Upheld, recommendations

Summary

Mrs C complained on behalf of her late husband (Mr A) who was being treated for a brain tumour at Dumfries and Galloway Royal Infirmary. Mrs C enquired with the board about the methylated status of Mr A's brain tumour as she had learned that it was useful to know this in deciding whether to accept chemotherapy. (Methylation is a chemical change which alters the MGMT gene, making treatment more effective.) The board told Mrs C that this information was not available at the time she enquired. Mrs C complained that the board failed to perform a test to confirm the methylated status of Mr A's brain tumour. She also complained that the board failed to respond to her queries within a reasonable timescale. The board responded and advised that the test was not available in the board area at the time.

In investigating Mrs C's complaint, the board carried out the test and it was found that the tumour was unmethylated. The board also confirmed that the methylation test is now carried out in all grade 3 and 4 gliomas (malignant tumours of the glial tissue of the nervous system) in the board area. We took independent advice from a consultant neurosurgeon. The adviser noted that knowing the methylation status of the tumour would have some bearing on the likelihood of the chemotherapy being effective. Our investigation found that even though the test was not routinely carried out by the board at the time Mr A was receiving treatment, the test could have been requested from another department. We also found the board failed to deal with Mrs C's complaints within the required timescale and they failed to advise her of their need to extend their response time. We upheld both of Mrs C's complaints and recommended that the board provide Mrs C with a written apology.

Recommendations

What we asked the organisation to do in this case:

• The board should provide Mrs C with a written apology, acknowledging that they failed to perform the test and failed to respond to her queries within a reasonable timescale.

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 after being put on the waiting list for a transurethral resection of the prostate (surgery used to treat urinary problems caused by an enlarged prostate), he was not given an appointment within the 12 week treatment time guarantee timescale, and that he was not updated about this or his place on the waiting list.

We took independent advice from a consultant urologist and found that the delay Mr C had experienced was unreasonable. Whilst the board had provided evidence of a number of actions they had taken to address the extended waiting times for urology services, including employing more urology consultants and opening extra theatre lists, they had not provided evidence that the board had taken steps to arrange for the procedure to be carried out by another NHS health board or by another provider as is stipulated by the Patient Rights (Treatment Time Guarantee) (Scotland) Regulations 2012. We also found that Mr C should have been contacted by the board and advised of the delay in treatment. 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 providing him with an appointment for transurethral resection of the prostate. 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 the treatment time guarantee is not going to be met, the board should take reasonable steps to arrange for the provision of the procedure by another NHS health board or another provider, as set out in the Patient Rights (Treatment Time Guarantee) (Scotland) Regulations 2012.
• Patients should be advised when the treatment time guarantee is not going to be met, and given an explanation as to why this is.

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, a prisoner, complained about how her complaints were being responded to by the board. The board had written to Ms C informing her that the volume of complaints, comments and feedback she was submitting was putting a disproportionate strain on their resources and impacting on their ability to assist other people. They asked Ms C to adjust her behaviour. They said they were taking action under their Unacceptable Actions Policy and would be limiting the responses they gave to her complaints, focusing only on those they deemed most significant and which had not been resolved at the time.

Ms C continued to submit complaints.

We found that the board's policies on restricting contact were confusing and that clearer information could have been given to Ms C regarding the board's expectations and what they would do to manage Ms C's behaviour if she continued to submit high volumes of complaints. For that reason we upheld the complaint and made a recommendation to address it. We did not recommend an apology for Ms C as, although there had been a lack of clarity on the board's part, Ms C was well aware of the impact her actions were having on the board and did not take the opportunity to modify her behaviour.

Recommendations

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

• The board should have a clearer policy for unreasonable or unacceptable actions, to enable them to efficiently manage unreasonable actions.

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 provided to his late father (Mr A) at Forth Valley Royal Hospital.

Mr A was referred to the board and diagnosed with prostate cancer. At a multi-disciplinary team (MDT) meeting, a decision was made to adopt a watchful waiting approach (an approach used in prostate cancer management in men with few symptoms). Mr A attended an appointment approximately six months later, then another twelve months after that. At that point, it was found that Mr A's prostate specific antigen (an indicator of prostate cancer or other prostate conditions) had risen. Following a further MDT meeting, he was seen by an oncologist who felt that he was suitable for radical radiotherapy. In the following months, Mr A's condition deteriorated and he died.

Mr C complained that staff failed to provide Mr A with appropriate clinical treatment. He questioned the decision to place Mr A on watchful waiting programme, and the level of review he received. The board partially upheld Mr C's complaint on the basis that communication could have been better. In particular, they acknowledged that it would have been appropriate for Mr A to have been seen by a consultant at the time the decision was made to put him on watchful waiting. The board advised that they had taken action as a result of Mr C's complaint, and that patients would be seen by a consultant following a decision to place them on watchful waiting.

We took independent advice from a consultant urological surgeon and an oncologist. We found that the board followed guidelines and reviewed Mr A at reasonable intervals once watchful waiting was decided on. However, we found that the watchful waiting decision should not have been made without clinical assessment by a consultant, which may have led to a decision to offer radiotherapy. We noted that Mr A's cancer followed a path that was significantly worse than could have been expected, and that a decision to offer radiotherapy would not necessarily have prevented this. On balance, we upheld Mr C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for failing to arrange a review with a consultant for Mr A when the decision was made to take a watchful waiting approach. The apology should comply with SPSO guidelines on making an apology, available at www.spso.org.uk/leaflets-and-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 about the care and treatment provided to her daughter by staff at the Victoria Hospital. Mrs C complained that when they arrived at the hospital, the nurse was unwelcoming and did not acknowledge how ill her daughter was. Mrs C also said that throughout the admission, nursing staff did not carry out appropriate observations. Mrs C went on to complain that when her daughter was assessed by medical staff, she was not thoroughly examined and a diagnosis of viral infection was made without full consideration of her symptoms and condition.

We took independent advice from a paediatric nurse and a paediatrician. We found that nursing staff did not provide Mrs C's daughter with appropriate nursing care, with failings identified in taking observations, record-keeping, and using the Children's Early Warning Score chart (CEWS chart - a set of patient observations to assist in the early detection and treatment of serious cases and support staff in making clinical assessments). We found that national guidance on children with fever was not appropriately followed by nursing staff. We also found that, whilst the examinations carried out by clinical staff were appropriate, they did not give enough consideration to the possibility of a serious illness. We upheld both aspects of Mrs C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C for failing to provide her daughter with appropriate nursing care and clinical treatment. 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:

• Paediatric nursing staff should be knowledgeable and proficient in undertaking nursing assessments, observations, and using CEWS, and be able to act quickly on these observations.
• Parents/guardians should be given written information on warning symptoms and how further healthcare can be accessed if a child who had suffered from fever symptoms is discharged without diagnosis.
• Clinical staff should give consideration to the possibility that a child that has symptoms of a viral infection may have a more serious illness, and should be aware of the National Institute for Health and Care Excellence Fever 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

Ms C complained to the board about the care and treatment provided to her mother (Mrs A) during an admission at University Hospital Ayr. Mrs A was admitted to hospital after her GP noted that she had low sodium levels. During the admission, Mrs A received treatment for heart failure and low sodium. Her condition did not improve and she died a number of days later. Ms C complained to the board about communication with the family, the nursing care provided to Mrs A, the medical treatment provided to Mrs A and the board's failure to respond to a claim for lost property.

In response to Ms C's complaint, the board arranged two meetings with the family to discuss their concerns. The board acknowledged that communication was poor and that nursing care could have been more compassionate, and apologies were offered for these shortcomings. Ms C remained dissatisfied and brought her complaint to us.

In the course of our investigation, we took independent advice from a medical adviser and a nursing adviser. The medical adviser found that Mrs A was very unwell and said that staff should have informed the family of this from the time of Mrs A's admission, not just at the time of her deterioration. The nursing adviser did not find evidence that nursing staff had advised the family of the seriousness of Mrs A's condition, although they could not confirm if nursing staff had recognised this themselves. We noted that the board had identified a number of points of learning and improvement in relation to communication, and we asked the board to provide evidence that appropriate action had been taken. We upheld this complaint and made further recommendations based on the advisers' comments.

We also investigated Ms C's concerns about nursing care. The nursing adviser noted a number of gaps in the fluid balance and clinical risk assessment recording, but otherwise found that the records were generally of an acceptable standard. However, the nursing adviser was critical that nursing staff did not escalate Mrs A's condition to medical staff earlier in the admission, given the family were raising concerns about her condition. The nursing adviser concluded that, on balance, the nursing care fell below a reasonable standard. We upheld the complaint and made a number of recommendations.

Ms C also raised concern about the medical care provided to Mrs A. The adviser noted that Mrs A was very unwell at the time of admission and her condition was complex to treat. The adviser was critical that there was not a proactive plan to manage Mrs A after the day of admission, and noted that the assessments by medical staff were more superficial than they would have expected to see. The medical adviser said that the most important aspect of Mrs A's care was to assess her response to treatment and make sure her sodium level was rising in a safe manner. The adviser noted that this did not happen, and concluded that the care was unreasonable in this case. We upheld this complaint and made a number of recommendations.

Finally, Ms C said that a number of items of Mrs A's jewellery had gone missing on the ward, and complained that the board had failed to respond timeously to a claim for lost property. The board acknowledged that the belongings procedure had not been followed in this case and apologised to Ms C for the delay in responding to the claim. We upheld the complaint and asked the board to supply us with evidence that their review of the lost property claim results in learning and improvement to ensure that the correct procedure is followed in the future.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms C and her family for the specific failings in medical assessment and treatment and the failings in nursing care. 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:

• Systems should be in place for senior nursing staff to monitor nursing communication sheets on an ongoing basis. Systems should also be in place to monitor feedback received from a range of sources about communication with relatives and significant others.
• Nursing staff should recognise when a patient's condition is deteriorating and take appropriate steps to respond.
• Medical staff should make a detailed plan of treatment for patients with heart failure and low sodium levels. Medical staff should also be proactive in providing treatment and monitoring the response to the treatment.

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 way the Scottish Prison Service (SPS) handled his sentence management was unreasonable. Mr C was particularly concerned that the final outcome of a disciplinary hearing was being reflected incorrectly in some of his paperwork. He was concerned that this was recorded as a guilty finding when it was overturned to not guilty after Mr C appealed. Mr C complained that this was impacting on his progression and that the SPS were wrongly saying in some of their communication that he had been downgraded when he had not been. Mr C was worried that inaccurate paperwork might eventually go to the parole board. We had no authority to decide how Mr C's sentence was managed. Nor could we decide whether or how he should progress. However, we found that some of the SPS's communication with Mr C about how he was progressing, and whether or not he had been downgraded, had been confusing and inconsistent. We also found that some of SPS's record-keeping was incomplete or inconsistent. As such, we upheld Mr C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for the communication failings and for the confusion and stress that this caused. This apology should comply with SPSO guidelines on making an apology, available at www.spso.org.uk/leaflets-and-guidance
• Ensure that all significant records note that Mr C was not downgraded, particularly those documents which will be included in submissions to the parole board.
• Share the findings of our investigation with the staff involved.

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

• The SPS should reflect on how and why the original disciplinary hearing guilty finding was arrived at, so that any learning and improvement can be identified in a supportive way.
• Staff should be aware of the importance of good record-keeping.

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 Mrs A, who is the director of a company. Ms C complained about the way the Scottish Government had handled a complaint about wages from a former employee of the company. Whilst working for the company, the former employee had contacted the Government in relation to the underpayment of agricultural wages. As part of their statutory investigation function in relation to agricultural wages, the Government inspected the employee's payslips and calculated that there had been underpayments of wages relative to the legislation that fixed the minimum rates of pay. The company disputed this finding and corresponded with the Government over the following months. In concluding their consideration of the case, the Government maintained that the former employee had been underpaid, but decided it was not in the public interest to take enforcement action in this case.

Ms C identified arithmetical errors in some of the calculations, and noted that the method the Government had used to calculate the underpayment of overtime pay in this case was not consistent with the method they had used in a previous case. Ms C complained that the Government had not explained the inconsistency in the handling of the two cases, or why the method they now adopted was correct. In response to Ms C's complaint, the Government apologised for the inconsistency and also identified a number of service improvements to ensure that calculations were correct in the future. In response to our enquiries, the Government provided us with further comments on the inconsistency and an explanation in relation to the legislation that they had taken into account when reaching their decision. We were satisfied with the explanation provided to us. However, we were critical that the Government did not provide this explanation to the company in the course of their handling of the former employee's case. We upheld this aspect of the complaint.

Ms C also complained that the Government had not provided an explanation in relation to the method they had used to calculate the holiday pay in the former employee's case. We did not find evidence that the Government had provided a reasonable explanation to the company. We considered that they should have explained what legislation they had taken into account in reaching their method of calculation. We upheld this aspect of the complaint.

In the course of our investigation, we found a number of instances where the Government did not follow their complaints procedure. In view of this, we made a recommendation for learning and improvement.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms C and Mrs A for failing to provide reasonable explanations in relation to their calculations. This apology should comply with the SPSO guidelines on making an apology, available at www.spso.org.uk/leaflets-and-guidance.
• Provide Ms C with an explanation of the legislation that was taken into account when the decision was made that, for the purposes of calculating overtime, hours taken as holiday count towards total hours worked.

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

• Officers should provide full and informative explanations of their decisions, including, as appropriate, details of the legislation under which they have calculated underpayments.

In relation to complaints handling, we recommended:

• Complaints should be recognised effectively. They should be logged, acknowledged and responded to appropriately, and in accordance with the Government's complaints handling procedure.

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 he was not fully informed about the process for his court case to be heard in his absence. Mr C called the court to advise that his wife would be unable to attend the hearing due to ill health. He said that he was told that as paperwork had been submitted, the case could be heard on the basis of those papers in his absence. The paperwork had not actually been submitted via the correct legal process and therefore, the case was dismissed as there were no attendees and no paperwork to determine the case. Mr C complained to the court service about this, but was informed that they do not record phone calls and therefore did not have evidence of what was discussed when he phoned to advise his wife would not be in attendance. The court service were satisfied that Mr C had not followed the correct process and said it was appropriate that the case was dismissed.

Mr C asked us to investigate the case and we gathered additional information from the court. We noted that they provided content from a 'remarks' field on their case management system which summarised Mr C's call following the hearing and when he wanted to make a complaint. We established that these fields are not used frequently but that information could have been recorded when Mr C called prior to the hearing. We also established that while the court website explained about the process involved in this type of case, Mr C had had his paperwork returned from the court with no indication that he needed to have this served and re-submit. On balance, we concluded this was unreasonable as without any information about the process, it was unclear to Mr C that his paperwork had not been accepted by the court. The content of his call could not be clarified as it was not documented or recorded despite the court having the facility to do so. We upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for failing to fully inform him of the process to have his case heard. This apology should comply with SPSO guidance on making an apology, available at www.spso.org.uk/leaflets-and-guidance.

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

• Applicants should be notified that paperwork needs to be served before being re-submitted prior to the hearing, and that they may wish to seek legal advice in this regard.
• The 'remarks' field should be routinely used to document a brief summary of phone calls when calls relate to matters such as attendance at hearings or the submission of paperwork.

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

Summary

Ms C complained that the council had failed to respond reasonably to the concerns she raised about the quality of service she had received from the council and their contractor in relation to the installation of a new heating system at her home. Ms C had complained to the council about the safety and reliability of the new heating system, as well as damage done to her carpet during the installation work. She was unsatisfied with the council's response to her complaints and brought them to us.

We found that, although the council acted in line with the requirements of the housing repairs policy, there were failings in their handling and response to Ms C's complaint. The council failed to log Ms C's initial complaint properly and they did not issue a reply to the concerns she had raised. They also failed to acknowledge a subsequent complaint Ms C submitted, and failed to respond within their timescales. We found that the council also failed to be clear with Ms C about their processes for applying for and granting compensation for damaged property. We upheld Ms C's complaint. We noted that the council had since acknowledged some of their failings, and we asked them to provide evidence of the action and staff training they had carried out as a result of Ms C's complaint.

Recommendations

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

• The council should develop a compensation policy.

In relation to complaints handling, we recommended:

• Staff responding to complaints should be aware of their responsibilities, as per the complaints handling procedure.

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.