that the partnership failed to reasonably involve Mr A's family members in decisions about his care. Miss C also complained that Mr A's care plan was not shared with his family, or made available to the rehabilitation centre, with no provisions implemented to ensure a smooth transition to his new tenancy.

Miss C complained to the partnership who advised that they were attempting to balance promoting independence for Mr A, who did have capacity, against involving his family. They acknowledged that communication had been poor but were vague about what steps would be taken to avoid similar problems occurring in the future. Miss C was unhappy with this response and brought her complaint to us.

The partnership responded to us and explained that on further review, they accepted many of the failings that Miss C identified in her complaint. We noted that communication had been poor between the partnership and Miss C and that relevant parties had not seen the content of the care plan. We upheld Miss C's complaints.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr A and his family for the distress and inconvenience caused by these issues. 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 adequate communication with a service user's family and should make sure that communication with the family is appropriately documented.
• The partnership should ensure that staff reflect on and learn from the findings of this investigation. In particular, there should be reflection on ensuring family members have sight of the up-to-date care plan and that existing care providers are appropriately informed of plans (and transition provisions) prior to a service user moving out of the care setting.

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 to us about the care and treatment her mother (Mrs A) had received after she was admitted to St John's Hospital with bipolar disorder (a mental health condition marked by alternating periods of elation and depression).

Ms C complained about a number of issues in relation to the nursing care provided to Mrs A. We took independent advice from a mental health nurse. We found that it had been unreasonable for nursing staff to allow Mrs A off the ward without an escort. Although Mrs A came to no harm, her safety and wellbeing were placed at undue risk as a result of this. We also found that, despite it being known that Mrs A had medication compliance issues, there was no evidence in the records of a coherent care plan designed to promote her compliance with oral medication. Neither her care needs nor her nursing care had been effectively planned or kept under review. Care plans in the records were dated four weeks after Mrs A had been admitted to hospital and we found that the manner in which the documentation had been used and completed was ineffective and unreasonable. In view of these failings, we upheld Ms C's complaint about the nursing care provided to Mrs A.

Ms C also complained about a number of aspects of the psychiatric and medical treatment Mrs A received in the hospital. We took independent advice on these issues from a psychiatric consultant. We found that there had been a delay in actioning Mrs A's electrocardiograph (ECG - a test that records the electrical activity of the heart) results and that the consultant psychiatrist had failed to make themselves aware of these results. We also found that it was unreasonable that specialist cardiology advice was not sought and that anti-psychotic drugs were prescribed to Mrs A without attention being paid to the cardiac risks or guidance being given to staff that she should be closely monitored after taking these. In addition, Mrs A received two anti-psychotic drugs at the same time, when the intention had been for staff to give Mrs A either one or the other. We also received advice that an alert should be put on Mrs A's records regarding one of the anti-psychotic drugs. We further found that the frequency of consultant review over a period of ten days had been unreasonable as adequate staff cover was not in place. Whilst it had not been unreasonable to start the application process for a compulsory treatment order for Mrs A, it was unreasonable that this had been done without a medical examination being carried out. We also found that staff failed to give Mrs A vitamin replacements that had been agreed. In view of these failings, we upheld Ms C's complaint about the psychiatric and medical treatment provided to Mrs A.

Finally, Ms C complained that the board had failed to provide a reasonable response to her complaint. We found that the board's response to her had not been reasonable, particularly that they had not informed Ms C of the outcome of their investigation into her complaints about staff behaviour. We upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms C for failing to provide nursing care and psychiatric and medical treatment to Mrs A, and for failing to provide a reasonable response to Ms C's 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.
• Consider putting an alert on Mrs A's records that she should not be prescribed one of the anti-psychotic medications in future.
• Inform both Ms C and us of the outcome of their investigation into Ms C's complaints about staff behaviour in relation to Mrs A's case.

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

• Relevant staff should be fully aware of their responsibilities in relation to the application of Nurses Holding Power under the Mental Health Act.
• Template documentation introduced to ensure the quality of record-keeping should be completed in full and as intended in order that nursing care, including medication compliance, is effectively planned, documented and kept under systematic review.
• Robust systems should be in place to ensure the results of medical investigations are accessed, recorded, considered and actioned in good time.
• Prescribing clinicians should be aware of the accepted prescribing guidance, especially with regard to the use of higher risk medications (such as some anti-psychotics) in vulnerable patient groups (such as the elderly) and there should be adequate processes in place for the physical monitoring of patients when such medications are administered.
• There should be adeqaute arrangements in place to cover medical staff's leave to ensure that all reasonable requests by patients and carers for consultant review are met.
• Staff prescribing medication should ensure that they provide appropriate guidance on when and how the medication is to be given.
• All staff taking decisions under the Mental Health Act should have due regard to the principles of the Act, as they are required to do, and adequate records should be made of these decisions and the rationale for reaching them.
• Patients should be given vitamin replacements where this has been previously agreed and there is no clinical reason not to give it.

In relation to complaints handling, we recommended:

• Complaints should be investigated appropriately.

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 treatment that he received at Raigmore Hospital when he was admitted via the emergency department. Mr C had undergone a vasectomy procedure (a procedure where the tubes that carry sperm from a man's testicles to the penis are cut, blocked or sealed) over two weeks earlier and had developed painful swelling. Mr C complained that, after admission for assessment/investigation in the urology department, he was examined and then discharged with advice to manage his symptoms conservatively. Mr C later had to be admitted for a number of days for treatment of an abscess.

We took independent advice from a consultant urologist. We found that there were several factors in Mr C's presentation that meant that, on balance, a more proactive approach to his symptoms would have been appropriate. We upheld this aspect of his complaint.

Mr C also complained that the board's response to his complaint was inaccurate. We found that key dates in the response were incorrect. We noted that the board acknowledged this failing and advised that they had taken steps to address it going forwards. We upheld this aspect of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise for the failure to consider and/or document consideration of, a more proactive approach to Mr C's care and for the inaccuracies in the final response to Mr C's complaint. The apology should comply with the SPSO guidelines on making an apology, available at www.spso.org/leaflets-and-guidance.

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

• All relevant clinical factors should be taken into account and this should be apparent from the notes made in the contemporary clinical 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

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.