Upheld, recommendations

Summary

Miss C complained to us that that the medical practice had failed to provide her with appropriate care and treatment when she phoned to report that she was suffering from vaginal bleeding and cramps and was in the early stages of pregnancy. Miss C believed that the GP who she spoke to had inferred that she had suffered a miscarriage. However, later testing revealed that Miss C had not suffered a miscarriage.

The GP had apologised for the miscommunication and said that they had not meant for their comments to be interpreted that Miss C had suffered a miscarriage, but had meant that it was a possibility. We took independent advice from a GP adviser and concluded that the GP had not put themselves in a position to arrive at a potential diagnosis for Miss C's symptoms and that they should have offered Miss C a face-to-face consultation so that they could carry out an examination. This would also have given Miss C some reassurance about her condition. We upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise for the failure to offer Miss C a face to face GP appointment.

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 board unreasonably failed to provide him with appropriate dental treatment when he was held on remand in prison. He said that the board failed to x-ray his tooth and should have tried to save his tooth, rather than only offering tooth extraction. Mr C was concerned that the board advised him that, as an untried prisoner, he did not qualify for the same dental treatment as a convicted prisoner or a person who was not in prison.

We took independent advice from a dental practitioner. The adviser said that the board should have carried out an x-ray of Mr C's tooth as part of his dental treatment. They said that the board failed to discuss the risks and benefits of all treatment options with Mr C and record the discussion in the dental records. The adviser also said that the board should have offered to provide root canal treatment for Mr C's affected tooth, in accordance with the NHS Guidance. As a result of these failings, Mr C suffered intermittent pain from his affected tooth for a considerable period.

The adviser explained that the board were correct in their view that Mr C did not qualify for the same dental treatment as a convicted prisoner or a person who was not in prison. This was because the NHS Guidance indicated that an untried prisoner was entitled to some, but not all, of the NHS treatments available to a convicted prisoner or someone who was not in prison. However, we were concerned that it appeared that the board were not aware of the full range of treatment available to prisoners on remand. Given the failings identified, we upheld Mr C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for:
• failing to x-ray his tooth
• failing to discuss the risks and benefits of all treatment options with Mr C and record this discussion in the dental records
• failing to offer root canal treatment, in accordance with NHS Guidance.
• 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:

• In circumstances such as Mr C's, the board should x-ray patients' teeth.
• The risks and benefits of all treatment options should be discussed with patients and these discussions should be recorded in the dental records.
• Root canal treatment should be offered in cases such as Mr C's, in accordance with the NHS 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

Mr C complained that his care and treatment over two admissions to the Royal Alexandra Hospital was inadequate.

Mr C had suffered from two separate incidences of a collapsed lung in quick succession. During the first admission, Mr C disputed the board's position that it had been reasonable to discharge him. During the second admission Mr C's condition worsened. An x-ray was requested and preparations were made for inserting a chest drain. There was then significant deterioration in Mr C's condition. The board accepted that Mr C could have died due to this deterioration. The board said that they did not believe a critical incident review (CIR) was appropriate in the circumstances. They said that Mr C had been suffering from a complex condition and that it was this, rather than any failings by staff, which had contributed to the deterioration. Mr C disputed this, and he disputed the standard of the nursing care he received. Mr C said his deterioration had not been noticed because he was not being monitored properly.

We took independent medical and nursing advice. The medical adviser said that the decision to discharge Mr C following his first admission was appropriate and was supported by the medical evidence. However, the adviser found that during Mr C's second admission there had been a failure by medical staff to identify that a chest drain had not been correctly inserted, which had contributed to his deterioration. It would therefore have been appropriate to conduct an CIR. The medical adviser noted that Mr C's condition could have deteriorated very quickly and it could not be assumed that the severity of Mr C's condition and deterioration was due to an absence of clinical observation. The nursing advice we received found that, aside from some acknowledged failings, the overall standard of care was reasonable. The board had accepted the nursing failings and had taken action to address them.

We found that the board should have conducted a CIR into Mr C's deterioration during his second admission, as this could have identified useful learning for staff. We also found that the board should provide evidence that it had followed through with the work it had committed to in order to address the nursing failings it had accepted had taken place. On balance, we upheld Mr C's complaint that the care and treatment provided to him across the two admissions had been inadequate.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for failings in his care, and for failing to carry out a critical incident review. This apology should comply with SPSO guidelines on making an apology.

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

• The board should review Mr C's second admission and his subsequent deterioration with the clinical staff involved. This review should include what action was taken to review the x-ray taken and the action taken on Mr C's subsequent deterioration. This review should also include evidence of the resultant learning or improvements.

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 care for her in a sensitive manner at Aberdeen Maternity Hospital after she had a miscarriage. Mrs C said that she had found staff to be lacking in empathy. There had also been some confusion in relation to the forms which required to be completed to confirm her wishes for disposal of the foetal remains. Mrs C said that she understood that she had completed the forms required and that she would not be contacted again unless there was any foetal abnormality, but she was contacted a couple of days later and asked to return to the ward to complete another form. Although Mrs C had stated her wish for the cremated remains to be scattered without her being present, she then received a phone call several months later advising that the ashes were ready to be collected.

We took independent advice from a nursing adviser, who noted that the board's correspondence with Mrs C had been poor, and that their apology in their response to her complaint had fallen short of a reasonable standard. We found that, although the board had apologised for some of the failings in Mrs C's care, they had failed to address all of the questions she had raised with them. We upheld Mrs C's complaint. We noted that the board had changed their processes in relation to recording patients' wishes about foetal remains, so we did not make any recommendations in this regard. However, we did recommend that the board re-issue an apology to Mrs C that is in line with SPSO guidance on apology.

Recommendations

What we asked the organisation to do in this case:

• The board should re-issue an apology for the failings identified. The apology should comply with the SPSO guidance on apology.

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 service, complained on behalf of her client (Mrs B) about the care and treatment provided to Mrs B's late husband (Mr A) when he was admitted to Dr Gray's Hospital. Mr A suffered from congestive heart failure and was admitted to the hospital due to feeling tired and unwell, having chest pain, weight gain, nausea and vomiting. Ms C complained that the medical care and treatment provided to Mr A was unreasonable, and that he was not discharged in a reasonable way.

We took independent advice from a consultant physician. We found that, whilst overall assessments of Mr A and the general care and treatment provided to him was of a reasonable standard, there were gaps in weight monitoring. We noted that the board had previously addressed this matter. We also found that the issue of Mr A's internal defibrillator (a small device implanted into the body used to treat abnormal heart rhythms) was not recorded as having been discussed when a Do Not Attempt Cardio-Pulmonary Resuscitation (DNACPR - a decision taken that means a healthcare professional is not required to resuscitate the patient if their heart or breathing stops) was put in place, and that the general record-keeping around the DNACPR decision was poor. We upheld this aspect of Ms C's complaint.

With regards to Mr A's discharge, we found that it was not reasonable to discharge Mr A as he had only recently been changed from having his medicine administered intravenously (into a vein) to taking it orally, and he was still on supplemental oxygen therapy at the point of the discharge decision. The adviser was critical that these issues were not monitored further prior to Mr A's discharge. Therefore, we upheld this aspect of Ms C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs B for failing to provide a reasonable standard of medical care and treatment to Mr A during his admission and for failing to ensure that Mr A was discharged in a reasonable way. 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:

• Discussions around de-activation of internal defibrillators should occur and be documented at the same time as discussions around DNACPR. DNACPR decisions should be adequately documented and should include the reason for the decision.
• Any switch from intravenous to oral medication should be checked to be effective, supplementary oxygen should be stopped and oxygen levels should be monitored prior to discharge.

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

Summary

Mrs C complained about the care and treatment provided to her late mother (Mrs A) at Forth Valley Royal Hospital. Mrs A was admitted to the hospital following a collapse at home. During her admission, she fell and sustained serious injuries. Mrs C believed that the fall in hospital contributed to Mrs A's death a few days later, and that healthcare professionals failed to take appropriate action to minimise the risk of Mrs A falling, particularly in light of her complex medical history. Mrs C also raised concerns about complaints handling issues, including a failure to respond thoroughly and a delay.

We took independent advice from a nursing adviser who specialises in falls prevention and a medical adviser who specialises in acute medicine. We found that, while there was evidence that nursing staff had highlighted Mrs A's risk of falling and had put in place a number of interventions to address it, there were shortcomings in this. Mrs A's condition deteriorated shortly before her fall and we found that a further review of her needs should have been carried out then. We also found that, in the lead up to the fall, the amount of time that Mrs A was left on a commode with little supervision was excessive. Having said that, the advice we accepted was that the fall did not directly lead to her death. On balance, we upheld this aspect of Mrs C's complaint.

With regards to Mrs C's concerns about complaints handling, we found that the board's investigation was thorough and their position that they could not give Mrs C a definitive account of how Mrs A fell because nobody saw it was reasonable in the circumstances. However, we upheld the complaint because the time it took the board to respond to Mrs C was unreasonable.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C for failing to take all reasonable steps to minimise the risk of Mrs A falling.
• Apologise to Mrs C for failing to deal with her complaint within a reasonable timescale.

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

• All reasonable steps should be taken to minimise the risk of patients falling.

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 dental care and treatment provided to her after she was diagnosed with gum disease. She complained that the dentist did not offer to refer her to a specialist for treatment, and instead recommended that she have her teeth professionally cleaned every three months. Miss C also complained that the dentist had not taken x-rays to assess for bone loss in the four years since she was diagnosed with gum disease. Miss C felt that as a result of the dentist's ineffective treatment of her gum disease, her condition had become worse.

We took independent dental advice. We found that whilst the treatment provided by the dentist to Miss C was reasonable in some respects, we found that they had not offered Miss C the opportunity to see a specialist for her gum disease when she was first diagnosed. We also found that the dentist had failed to follow guidelines with regards to charting the progression of the gum disease. We further found that the dentist had failed to record basic periodontal examination (BPE) scores, which according to the relevant guidance should be recorded at every appointment. We also found that the dentist failed to follow good practice and take radiographs when Miss C's BPE score was four (any score of four or above is considered to require monitoring and/or treatment). On this basis, we upheld Miss C's complaint.

Miss C also complained that the dentist did not reasonably respond to her complaint. We found that the complaint response did not tell Miss C that she could bring her complaint to us if she remained dissatisfied. Therefore, we upheld this aspect of Miss C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Miss C for failing to provide her with appropriate dental care and treatment for her gum disease.
• Apologise to Miss C for failing to respond reasonably to her complaint.

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

• When appropriate, offers to refer should be made. The offer and the response should be recorded.
• Charting should be carried out annually for patients who have undergone periodontal treatment.
• BPE scoring should be undertaken at least annually for all patients, in line with guidance.
• Radiographs should be taken for patients with a BPE score of four, in line with good practice.

In relation to complaints handling, we recommended:

• Complaint responses should include details for the SPSO.

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 board unreasonably made changes to the arrangements for her to see the board's community psychiatric nursing (CPN) service. She said that her appointments with the CPN service had been changed from weekly to once every three weeks and that the appointments were held in a hospital rather than at her home. We took independent advice from a mental health nurse. We found that the board did not adequately listen to Ms C and did not take her views into account when it was decided to make these changes to her appointments. We upheld this aspect of Ms C's complaint.

Ms C also complained about the care she had received from the CPN service. We also took independent advice from a mental health nurse on this aspect of the complaint. We found that the care Ms C had received had not been of a reasonable standard. Ms C said that she had left messages on the service's answer machine, but that no one had called her back. The board's response to Ms C's complaint referred to restrictions in relation to the frequency of her phone calls, but there was no care plan or documentation within the case notes that outlined what these restrictions should be. We found that a care plan or protocol should have been in place to manage phone communication with Ms C, which could then have been followed by any member of staff. We also found that the board had failed to respond to correspondence from Ms C's GP and had failed to keep the GP adequately informed about her care. In light of these failings, 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 not adequately listening to her and for not taking into account her views when it was decided to change her CPN appointment arrangements. Also apologise for the failings in CPN 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.
• Arrange a discussion with Ms C about her needs and wishes. A care plan should be created which reflects these. A mutually suitable location for visits should also be agreed between Ms C and a member of the CPN team. If Ms C does not wish to engage with this process, a care plan should still be created to guide the interventions of the team and this should be shared with Ms C.
• The care plan referred to above should be put in place and within it there should be:
• risk assessments
• agreements on phone use and any limitations around this
• what can reasonably be expected in terms of return of any messages left for staff to ensure no misunderstanding
• the frequency and location of visits
• identification of goals
• any psychological therapies.

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

• To ensure that care is provided to a reasonable standard, the pathway and available interventions for people with Ms C's conditions should be reasonable, evidence-based and appropriate. The board should ensure that staff are implementing them appropriately.
• To ensure that care is provided to a reasonable standard, the arrangements for clinical and case load supervision of CPNs should be adequate and should enable staff to reflect upon their performance and discuss individual cases in depth.
• There should be regular and timely communication of any changes to care to relevant GPs and other health care providers who are part of the wider multi-disciplinary team.

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 contacted Revenue Scotland (RS) for clarification on whether Additional Dwelling Supplement (ADS) (a tax supplement on most purchases of additional residential properties in Scotland) would apply to him when purchasing a property. RS's initial response was that it did not apply. When Mr C was in the final stages of purchasing a property, he discovered that ADS did apply and that he would have to pay it. Mr C complained to us that RS failed to advise him of their opinion request process at the point of his first enquiry, that they failed to provide him with correct advice about the application of ADS in his situation, and that they failed to handle his complaint appropriately.

We found that RS mentioned the opinion request service to Mr C when they responded to his complaint, but that they did not inform him about it when he first contacted them asking for advice. Had they done so, he would have been able to request an opinion on the application of ADS at an earlier stage in the conveyancing procedure. We upheld this aspect of Mr C's complaint.

RS said that they do not provide advice on individual tax liability. However it was clear to us that, on this occasion, that RS had done this. Their response to Mr C's first enquiry clearly stated that ADS did not apply to him. This response to Mr C did not ask him for any further detail, did not indicate that Mr C could not rely on the accuracy of this response, did not ask him for any further detail, and did not signpost him to the opinion request service or refer him to his solicitors. As such, we found that RS had provided Mr C with inaccurate advice, and we upheld this aspect of his complaint.

We found that RS's response to Mr C's complaint did not adequately address the financial implications that their failure to give correct advice had had on him. Whilst organisations are entitled to reach their own conclusions on complaints following consideration of the available evidence, the conclusions should be reasonably supported by the evidence. In this case, we found that it was not reasonable for RS to conclude that the evidence did not support Mr C's complaint, at least in part. We upheld this aspect of Mr C's complaint.

We noted that RS had already taken action to ensure that the opinion request service is now referenced in all responses sent out, and that they had undertaken work with their staff to ensure that their responses to enquiries are now consistent with the position that they do not provide advice on individual tax liability. We also found that RS had apologised to Mr C more than once for their failings. As such, we did not make any further recommendations with regards to these aspects of Mr C's complaint.

RS told us that they have no discretion over whether to charge ADS, and that there is no legal mechanism under which they can waive or repay tax which is legally due. We accept this is the case. However, given that Mr C suffered financial detriment because of the inaccurate advice they provided to him, we made a recommendation to address this point.

Recommendations

What we asked the organisation to do in this case:

• Make a payment to Mr C as redress for the unanticipated financial loss he suffered as a result of their incorrect advice. The payment should be made by the date we have indicated. If payment is not made by that date, interest should be paid at the standard interest rate applied by the courts from that date to the date of payment.

In relation to complaints handling, we recommended:

• Complaint investigation decisions should be supported by, and make reference to, the available relevant evidence.

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 council's failure to empty her communal food waste bins and their failure to investigate her complaint.

Ms C told us that the communal bins were overflowing and that there was no bin liner in the bin. The problem continued to persist for a long time and Ms C tried to raise a formal complaint with the council. The council did not provide Ms C with a final response to her complaint.

We found that the council failed to empty the communal food waste bins on numerous occasions over a protracted length of time. We also found that the council failed to thoroughly investigate Ms C's complaint and failed to provide a satisfactory response for their failings. We upheld Ms C's complaints.

The council told us that they had been in touch with Ms C regularly to ensure that the service was now satisfactory. We asked for evidence of this and did not make any further recommendations regarding bin pick-ups. However, we did make recommendations regarding the handling of Ms C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Write to Ms C to apologise for failing to investigate her complaint in line with their procedures. They should provide an explanation for their failings.

In relation to complaints handling, we recommended:

• Complaints handling staff should be reminded of 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.