Upheld, recommendations

Summary

Ms C, who works for an advocacy agency, complained on behalf of her client (Ms A). Ms C complained that Ms A did not receive a reasonable standard of psychiatric care and treatment when she was admitted to the Royal Alexandra Hospital. Ms A had been unwell and when she was admitted to hospital a psychiatrist diagnosed her as suffering from anorexia nervosa (an eating disorder) and implemented a care plan. Ms C said that Ms A did not agree to all aspects of the care plan, which she felt was very restrictive and intrusive, and that the communication with her and her family about the severity of her condition and treatment decisions was unreasonable.

We took independent advice from a psychiatry adviser. We found that, while there were no failings in relation to the psychiatric assessment and treatment provided to Ms A, the board had failed to evidence that Ms A had fully consented to her treatment, and that there were failings surrounding the extent to which she was informed of the details of her proposed care plan. We were also concerned that such a restrictive and intrusive care plan was implemented when Ms A disagreed with it, and that it was not subject to mental health legislation which would have afforded protection to Ms A. As a result, we found that Ms A was likely to have experienced distress which may have a long-term impact on her future relationships with mental health professionals. We upheld Ms C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms A for failing to evidence consent to treatment. 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:

• Care plans (in particular intrusive or restrictive care plans) should be fully explained to patients and relevant consent procedures should be followed and clearly documented.
• Professionals taking decisions about detention under the Mental Health Act should be mindful of de facto detention (where a patient feels under pressure to agree to admission to hospital or to remain in hospital, often because they feel threatened by the possibility of detention, and are, therefore, not giving valid consent to their stay in hospital) and should document their reasoning for their decisions (including consideration of the mental health legislation) clearly.

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 had been on a waiting list for a knee operation for a number of months and, despite the board telling him that he would undergo the operation within 12 weeks, it took approximately five months after Mr C was first put on the waiting list for him to have the operation. Mr C said this was contrary to the treatment time guarantee (12 weeks) and did not take into account his clinical need. Mr C had told the board he was willing to travel to any hospital in the UK to undergo the operation. Mr C said that, as a result of the board's failings, his physical and mental health had deteriorated. Mr C complained to us that the board failed to provide him with a knee operation within a reasonable time and that they failed to respond to his complaint in a reasonable way.

We took independent advice from an orthopaedic adviser. We found that the board's failure to meet the treatment time guarantee or consider other healthcare providers meant that Mr C suffered pain and discomfort for number of months, with implications for his emotional health as a result. We also found it unreasonable that, at times, Mr C had to take the initiative to find out what was happening once the 12 weeks treatment time guarantee period had passed. We were not satisfied from the evidence available that the board had reasonably had regard to the legislation concerning the treatment time guarantee, and we upheld the complaint.

In relation to complaints handling, we found that the board had wrongly told Mr C that it was not NHS policy to offer surgery outwith the health board area when the guidance around the treatment time guarantee is clear that one of the things health boards must do when the guarantee is breached is consider alternative providers within and outwith Scotland and the NHS. We upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for failing to provide treatment within a reasonable time. 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:

• Identify any training needs to ensure staff fully understand the legislation and guidance around the treatment time guarantee, and its application.

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, who is an advocacy and support worker, complained on behalf of her client (Mr B) about the care and treatment provided to Mr B's wife (Mrs A) during her admission to the Royal Alexandra Hospital. Mrs A suffered two falls while in the hospital. Ms C complained that the standard of nursing care and treatment provided to Mrs A was unreasonable. We took independent advice from a nursing adviser. We found that, in general, the nursing care was reasonable and the action taken by nursing staff to assess and protect Mrs A against the risk of falls was reasonable. However, the advice we also received was that Mrs A should have been referred to the falls team earlier than she was and that one of the two falls had not been recorded on the computer system which is used to record clinical incidents, such as falls. This computer system is an important mechanism to record incidents so that learning and improvement can take place. On balance, we upheld Ms C's complaint about the nursing care and treatment provided to Mrs A.

Ms C also complained that the medical care and treatment provided to Mrs A was unreasonable. We took independent advice from a consultant in general medicine. We found that, in general, the medical care and treatment was reasonable. However, we also found that the assessment carried out after the first fall was inadequate and that there was no evidence in the medical records that a medical review had taken place after the second fall. In addition, we found that the communication by medical staff was poor and that they had not fully explained the prognosis for Mrs A and their concerns about her recovery. Given the failings identified we upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr B for failing to adequately review Mrs A after her falls, and for failing to adequately explain her prognosis to her family. 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:

• Patients should receive a full medical assessment following a fall.

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 practice delayed in referring his late father (Mr A) for appropriate specialist investigation of his iron deficient anaemia (a condition where the blood lacks an adequate amount of healthy red blood cells). Mr C considered that an urgent colonoscopy should have been arranged, in line with cancer referral guidelines. He also raised concerns about the chosen referral pathway once a referral was eventually made, as the referral was to a vascular surgeon rather than directly for colonoscopy. Mr A was subsequently diagnosed with colorectal cancer which was not amenable to treatment and he later died. In responding to Mr C's concerns, the practice said they did not deem an earlier referral appropriate at the time in light of Mr A's other complex medical conditions.

We took independent medical advice from a GP, who advised that there were no current complex medical conditions which could have explained the significant deterioration in Mr A's red blood count. As such, they advised that cancer referral guidelines should have been followed and Mr A should have been appropriately assessed and referred for urgent investigation. We found no evidence of an appropriate examination having occurred and a referral was not made until almost nine months after iron deficient anaemia was diagnosed. We found that the referral should have been sent to a gastroenterologist or surgical doctor, rather than a vascular surgeon. In addition, the adviser highlighted that Mr A was prescribed an inappropriate dosage of iron supplements and he was not adequately monitored to assess his response to these. We concluded that there was an unreasonable failure to appropriately assess, treat and monitor Mr A's iron deficient anaemia, and an unreasonable delay in arranging appropriate specialist investigation. We upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for the unreasonable failure to appropriately assess, treat and monitor Mr A's iron deficiency anaemia; and the unreasonable delay in arranging appropriate specialist investigation. 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 GP involved in Mr A's care should refer themself to NHS Grampian's clinical support group for review of their knowledge and practice in relation to clinical assessment, prescribing and referral guidelines.

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 husband (Mr A) about the care and treatment he received from the board at Dumfries and Galloway Royal Infirmary. Mrs C complained that there was an unreasonable delay in diagnosing that Mr A was suffering from renal cancer, that there was an unreasonable delay in providing him with treatment and that staff had failed to communicate appropriately with Mr A and his family about his diagnosis and treatment.

We took independent advice from a consultant urologist who said that there was a severe failure to follow-up on a radiologist's report of a scan. The radiologist had suspected that an area of abnormality which showed in Mr A's kidney was renal cancer and had made a recommendation that the scan should be discussed at a urology multi-disciplinary team meeting (MDT). The radiologist's recommendation to discuss this at MDT was not actioned. There was also a failure to mention the scan finding in any of the correspondence on Mr A's discharge from the hospital. As a result, the suspected renal cancer was neglected until the same renal mass was found, by chance, a number of months later when Mr A had a scan to investigate a problem that was unrelated to his renal cancer. While it appeared that Mr A's tumour had not progressed when found, we found that the delay was unacceptable and that the diagnosis, management and treatment of his renal cancer was well below an expected standard. We upheld Mrs C's complaints about delays in diagnosis and treatment.

We also took independent advice from the consultant urologist, as well as a nursing adviser, about how staff communicated with Mr A and his family about his diagnosis and treatment. We did not find any reference in Mr A's medical records of medical staff having a discussion with him about his cancer diagnosis and treatment. We found that the actions taken by nursing staff had fallen short of the standard expected and needed for Mr A and his family at the time. We upheld this aspect of Mrs C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C and Mr A for:
• an unreasonable delay in diagnosing that Mr A was suffering from renal cancer;
• an unreasonable delay in providing treatment to Mr A; and
• a failure in 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:

• A system should be in place to ensure that unexpected findings of scans are appropriately reported and acted upon in a timely manner.
• It should be ensured that radiology are summarising any significant incidental findings at the end of a scan report, as per the requirements of a previous audit, and that these findings are brought to the attention of relevant staff in a timely manner.
• Staff should be aware of the importance of communication with patients and their families. Newly appointed staff should be supported and mentored in this regard and provided with appropriate training.

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 the council as her bins were not being collected as required. Ms C was part of an assisted take out service due to her ill health but her bins were not always being lifted or, when they were, they were not returned to the correct place. Ms C made numerous complaints about this but believed that the situation noticeably worsened when she witnessed her neighbour speaking with a member of staff who, following the conversation, did not empty Ms C's bin. She was of the view that her neighbour was influencing staff not to empty her bins as part of a long running dispute. The council's response was to advise Ms C that she needed to leave her bins within the boundary of her property, and not place them on the shared driveway, as this was confusing for staff. Ms C remained unhappy with the council's position and brought her complaint to us.

Ms C complained that the council failed to provide a reasonable bin collection service and that their response to her complaint was unreasonable. We investigated information provided by both parties and advised Ms C we would not be investigating her neighbour's involvement as records from the council showed that Ms C had been experiencing this problem long before the incident with her neighbour. The records from the council showed a clear pattern of repeated failings. We upheld Ms C's complaint and asked the council to apologise to her for continually failing to empty her bins. We also noted the council had introduced a number of new processes to increase accountability for staff and they hoped this would see an improvement in service provision. We asked the council to evidence the impact of the changes they had made.

Regarding the council's response to Ms C's complaint, we found that the response was inadequate as it appeared to suggest Ms C was to blame for her bins not being emptied. We also found that the changes that the council told us they had implemented to improve the service were not referred to in their complaints response. 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 repeated failings when collecting her bins and for the poor content of the response to her complaint.

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 and Mrs C complained about the council as they were unhappy with the way their child (child A) was dealt with when they suffered a head injury at their primary school. The head injury occurred when child A fell during playtime. Following the injury they were confused, distressed, and were suffering from loss of memory. Mr and Mrs C felt that an ambulance should have been called immediately. Instead, the school observed child A for a short time, before calling Mr and Mrs C and asking them to pick child A up and take them to the GP. This meant that there was a period of around 45 minutes from the injury occurring to them attending to pick up their child. Mr and Mrs C complained that the relevant council procedure was not appropriately followed when the school were dealing with child A's head injury. Mr and Mrs C were also dissatisfied with the standard of the council's complaints handling.

The council provided us with a copy of their Accidents to Pupils procedure, which instructed staff on when emergency medical assistance should be sought for head injuries, as well as providing more general guidance about how injured children should be transported to hospital if medical treatment not needing an ambulance was required. The procedure said that an ambulance should be called immediately where: the child was unconscious for any length of time; the child was vomiting frequently; neck pain was associated with the injury; or where the child's condition was 'giving cause for concern'. It appeared clear from the council's records that staff were concerned by child A's condition. This is why staff requested the child was collected and taken to their GP. However, the procedure required that they should have called an ambulance or, if they did not consider their condition serious enough to warrant emergency transport, they should have arranged for them to be transported directly to hospital by taxi or a member of staff's personal vehicle. Instead, they attempted to call Mr and Mrs C, resulting in the delay of around 45 minutes before they could collect their child and seek medical attention for them. We upheld the first complaint.

Further to this, we did not consider that the council's Accidents to Pupils procedure was sufficiently detailed for use by non-medical staff. We took independent advice from a GP adviser and we were advised that child A's condition should have been a cause for concern. The adviser's recommendation would have been that an ambulance was called. However, it is not reasonable to expect school staff to have detailed knowledge of complex medical issues, which is why it is important that the council's procedures are robust and give clear guidance that is easily understood. The adviser suggested that the school should liaise with NHS 24 to review the Accidents to Pupils procedure to ensure that it is both manageable for their staff and clinically sound.

We considered that the council's complaints handling had been unreasonable. In particular, we felt that a reasonable investigation should have highlighted that the school's failure to arrange direct transport to hospital was in clear contravention of the Accidents to Pupils procedure. As such, we also upheld the second complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr and Mrs C for failing to follow the Accidents to Pupils procedure, for the delay this caused in child A receiving medical attention and for failing to identify this as part of their complaints investigation. 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 liaise with NHS 24 to review the Accidents to Pupils procedure.
• All relevant staff should be aware of the Accidents to Pupils procedure and ensure it is followed when a pupil is injured.

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 council delayed telling her about an incident involving her child (child A) and their teacher. The incident occurred just prior to the start of the summer holidays and Mrs C was not notified until after the start of the new school year in the autumn. Mrs C felt this was unreasonable because her child's communication needs meant that they could not simply tell her what had happened and, as a result, she was unaware of the incident for around ten weeks.

The council did not feel that there had been an unreasonable delay in informing Mrs C. They said their decisions were risk assessed carefully, communicated appropriately and took account of the wellbeing and rights of employees. The council felt that the school had acted appropriately and in line with their confidential reporting and disciplinary procedures. They also explained that, as the summer holidays would prevent direct contact between child A and the teacher for seven weeks, there was no risk directly linked to the incident at that time.

Our role was to consider the council's administrative handling of the matter. Our review of their procedures found that the council's internal documents about reporting, investigating and dealing with such incidents did not detail the process for notifying parents of a possible incident. Although we recognised the balancing act the council had in the circumstances, we also recognised that Mrs C, as a parent, wanted to know about this incident promptly. While the evidence indicated that the council had followed their confidential reporting and disciplinary procedures, we felt the fact that the lack of any mention of notifying parents within those documents was a shortcoming. On that basis we upheld this complaint.

Recommendations

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

• Procedures should highlight the importance of giving consideration to informing parents of allegations that may affect their children. The council should also document the reasons for their decision.

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 council failed to deal with complaints she had made about her child's school in line with their obligations. She said that the council had not investigated her concerns correctly, that they had responded to her complaint outwith the timescale of 20 working days and that they had not implemented any changes as a result of failings they had identified.

We found that the council had delayed in commencing their investigations and that, whilst it was reasonable that the investigations took more than 20 working days, it was unreasonable that the council failed to keep Mrs C updated on their progress or seek to agree reasonable timeframes by which they would provide their response. In addition, the council's complaints response was overly complex, hard to understand and failed to clearly state the elements of the complaint they had upheld, and what actions were identified to address the failings. We also considered that the council had failed to provide clear explanations of the actions they had taken with respect to certain failings identified. We upheld Mrs C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Provide an apology for failing to comply with their complaints handling procedure. This apology should comply with the SPSO guidelines on making an apology available at www.spso.org.uk/leaflets-and-guidance.
• Provide Mrs C with additional detail and appropriate explanations in relation to how they plan to appropriately address certain failings that were identified by their investigation.

In relation to complaints handling, we recommended:

• All relevant members of staff should review the Complaints Handling Procedure and confirm they understand it.
• Letters confirming delay in investigations should include an appropriate explanation of the reason for delay and seek to confirm a reasonable timeframe for the provision of the response.

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 an adult support and protection (ASP) investigation that was carried out following an incident involving her father (Mr A). Mr A was a hospital in-patient at the time of the incident and Mrs C held welfare power of attorney for him. There was a delay between the incident being identified by a student nurse and the matter being reported as an ASP issue. An ASP investigation took place over an extended period and Mrs C was interviewed as part of this process. During her interview, Mrs C raised highlighted concerns about Mr A having appeared over-sedated. In addition to the individual ASP investigation for Mr A, a large scale investigation also took place, alongside other investigations and enquiries.

Mrs C was not informed about the outcome of the ASP investigation until several months after the incident. In the interim period, Mrs C had complained directly to the local health board about the lack of information provided and the poor standard of communication in relation to the ASP investigation. In responding to the complaint, the local health board acknowledged that the ASP timescales had been extended due to the exceptional circumstances of the case and that issues with the multiple investigations had resulted in an unsatisfactory timescale. Mrs C was advised that there was no allegation investigated regarding Mr A's medication. The conclusion of the ASP investigation was that Mr A had been an adult at risk of harm, however, there was no evidence of actual physical or psychological harm to him as a result of either the incident or staffing levels on the ward (it was acknowledged that there was, at that time, evidence of staff shortages on the ward). Mrs C was unhappy with the way that her concerns were handled and asked us to consider her case. After making enquiries it was determined that the complaint response issued by the local health board did not represent the final position from the social work point of view. Mrs C met with members of staff at the partnership and they agreed to investigate her concerns fully. As a result, we closed our own investigation at that time as it was considered that the outcome Mrs C wanted was most likely to be achieved from the partnership's consideration of her concerns. However, Mrs C did not receive a response and we opened a new investigation with an expanded remit.

Mrs C complained to us that the partnership:

unreasonably failed to follow ASP investigation procedures;

unreasonably failed to use relevant planning tools to ensure safe staff numbers on the ward;

unreasonably failed to evidence that no harm resulted from the incident involving Mr A or from staffing levels on the ward; and

failed to communicate reasonably with the family.

We took independent advice from a social work adviser. We found that there had been delays in reporting the initial incident and that the ASP process could have been concluded earlier, without awaiting the outcome of other investigations that were ongoing. We also found that there was a lack of clarity regarding who would action the recommendation of the large scale investigation. We upheld Mrs C's complaint about the failure to follow ASP investigation procedures.

Mrs C highlighted particular concerns about a failure to use planning tools to ensure safe staff numbers on Mr A's ward. We took independent advice from a mental health nursing adviser on this issue. We found that there were acknowledged delays in the implementation of planning tools on the ward (although there were reasons for this) and the advice we received highlighted issues with staffing numbers on the day of the incident and some more general issues, including the use of student nurses to bolster staff numbers on wards. We upheld this aspect of Mrs C's complaint.

We took independent advice from a consultant old age psychiatrist in relation to Mrs C's concerns about over-sedation and that there had been an unreasonable failure to evidence that Mr A had not been harmed. The advice we received was that the management of Mr A's medication was reasonable and that there was no indication that he had been harmed by the incident. However, we upheld Mrs C's complaint as we found that there had been an unreasonable failure to provide Mrs C with evidence to support this position.

Finally, we upheld Mrs C's complaint about communication. We found that there had been failings in this area in relation to aspects of Mr A's treatment and that overall communication on ASP matters was inadequate. In addition, we found that the handling of Mrs C's complaint was unreasonable. We made a number of recommendations to address the failings identified.

Recommendations

What we asked the organisation to do in this case:

• Apologise for the failures in reporting the incident in terms of the ASP procedures. Also apologise for the failures in communication and failure to evidence that no harm came to Mr A from the incident. The apology should meet the SPSO guidance on apology available at https://www.spso.org.uk/leaflets-and-guidance.

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

• In similar cases individual ASP investigations should be carried out without awaiting the outcome of any other investigations unless, for a specific reason, these are inextricably linked. There should be clarity on who will action recommendations arising from a large scale investigation. Organisational issues uncovered when making ASP enquiries should be placed back in the hands of that organisation (or other organisations concerned) to investigate and report back.
• Communication with adults or their representatives should be clearly defined and agreed early in the ASP process. Representatives with welfare power of attorney should be proactively involved in care and treatment.
• There should be clear reasoning documented in the notes when as-needed medications are administered.
• The supernumerary status of student nurses in training should be respected except for the planned rostered service contribution which is part of their course syllabus.

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.