Upheld, recommendations

Summary

Mrs C complained about the care and treatment provided to her late relative (Miss A). Miss A attended her GP practice with an abdominal swelling, which led to an urgent referral to the gynaecology service at Glasgow Royal Infirmary. Tests showed that Miss A had an ovarian cyst and arrangements were made for her to have it surgically removed. She was then discharged from the gynaecology service. Over the course of the following year Miss A attended her GP with various symptoms and ultimately attended the emergency department at Glasgow Royal Infirmary. After several attendances at hospital, tests identified that she had advanced cancer. Miss A was then transferred to the Beatson West of Scotland Cancer Centre for treatment and she died a short time later.

Mrs C complained that there was an initial failure to diagnosis that Miss A had cancer when she was referred to gynaecology and the ovarian cyst was removed. Mrs C also complained that there was a delay in diagnosing Miss A with cancer after she attended the emergency department the following year, and that appropriate treatment had not been given to Miss A.

We took independent advice from consultants in pathology, gynaecology and surgery. We found that appropriate tests and investigations were initially carried out when Miss A attended the gynaecology service. However, we found that there should have been a record to show that family history of ovarian or breast cancer had been enquired into, in line with relevant guidance. In addition, we found that there was evidence to indicate that the ovarian cyst had burst during surgery, but that the records did not contain clear information about this having occurred. We also found that there was a failure to accurately report the pathology specimens after the cyst was removed. We considered that, had these been reported in a timely manner, this would have altered Miss A's clinical management and she would not have been discharged from the gynaecology service with no follow-up. We upheld Mrs C's complaint about an initial failure to diagnose Miss A.

Regarding the delay in diagnosing Miss A the following year, we found that biopsies taken at the time of a sigmoidoscopy (a procedure to visualise the rectum and lower colon) showed evidence of cancer, but that there was a two week delay in this being recognised by the clinical team and Miss A being informed of the results. We upheld this aspect of Mrs C's complaint.

We found that the appropriate option of palliative chemotherapy was decided upon and that reasonable surgical care had been provided to Miss A. However, we concluded that there may have been a lost opportunity to halt the progression of the cancer because of the time taken to communicate the findings of the sigmoidoscopy and also because of a delay in arranging treatment for blocked kidneys which Miss A had also developed. On balance, we concluded that Miss A had not been provided with appropriate treatment, and we upheld this part of Mrs C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C and the family for the inaccurate reporting of the pathology specimens, the delays in communicating the cancer diagnosis and a delay in treating blocked kidneys. The apology should comply with the SPSO guidelines on making an apology, available at www.spso.org.uk/leaflets-and-guidance.

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

• Staff should follow the guidance about enquiring into family history of ovarian or breast cancer, as recommended in the Royal College of Obstetricians and Gynaecologists' Green-top guideline No.62.
• Consideration should be given to amending the proforma to include a subheading for family history.
• Staff should record whether a cyst has been removed intact or has burst during surgery.
• Staff should ensure that pathology specimens are sampled and correlated in accordance with the Royal College of Pathologists' guidelines on ovarian tumours.
• Staff should ensure they are aware of the Royal College of Pathologists' guidelines on the examination of ovarian tumours.
• Pathology staff should ensure that new cancer diagnoses are communicated promptly to the clinical team.
• Staff should ensure in similar cases that appropriate treatment for blocked kidneys is commenced in a timely manner. An appropriate care pathway should be in place.

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 Business Stream was incorrectly charging him for surface water drainage at his business premises. He said he was not liable for this as the guttering and downpipe along the building fed into a soak away in the ground. Business Stream made three requests for the supply point ID (SPID) to be de-registered by Scottish Water. Each request was refused and Business Stream requested that a verification of service visit was undertaken by Scottish Water to clarify if surface water charges should apply. A visit found that the guttering and downpipe were not connected to the main sewerage system. This report was sent back to Scottish Water, who determined that the water which landed on the car park adjacent to Mr C's business premises dispersed onto nearby roads which did connect to the main sewerage network, therefore charges remained liable. Business Stream reflected the view of Scottish Water, despite their inference that they did not agree with this view. Mr C remained unhappy and asked us to investigate.

We asked Business Stream for all of the information they held regarding the complaint and their determination of Mr C's liability for charges. They provided details of the responses from Scottish Water to the three de-registration requests which indicated differing reasons for refusals on each decision. The information indicated that Business Stream did not question this further and applied the charges to Mr C. Business Stream did not begin a dispute process, which is outlined in their operational code. We were not satisfied that Business Stream had made a clear decision themselves and we considered that this had resulted in delays for Mr C and potentially incorrect charges. We took the view that Scottish Water had arranged for the premises to be inspected and this report advised that the property was not connected to the main sewer system. We found that Scottish Water then took an opposing view on this based on assumptions about the rainfall flowing from the adjacent car park. We were of the view that there was not sufficient evidence that the charges should apply and we upheld the complaint. We asked Business Stream to clarify their position and justify this in terms of the legislation and operational code.

Recommendations

What we asked the organisation to do in this case:

• Business Stream should provide their view on Mr C's liability for property drainage and roads drainage charges. The explanation should provide a clear legal basis for any applicable charges, citing the appropriate sections of relevant legislation or operational code.

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 was in receipt of a public pension and the administration of her pension was taken over by the Scottish Public Pensions Agency (SPPA). On P60s issued to members at the end of the tax year, the figure in the red box marked 'Figures shown here should be used for your tax return, if you get one' showed only the amount paid since SPPA took over administration of the fund. Another figure on the P60 showed the amount paid by the previous pension administrators. SPPA were aware of this but did not inform members, as the correct tax was being deducted on a monthly basis and paid to HM Revenue and Customs (HMRC). Mrs C followed the instructions on the P60 and, as a result of having included the figure in the red box on her tax return, received a tax refund from HMRC. HMRC then investigated the matter as there were discrepancies between her tax return and the information received from SPPA. Mrs C had to repay the tax refund, with interest. She was unable to pay it back straight away, so interest accrued.

When she complained to SPPA, they said it was her responsibility to provide HMRC with the correct information about her income. Mrs C then complained to us that SPPA had unreasonably failed to provide her with clear guidance regarding the information displayed on her P60. We accepted that the P60 form itself could not be changed. However, we thought that SPPA could have included a covering letter highlighting the issue with the P60 for clarification. Given the clear instruction on the P60 to use the figure in the red box on her tax return, we thought it reasonable that Mrs C had done that. We considered it unreasonable for SPPA not to have provided clear guidance regarding the information displayed on the P60. We recommended that SPPA apologise and reimburse Mrs C for the interest she had been charged on the overpaid tax refund.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C for providing confusing information on the P60, without any accompanying guidance.
• Reimburse Mrs C for the interest charged by HMRC on her overpaid tax refund, on receipt of proof of interest charges paid by her.

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 had failed to implement the recommendations of a social work complaints review committee (CRC). The CRC had been held and, despite a statutory timeframe of 42 days within which the recommendations should have been considered, the council did not consider the recommendations for six months. In terms of the complaints handling procedure in place at the time, the recommendations had to be reported for consideration by a council committee. The council's position was that this had been hampered by the intervening local elections and recess period, but we considered the delay to be unreasonable. We also considered that the council should have kept Mrs C updated with an explanation for the delay and advice as to likely timescales for implementing the recommendations. We upheld Mrs C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C for not keeping her updated with regards to likely timescales and for not providing an explanantion for the delay in implementing the recommendations.

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

• The council should be mindful of the importance of keeping complainants updated.

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 council had unreasonably failed to provide their school transport drivers with child protection awareness training. Mr C reported an incident involving his daughter and the school bus driver to the council and, following an investigation, questioned why the bus driver had not received any training regarding child protection. The council confirmed that their policy states child protection awareness training is only a requirement for bus drivers who transport children with additional needs.

We took independent advice from a social worker. The adviser referred to the relevant national guidance and identified that training should be provided to all adults, including school bus drivers, who have regular contact with children as part of their job. We therefore upheld Mr C's complaint. Before our investigation reached a conclusion, the council acknowledged that they failed to take into account the guidance and confirmed that they have already taken steps to remedy the situation. We recommended the council apologise to Mr C and to provide our office with an update on the progress of their improvements.

Summary

Mrs and Mrs C complained about a delay in diagnosing their child (child A) with autism spectrum disorder (ASD). In particular, they complained that an autism diagnostic observation schedule (ADOS) was not carried out. Child A was subsequently diagnosed with ASD after an ADOS was carried out.

The board did not consider there was an unreasonable delay in diagnosing child A with ASD. They also explained that their ASD assessment pathway has developed since the events complained about occurred.

During our investigation we took independent advice from a consultant paediatrician. The adviser considered that child A should have been referred for a multi-disciplinary ASD assessment, given their family history, their symptoms and Mr and Mrs C's strong concerns. The adviser explained that an ADOS is not a requirement to diagnose ASD but that it can be a helpful tool. In light of the failure to refer child A for a multi-disciplinary ASD assessment, we upheld the complaint and made recommendations in light of our findings.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr and Mrs C for not referring child A for a multi-disciplinary autism spectrum disorder assessment. The apology should comply with the SPSO guidelines on making an apology, available at: www.spso.org.uk/leaflets-and-guidance.

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

• Parental concerns should be taken into account when deciding if a child should be referred for an autism spectrum disorder assessment, in line with the relevant guidelines, as should any reported symptoms and family history of learning difficulties.

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 developed a lump on his ear and his GP referred him to Hairmyres Hospital for investigations. Mr C was seen at the dermatology clinic at the hospital six weeks after his GP referral. He was diagnosed with squamous cell carcinoma of the ear (a type of cancer in the skin's cells). Mr C was routinely referred to the hospital's plastic surgery department for treatment and he was offered a plastic surgery appointment around two months later. In the meantime, Mr C contacted the dermatology clinic, as the lump on his ear was increasing in size daily. Mr C's referral to the plastic surgery department was upgraded to urgent and he was offered an appointment a week later. When Mr C attended that appointment, he confirmed that he had already arranged private surgery to treat his squamous cell carcinoma, as he felt the treatment time at the hospital had been too long. Mr C complained to us about delays in diagnosing and treating his squamous cell carcinoma.

We took independent advice from a consultant dermatologist. We found that there was no unreasonable delay in the hospital diagnosing Mr C's squamous cell carcinoma. However, we found that squamous cell carcinoma on the ear is considered a high-risk site, as it has the potential to spread around the body. Therefore, we considered that Mr C should have been urgently referred to the plastic surgery department after his diagnosis. We found that it was unclear whether Mr C would have been treated within the 18 week referral to treatment standard, which applies to 90 percent of all routine surgeries in Scotland. We considered that this standard may not have been met, given how complex the surgery would be and how long Mr C's clinical journey had already taken. We recognised that it is not a 100 percent standard, but given the level of risk of having squamous cell carcinoma on the ear, we considered that Mr C should have been treated within that timescale. For this reason, we upheld Mr C's complaint. However, we did not recommend that Mr C's private treatment costs be refunded. This is because we noted that he had arranged private surgery before he received a date for surgery from the hospital. Although we had concerns that the hospital may not have met the 18 week standard, we were unable to say with certainty they would not have done so, and so we did not consider it to be reasonable to recommend that the board reimburse Mr C's private treatment costs.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for referring him to plastic surgery as a routine referral when his squamous cell carcinoma was on a high-risk site. 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 with squamous cell carcinoma should receive the appropriate treatment, from the correct clinician(s), at the appropriate time, taking into account the relevant clinical guidance.

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 practice unreasonably removed her from the patient list. Mrs C had been expecting to receive a call from the receptionist about whether her adult son could have an appointment with a GP to discuss blood test results. Mrs C had earlier tried to speak to a GP by phone to see about an appointment for her son but was told that the GP would not speak to her. Mrs C left her contact details and asked that the practice return her call with details of an appointment time. Mrs C then received a phone call from the practice manager who said that the decision had been taken to remove her from the patient list. Mrs C could think of no reason why she had been removed from the patient list.

We took into account the contractual regulations and relevant guidance regarding the removal of patients from the practice list. This sets out that, other than in cases involving violence or aggression, a patient whose behaviour is giving cause for concern should be given a written warning informing them that they will be removed from the practice list if they do not alter their behaviour. The warning should last for 12 months. While the practice did provide us with two examples of why they had concerns about Mrs C's actions, staff did not formally bring them to Mrs C's attention in line with the regulations and guidance and therefore she was unaware of the practice's concerns. We upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C for unreasonably removing her from the practice list. The apology should comply with the SPSO guidelines on making an apology, available at www.spso.org.uk/leaflets-and-guidance.

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

• Staff should be aware of and comply with the guidance and regulations where there are concerns about patient behaviour.

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 raised concerns about the way hospital nursing staff arranged a care package with the council for her late father (Mr A) upon his discharge from Glasgow Royal Infirmary. Mr A's discharge from hospital was delayed as Ms C was told that the care providers were closed over the holidays. After being discharged no carers arrived to assist Mr A. Ms C contacted the hospital but was told nothing could be done as it was the weekend and there was no out-of-hours service. Ms C complained that the board failed to ensure that a package of care was in place for Mr A on his discharge from hospital and that she was not provided with an out-of-hours emergency phone number for the care provider.

We considered that there was a failure to reasonably ensure that the council was contacted to put a package of care in place. We found that there was contradictory information regarding how the package of care had been arranged and who within the nursing staff had arranged it with the council. It was not possible to determine with any certainty who arranged this and what was arranged. We upheld this aspect of the complaint.

We also found that nursing staff were not aware of the fact that an out-of-hours number was available and could be called at the weekend and on public holidays. We found that it was possible that Mr A could have been provided with a package of care over the holidays or at the weekend if the out-of-hours service had been contacted by the nursing staff or if Ms C had been provided with the number. We upheld this aspect of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms C for failing to ensure that a care package was arranged with the council for Mr A's discharge from hospital.
• Apologise to Ms C for not calling the out-of-hours phone number for packages of care and for not providing Ms C with this number. The apology should meet the standards set out in the SPSO guidelines on making an apology, available at www.spso.org.uk/leaflets-and-guidance.

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

• All nursing staff should be aware of the requirement to record who contacted the council to arrange a package of care; the name of the person this was arranged with; the date the care package would start and any discussion regarding the care the patient would require at home.
• All nursing staff should be aware of the out-of-hours contact phone number for packages of care for public holidays and weekends. Staff should contact this number where appropriate to do so. The number should be provided to families where appropriate to do so.

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 works for an advocacy and support agency, complained on behalf of her client (Mr A). Mr A had been on a waiting list for a prostate operation for severe incontinence for a number of months and, despite several letters from the board saying that he would undergo the operation within weeks, he was still waiting when Ms C made the complaint to us, approximately nine months after Mr A was first put on the waiting list. Ms C said this was contrary to the treatment time guarantee (12 weeks) and did not take into account Mr A's clinical need. She also noted that Mr A was willing to travel to any hospital in the UK to undergo the operation. Ms C told us that Mr A's operation had been cancelled on three occasions at the very last minute and said that, as a result of the board's failings, his physical and mental health had deteriorated.

We took independent advice from an adviser who specialises in urology. We found that the board's failure to meet the treatment time guarantee or consider other healthcare providers meant that Mr A suffered severe lower urinary tract symptoms unnecessarily for an unreasonable number of months, with significant implications for his physical and emotional health as a result. In relation to communication, we also found it unreasonable that, at times, Mr A 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.

Recommendations

What we asked the organisation to do in this case:

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

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

• Review their process and patient letters to ensure that they comply with the treatment time guidance, including considering alternative providers and communication with patients.
• Reflect on this case in relation to whether opportunities to reassess Mr A's clinical priority were missed and report back to us on the findings.

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.