Highlands and Islands

  • Report no:
    202105473
  • Date:
    November 2022
  • Body:
    Highland NHS Board
  • Sector:
    Health

The complainant (C) complained to my office about the care and treatment provided during the period January 2018 to September 2021. In January 2018 C underwent emergency surgery for a perforated sigmoid diverticulum (a complication of diverticulitis, an infection or inflammation of pouches that can form in the intestines). An emergency Hartmann's procedure (a surgical procedure for the removal of a section of the bowel and the formation of a stoma - an opening in the bowel) was performed. In April 2018, C was seen in an outpatient clinic and informed it would be possible to have a stoma reversal.

C complained that the Board had continually delayed the stoma reversal surgery which they required, which as of September 2021 had not taken place. C also complained that COVID-19 could not account for the delays between the Board informing C they were ready for surgery around December 2018 and the start of the pandemic in March 2020. C noted that as a consequence they had developed significant complications: a large hernia. C added that this had severely impacted their personal life and self-esteem, and left them unable to work and reliant on welfare benefits.

The Board apologised that C had experienced delays waiting for their operation. They explained that despite a positive reintroduction of surgery in June 2021, they were required to significantly reduce elective surgical activity as COVID-19 patients again increased. C was said to be at the top of the list for their surgery, however, C would require two consultants to perform a joint procedure. They added that there were limited high dependency beds available, necessary for C's post-operative care, causing further delay. The Board were therefore unable to offer a definitive timescale for C's surgery.

I sought independent advice from a consultant general and colorectal surgeon (the Adviser). The Adviser told me that it was unreasonable for C to have waited eight months between being seen in an outpatient clinic in April 2018 and having a flexible sigmoidoscopy (a non-surgical examination) in December 2018. The Adviser considered that this delay had been due to C having been unnecessarily placed on a 'named person list' requiring a specific consultant to carry out what was a routine investigation. The Adviser also noted that it was a further year before C was placed on the waiting list for surgery and that it appeared that there was no monitoring of C's timeline during this period. Lastly, the Adviser told me that there appeared to have been insufficient priority given to C's treatment post-pandemic. In conclusion, the Adviser said that the delays were unreasonable and noted that as a consequence C required more complex, demanding, and risky surgery.

In light of the evidence I have seen and the advice received, I found that: the Board unreasonably delayed performing a reversal of Hartmann's procedure. As such, I upheld C's complaint. I was also critical of the Board's own investigation of C's complaint. During the course of my investigation, in June 2022, C underwent surgery to reverse the Hartmann's procedure and repair the hernia.

 

Redress and Recommendations 

The Ombudsman's recommendations are set out below:

What we are asking the Board to do for C:

What we found

What the organisation should do

What we need to see

The length of time C waited for a flexible sigmoidoscopy to be carried out was unreasonable.

The use of a 'named person' list led to an unreasonable delay in carrying out a flexible sigmoidoscopy.

The length of time C waited to be seen at an outpatient clinic in January 2020 to discuss surgery following a flexible sigmoidoscopy was unreasonable.

The length of time C waited for their planned surgery was unreasonable.

There was a failure in complaint handling by the Board in relation to C's complaint.

Apologise to C for the failings identified.

The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

A copy or record of the apology.

By: 23 December 2022

We are asking the Board to improve the way they do things:

What we found

Outcome needed

What we need to see
The length of time C waited for a flexible sigmoidoscopy to be carried out was unreasonable. Patients awaiting elective surgery, particularly flexible sigmoidoscopy/endoscopy should have treatment carried out as soon as possible and where clinically necessary the patient's care should be prioritised.

Evidence that the Board have reviewed the systems they have in place for the management and prioritisation of patients awaiting elective surgery, particularly in relation to the endoscopy service to ensure that they are both appropriate and effectively managed.

By: 23 February 2023

 
The use of a 'named person' list led to an unreasonable delay in carrying out a flexible sigmoidoscopy. Patients requiring flexible sigmoidoscopy/endoscopy should be added to the most appropriate waiting list for this type of treatment.

Evidence that the Board have carried out a review of the use of a named person's list in relation to the endoscopy service.

By: 23 January 2023

Evidence of any actions or changes taken or planned as a result, with timescales if part of an ongoing action plan.

By: 23 February 2023
The length of time C waited to be seen at an outpatient clinic in January 2020 to discuss surgery following a flexible sigmoidoscopy was unreasonable. Patients should be followed up at outpatient clinic appointments following flexible sigmoidoscopy/endoscopy within a reasonable timeframe.

Evidence that the Board have reviewed their arrangements for administering and monitoring the waiting list for outpatient clinic appointments in particular in relation to the endoscopy service, to ensure future delays such as this are avoided with a note of any actions or changes as a result.

By: 23 February 2023
The length of time C waited for their planned surgery was unreasonable. A clear treatment path should be in place for patients whose surgery is delayed that is based on current recognised prioritisation criteria.

Evidence that my findings have been shared with relevant staff in a supportive manner that encourages learning, including reference to what that learning is (e.g. a record of a meeting with staff; or feedback given at one to-one sessions).

By: 23 January 2023

 We are asking the Board to improve their complaints handling:

What we found

Outcome needed

What we need to see

The Board's own complaint investigation was of poor quality and did not address all of the issues raised by C in their complaint to them.

The Board failed to address and acknowledge the significant and unreasonable delays in C's care and treatment, which occurred during the period before the COVID-19 pandemic started.

The Board's complaint handling monitoring and governance system should ensure that failings (and good practice) are identified; and that learning from complaints is used to drive service development and improvement.

The Board should comply with their complaint handling guidance when investigating and responding to complaints.

Evidence that these findings have been fed back to relevant staff in a supportive manner that encourages learning, including reference to what that learning is (e.g. a record of a meeting with staff; or feedback given at one to-one sessions).

By: 23 January 2023

 

 

Related reading

  • Report no:
    201901343
  • Date:
    August 2020
  • Body:
    Highland NHS Board
  • Sector:
    Health

Ms C complained about the care and treatment her late father (Mr A) received at Raigmore Hospital after he died unexpectedly following elective knee surgery. Ms C also complained about Highland NHS Board's investigation of her complaint.

The Board's investigation of Ms C's complaint did not identify any failings in Mr A's care. We took independent advice from a consultant trauma and orthopaedic surgeon. We found that Mr A's symptoms prior to discharge were not appropriately acted on. Had they been, there is a possibility that other specialities could have been called in to assess and assist. However, we could not say whether this would have affected Mr A's outcome. We concluded that Mr A's postoperative care and treatment was of an unreasonable standard and upheld the complaint.

In terms of the consent process for Mr A's surgery, we were also critical that there was no record to demonstrate that all the specific recognised risks of a total knee replacement surgery were covered sufficiently during a clinic consultation. We concluded that this is contrary to national guidance on consent and was unreasonable.

We also found that the Board's investigation and response to Ms C's complaint contained inaccurate information; did not reasonably address all the concerns Ms C raised; and did not reasonably identify and address the failings in Mr A's care. The letter concentrated mainly on the opinion as to the cause of Mr A's death rather than systematically addressing the points Ms C had written in her complaints form. We concluded that the response to Ms C's complaint was not compliant with the NHS Complaints Handling Procedure (NHS CHP) because the investigation and response should have been more comprehensive, clearer and easier to understand. We upheld the complaint.

 

Redress and Recommendations

The Ombudsman's recommendations are set out below:

What we are asking the Board to do for Ms C:

Complaint number

What we found

What the organisation should do

What we need to see
(a)

There was an unreasonable failure to act upon Mr A's acute kidney injury and episodes of vomiting;

there was an unreasonable failure to demonstrate that all the recognised risks of total knee replacement surgery were covered sufficiently during the consultation on 30 January 2018; and

the Board's investigation and response to Ms C's complaint contained inaccurate information; did not reasonably address all the concerns Ms C raised; and did not reasonably identify and address the failings in Mr A's care

 

Apologise to Ms C and the family for failing to:

  • act upon Mr A's acute kidney injury and episodes of vomiting;
  • demonstrate that all the recognised risks of total knee replacement surgery had been fully explained to Mr A; and
  • provide accurate information in their complaint response to Ms C, address all the concerns Ms C raised, and identify and address the failings in Mr A's care

 

 

A copy or record of the apology.

By: 16 September 2020

 

We are asking the Board to improve the way they do things:

Complaint number

What we found

Outcome needed

What we need to see
(a)

The fluid balance chart was discontinued despite there being a significant fluid imbalance and an acute kidney injury having been identified;

the acute kidney injury was not acted upon (no intravenous infusion was given and no repeat blood testing carried out); and

no physical examination was performed prior to discharge

 

 

Patients with acute kidney injury should have their symptoms acted on and managed in line with relevant standards and guidance, where appropriate

Evidence that:

  • these findings have been shared with all relevant staff involved in Mr A's care in a supportive manner that encourages learning (e.g. a record of a meeting with staff; or feedback given at one-to-one sessions); and
  • there is a standard operating procedure for the management of acute kidney injury and ensure it is included in junior doctor induction.

By: 11 November 2020

 

 
(a) The orthopaedic team did not seek assistance regarding the acute kidney injury from other specialities Patients should receive appropriate medical review for their symptoms

Evidence to:

  • demonstrate that these findings have been shared with the surgical staff involved in Mr A's care in a supportive manner that encourages learning (e.g. a record of a meeting with staff; or feedback given at one-to-one sessions); and
  • demonstrate how junior doctors are supported on the surgical ward.

By: 11 November 2020
(a) There was an unreasonable failure to demonstrate that all the recognised risks of total knee replacement surgery were covered sufficiently during the consultation on 30 January 2018 Patients should be fully advised of all material risks of total knee replacement surgery and the discussion should be clearly recorded, in accordance with the Royal College of Surgeons standard

Evidence that:

  • surgical staff undertaking total knee replacement surgery have been reminded of the requirement to obtain informed consent in line with relevant standards and guidance; and
  • the consent form has been reviewed to ensure there is a section on the template to clearly capture material risks of the proposed procedure.

The SPSO thematic report on informed consent may assist in encouraging learning for staff in this area:

https://www.spso.org.uk/thematicreports

By: 11 November 2020

We are asking the Board to improve their complaints handling:

Complaint number

What we found

Outcome needed

What we need to see
(b)

The Board's investigation and response to Ms C's complaint contained inaccurate information; did not reasonably address all the concerns Ms C raised; and did not reasonably identify and address the failings in Mr A's care

The Board's complaint handling and governance systems should ensure that complaints are investigated and responded to in accordance with the NHS CHP. They should ensure that failings (and good practice) are identified; and that learning from complaints is used to drive service development and improvement

Evidence that:

  • these findings have been shared with complaint handling staff (both clinical and non-clinical) in a supportive manner that encourages learning (e.g. a record of a meeting with staff; or feedback given at one-toone sessions); and
  • the Board have reviewed why its own investigation into the complaint did not identify or acknowledge all the failings highlighted here and any learning they have identified.

By: 11 November 2020

Feedback

Points to note 

As well as the recommendation above to ensure there is a standard operating procedure for the management of acute kidney injury and to include this in junior doctor induction, the Board may wish to consider the placement of ward posters informing others about the issue.

Related reading

  • Report no:
    201707281
  • Date:
    August 2020
  • Body:
    The Moray Council
  • Sector:
    Local Government

Summary

Ms C complained on behalf of Mrs A, about Moray Council (the Council) Children and Families social work department. Mrs A's two children, Child Y and Child Z, were removed from Mrs A's care in September 2016 as a result of a Child Protection Order (an emergency legal order granted by a Sheriff which allows the local authority to remove a child from their parent's care). Ms C complained that the Council unreasonably failed to gather and take into account relevant information when making decisions regarding the children's care and education, both before and after the children were removed from Mrs A's care and placed into accommodation.

During our investigation, we took independent advice from a social worker (the Adviser). We identified the following failings: 

  • Prior to the children being accommodated:
    • little or no evidence of exploring parenting style, family or other supports; or questioning and challenging what was observed;
    • little or no evidence of clear assessments of risk and need;
    • little evidence of the Getting It Right For Every Child practice model (GIRFEC; the Scottish Government's approach to supporting children and young people) being utilised, including a robust, multi-agency assessment; and
    • failure to make attempts to engage the family in supporting the prevention of a breakdown in the family or to provide kinship care as a means of preventing statutory care.
  • Following the children being accommodated:
    • failure to consider and arrange independent advocacy for the children in a timely manner; 
    • in the absence of independent advocacy, failure to explore ways of communicating with the children to elicit their views and feelings;
    • failure to include the views and feelings of the children in many reports;
    • failure to facilitate Child Y attending their hearings when Child Y voiced their wish to attend;
    • when Child Y changed their story about allegations made, it appeared that the allegations were given less weight and there was not enough understanding of the way in which children and young people may retract their stories. Rehabilitation with the children's father (Mr A) went ahead without this being resolved or there being more clarity on the risks and safeguards in place;
    • failure to reasonably consider and assess potential kinship placements and follow national guidance and legislation in relation to kinship care assessments;
    • failure to communicate in a reasonable and timely way with extended family in relation to kinship care;
    • no evidence that Child Z's views were obtained in relation to moving school; or that Child Z or the new school were prepared for the transition;
    • failure to promote or encourage extended family relationships;
    • failure to inform Mr & Mrs A of Child Z's admission to hospital shortly after they were accommodated; and
    • failure to complete a number of Looked After Child forms which should have been completed at the point of the children being accommodated, in a timely manner.

Given these numerous and significant failings, we upheld the complaint and made a number of recommendations to address these failings.

Ms C also complained that the Council failed to handle complaints raised by herself and Mrs A in a reasonable and timely manner. We acknowledged that the complaint was complex, involved correspondence from a number of different people, some of which had overlapping issues, and that there were concurrent information requests. The Council had taken some action to address their complaint handling failings. However, we considered that it remained that much of the handling of Ms C and Mrs A's complaints was unreasonable and we did not consider the action previously taken by the Council to address all of the complaint handling failings. We therefore upheld this aspect of Ms C's complaint.

 

Redress and Recommendations

The Ombudsman's recommendations are set out below:

What we are asking the Council to do for Ms C and Mrs A:

Rec. number

What we found

What the organisation should do

What we need to see
1.

Under complaint (a) we found that the Council unreasonably failed to gather and take into account relevant information when making decisions regarding the children's care and education. (The individual failings are listed below.)

Under complaint (b) we found that the Council failed to deal with complaints raised by Mrs A and Ms C in a reasonable and timeous manner

Apologise to Mrs A, Child Y and Child Z for the failure to reasonably gather and take into account relevant information when making decisions regarding the children's care and education.

Apologise to Mrs A and Ms C for the failure to reasonably and timeously respond to their complaints.

The apologies should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/informationleaflets

Copy or record of the apologies.

By: 16 September 2020

We are asking the Council to improve the way they do things:

Rec. number

What we found

Outcome needed

What we need to see
2.

Under complaint (a) we found that there was no clear use of the Getting It Right For Every Child practice model being applied (including appropriate multi-agency and risk assessments) when recording the concerns highlighted in the months prior to the children's admission to care; which would have assisted practitioners to identify the cumulative concerns and collated information from other agencies

 

The Council's child protection function should be delivered within the context of supporting families and meeting children's needs through the Getting It Right For Every Child practice model as stated in the National Guidance for Child Protection In Scotland and the Children and Young People (Scotland) Act 2014

 

 

Evidence that the findings of this investigation have been fed back to relevant staff in a supportive manner that encourages learning.

Evidence that the Council have considered any training needs for social work staff in relation to the Getting It Right For Every Child practice model and child protection. The Council may wish to consider using this case as a training tool.

Evidence that the Council have reviewed their Child Protection guidance to ensure it takes into account the Getting It Right For Every Child practice model and the relevant legislation in relation to supporting families and meeting children's needs.

By: 9 December 2020
3. Under complaint (a) we found that there was a failure to engage the extended family in supporting the prevention of a breakdown in the family or to provide kinship care as a means of preventing statutory care In line with the Children (Scotland) Act 1995, the Council should promote the upbringing of children by their families and the possibility of kinship care placements should be considered at the earliest opportunity and if this is not possible, the reasons should be recorded

Evidence that the findings of this investigation have been fed back to relevant staff in a supportive manner that encourages learning.

Evidence that there is appropriate policy and guidance in place to ensure that the possibility of kinship care placements are considered at the earliest opportunity.

By: 9 December 2020
4. Under complaint (a) we found that there was both an absence and delay in properly seeking the views of the children, including by use of independent advocacy, and including these views in the relevant plans and paperwork The views of children should be sought in line with the Getting It Right For Every Child Framework and as laid down in the Children (Scotland) Act 1995 and the Children and Young People (Scotland) Act 2014. The views of children should be listened to, considered and recorded; and independent advocacy should be considered for children in a timely manner

Evidence that social workers have been reminded of the importance of recording children's views appropriately and considering the use of independent advocacy.

Evidence that the Council have considered any training needs for social work staff in relation to seeking and including children's views.

Evidence of an audit being carried out of Looked After Child and Child Protection paperwork, and Child's Plans, to ensure that children's views are being sought and included appropriately.

By: 9 December 2020
5. Under complaint (a) we found that there was a failure to facilitate Child Y attending their hearings when Child Y voiced their wish to attend If a child expresses a wish to attend their Children's Hearing, they should be facilitated to attend, regardless of whether they have previously been excused; in line with national guidance

Evidence that social workers have been reminded of a child's absolute right to attend their hearings; and of their responsibility to facilitate this if a child has expressed a wish to attend.

Evidence that the Council have considered any training needs for staff in relation to their responsibilities to facilitate children to attend their hearings.

By: 9 December 2020
6. Under complaint (a) we found that the timescales to complete the kinship care assessments were considerably outwith the recommended timescales laid down by the statutory guidance Timescales for kinship care assessments should be in line with the Looked After Children (Scotland) Regulations 2009 and the Adoption (Scotland) Act 2007 - Part 9 Kinship Care unless the reasons as to why this is not possible are specifically recorded

Evidence that the Council's policy and procedures on kinship care assessments are in line with the timescales in statutory guidance.

Evidence that social work staff at the Council have been reminded of the guidance in relation to kinship care assessments.

Evidence that there is a system in place to monitor timescales for kinship care assessment and management action taken to address when timescales are not being adhered to.

By: 9 December 2020
7. Under complaint (a) we found that communication with the extended family regarding consideration and assessment of kinship care placements was delayed, unclear, and not proactive Communication with extended family in relation to potential kinship care placements should be proactive, clear, and timely

Evidence that the findings of this investigation in relation to communication with extended family members have been fed back to relevant staff in a supportive manner that encourages learning.

By: 9 December 2020
8. Under complaint (a) we found that Child Z moved school without any proper sharing of information and preparation and the decision was made outwith a Looked After Child review and prior to a Children's Hearing, without reasonable evidence that this was warranted Prior to any decision that brings about a change to the child's plan, or before a decision to seek a Children's Hearing for a child whose supervision order they think should be varied or terminated, a Looked After Child review should be held

Evidence that social workers have been reminded that significant decisions concerning a child should not be made outwith a formal review.

Evidence of an audit to ensure Looked After Child reviews are being held appropriately.

By: 9 December 2020
9. Under complaint (a) we found that when Child Z moved school, the new school were not notified of the background and did not learn of the involvement of other agencies until they received the child's educational file some time later When a child who has social work involvement moves school, the new school should be informed of this in a timely manner in line with the Getting It Right For Every Child national framework principles of working collaboratively with the child at the centre

Evidence that the findings of this investigation in relation to the Getting It Right For Every Child national framework principles of working collaboratively with the child at the centre have been fed back to the relevant staff in a supportive manner which encourages learning.

By: 9 December 2020
10. Under complaint (a) we found that the records evidence that the attitude of social work was at times judgemental and based on pejorative personal opinions Social workers should avoid making statements based on assumptions and pejorative personal opinion

Evidence that the findings of this investigation in relation to record-keeping and attitude towards families have been fed back to relevant staff in a supportive manner that encourages learning.

By: 9 December 2020
11. Under complaint (a) we found that the parents were not notified that their child was admitted to hospital despite still having parental responsibilities and rights Parents with parental rights and responsibilities should, as far as possible, be consulted prior to medical treatment or in cases of an emergency admission be notified as soon as possible, in line with the Children (Scotland) Act 1995

Evidence that social workers have been reminded of and understand their legal obligations in respect of children and parents.

By: 9 December 2020
12. Under complaint (a) we found that although Child Z moved to a new local authority area, a letter to the authority informing them that Child Z was living there and requesting a transfer Child Protection Case Conference was not sent until three weeks after they moved. This was outwith guidance and also caused the receiving local authority to be outwith the timeframe for holding the Child Protection Case Conference The Council should adhere to the National Guidance for Child Protection in Scotland in relation to notifying the receiving local authority immediately when children and/or their family move

Evidence that social workers have been reminded of their obligations under the National Guidance for Child Protection in Scotland.

Evidence that the Council's procedures and guidelines meet the National Guidance for Child Protection in Scotland standards.

By: 9 December 2020
13. Under complaint (a) we found that Looked After Child forms, including a general medical consent form, were not completed at the point of admission to care and there was a delay of almost four weeks following accommodation The relevant Looked After Child forms, including general medical consent, should be completed at the point of a child being admitted to the care of the local authority, or in cases of emergency, as soon as is practicably possible after the child is placed; in line with The Looked After Children (Scotland) Regulations 2009

Evidence of an audit to ensure that Looked After Child forms are completed prior to or at the point of a child being accommodated.

By: 9 December 2020
14. Under complaint (a) we found that there were numerous and significant failings in relation to gathering and taking into account relevant information when making decisions regarding the children's care and education When making decisions regarding the care and education of children, the Council should appropriately gather and take into account relevant information

Evidence that the findings of this investigation have been reviewed in full by a senior member of staff at the Council and that they are satisfied that all failings have been addressed by the recommendations above or actions already taken by the Council. If they are not, an action plan should be devised to ensure that all issues are addressed appropriately and fully.

By: 9 December 2020

We are asking the Council to improve their complaints handling:

Rec. number

What we found

Outcome needed

What we need to see
15.

Under complaint (b) we found that there were serious and significant failures in relation to complaints handling

 

Complaints should be handled in line with the relevant complaint handling procedure

 

 

Evidence that the Council have carried out a review into the handling of this complaint, identified where improvement action (such as training) is required, and developed an action plan to improve complaint handling.

By: 9 December 2020

 

Feedback

Points to note

The Adviser noted that there was a regular programme of supervised contact with both parents, but commented that, in their view, the timetable of contact placed a heavy burden on the children as on occasion they were having two contact visits a day, one with each parent and some that included extended family. The Adviser acknowledged that it is always a difficult balance to ensure there is sufficient contact but also that it is relaxed and comfortable to promote a good experience and build relationships. However, they considered the contact plan, while demonstrating a regular arrangement, was a demanding one for everyone, not least the children. The Council may wish to reflect on this matter.

Related reading

  • Report no:
    201811019
  • Date:
    April 2020
  • Body:
    The Moray Council
  • Sector:
    Local Government

Summary

Ms C complained to my office on behalf of her son, Mr A, about the care and support provided to Mr A by the Council. Mr A was a Looked After Child under Section 25 of the Children (Scotland) Act 1995 (a child who is looked after by the local authority as part of a voluntary arrangement). In September 2015, Mr A moved to a residential school placement outwith the Moray area. In June 2019, the Education component of Mr A’s placement ended following his eighteenth birthday. The Council then transitioned Mr A from Children’s to Adult Social Work Services. Adult Services agreed to financially support Mr A to remain in the residential placement for one year until June 2020 or until an appropriate resource was found in the Moray area.

Ms C is concerned that the Council have not fulfilled their responsibility to provide her son’s residential placement under Continuing Care (the local authority’s duty to provide the same accommodation and other assistance as was being provided by the local authority, immediately before the young person ceased to be looked after).

We took independent advice from a social work adviser. We found that:

  • the Council failed to begin transition planning for Mr A at least 3 years before he was due to leave school;
  • the Council failed to carry out a pathway assessment prior to making the decision that Continuing Care was not available to Mr A and prior to transitioning Mr A to Adult services; the Council did not take reasonable steps to ensure that Mr A could make informed choices. In particular:
    • there is no evidence in the records that Mr A was given concrete examples of the type of care he might be offered or that he was taken to see possible care settings;
    • a recommendation made at a Looked After Child Review in January 2018 to offer Mr A independent advocacy was not actioned until over a year later.

In view of these failings, we upheld Ms C’s complaint that the Council failed to act reasonably regarding Mr A’s care and support.

Ms C also complained about the Council’s communication with her about her son’s care and support. Following advice from a social work adviser, we found that:

  • the Council largely engaged with Ms C via email rather than holding meetings outwith the formal Looked After Child Review process;
  • an invite to a Looked After Child Review was sent three days before the Review was due to take place;
  • there was a delay in the Looked After Child Review minutes being available and there was a delay in these being sent to Ms C;
  • Ms C was not provided with information on how to make a Continuing Care request when she requested this.

In light of these findings, we upheld Ms C’s complaint that the Council failed to communicate reasonably with her.

Lastly, Ms C complained about how the Council handled her complaint. We found that there was an unreasonable delay in Ms C receiving a response to her complaint and the Council’s complaint response had been copied directly from an email that had been sent to Ms C before she submitted her complaint.  There was no evidence that the Council had investigated Ms C’s complaints, and the Council’s complaint response did not address all the complaints that Ms C made to the Council or indicate whether her complaints were upheld or not upheld. In view of these significant failings, we upheld Ms C’s complaint that the Council had failed to handle her complaint reasonably.

 

Redress and Recommendations

The Ombudsman's recommendations are set out below:

What we are asking the Council to do for Ms C and Mr A:

Rec. number

What we found

What the organisation should do

What we need to see
1.

Under complaint (a) we found that:

  • the Council failed to begin transition planning for Mr A at least three years before he was due to leave school.
  • the Council failed to carry out a pathway assessment prior to making the decision that Continuing Care was not available to Mr A and prior to transitioning Mr A to Adult Services.
  • the Council did not take reasonable steps to ensure that Mr A could make informed choices. In particular:
    • there is no evidence in the records that Mr A was given concrete examples of the type of care he might be offered or that he was taken to see possible care settings.
    • a recommendation made at a Looked After Child Review in January 2018 to offer Mr A independent advocacy was not actioned until over a year later.

Under complaint (b) we found that the communication with Ms C was unreasonable. In particular:

  • the Council largely engaged with Ms C via email rather than holding meetings outwith the formal Looked After Child Review process.
  • an invite to a Looked After Child Review was sent three days before the Review was due to take place.
  • there was a delay in the Looked After Child Review minutes being available and there was a delay in these being sent to Ms C.
  • Ms C was not provided with information on how to make a Continuing Care request when she requested this.

Under complaint (c) we found that:

  • there was an unreasonable delay in Ms C receiving a complaint response.
  • the Council’s complaint response was copied directly from an email that had been sent to Ms C before she submitted her complaint.
  • there was no evidence that the Council had investigated Ms C’s complaints.
  • the Council’s complaint response did not address all the complaints that Ms C made to the Council or indicate whether her complaints were upheld or not upheld.

Apologise to Ms C and Mr A for:

  • failing to begin transition planning for Mr A at least three years before he was due to leave school.
  • failing to carry out a pathway assessment prior to making the decision that Continuing Care was not available to Mr A and prior to transitioning Mr A to Adult Services.
  • failing to communicate reasonably with Ms C about her son’s care and support.
  • failing to handle her complaint reasonably.

The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/informationleaflets

A copy or record of the apology.

By: 20 May 2020
2. Under complaint (a) we found that the Council failed to act in line with their ordinary residence policy when they indicated that all out of area children have to move back to the Moray area as the basis for only providing funding for Mr A to remain in the residential placement for one year. Consider whether it would be appropriate to fund Mr A to remain in the residential placement until he is 21 years of age or whether this could be achieved through Self-Directed Support.

Evidence that the Council have considered funding Mr A’s residential placement until he is 21 years of age or whether this could be achieved through Self-Directed Support, taking into account the findings of this investigation, discussing the matter with Ms C and providing Ms C with full reasons for any decisions reached.

By: 20 May 2020

We are asking the Council to improve the way they do things:

Rec. number

What we found

Outcome needed

What we need to see
3.

Under complaint (a) we found that the Council failed to begin transition planning for Mr A at least three years before he was due to leave school.

Where a young person has significant additional support needs, transition planning should begin at least three years before a young person is due to leave school.

 

 

Evidence that the findings on these complaints have been fed back to relevant staff in a supportive way (e.g. a record of a meeting with staff; or feedback given at one-to-one sessions).

Evidence that the Council have considered any training needs for social work staff in relation to transition planning.

By: 22 October 2020
4. Under complaint (a) we found that the Council failed to carry out a pathway assessment in line with their Transition to Adult Services Policy prior to making the decision that Continuing Care was not available to Mr A. Where a young person is approaching adulthood, a pathways assessment should also be carried out to assess throughcare and aftercare options (including an assessment of whether it is in the young person’s best interests to remain in their current placement under Continuing Care rather than transitioning to Adult Services) with the input of the young person, their parents/guardians, Adult Services and any other interested agencies.

Evidence that the findings on these complaints have been fed back to relevant staff in a supportive way (e.g. a record of a meeting with staff; or feedback given at one-to-one sessions).

Evidence that the Council have considered any training needs for social work staff in relation to pathways assessments, Continuing Care and Ordinary Residence.

Evidence that the Council have reviewed their Continuing Care Procedure taking into account Mr A’s case and the legislative framework.

By: 22 October 2020
5.

Under complaint (a) we found that the Council did not take reasonable steps to ensure that Mr A could make informed choices. In particular:

  • there is no evidence in the records that Mr A was given concrete examples of the type of care he might be offered or that he was taken to see possible care settings.
  • a recommendation made at a Looked After Child Review in January 2018 to offer Mr A independent advocacy was not actioned until over a year later.

Looked After Children with complex needs should be given examples of the type of care they might be offered and be taken to see possible care settings.

Where a recommendation has been made to offer a Looked After Child independent advocacy, this should be acted on timeously.

Evidence that the findings on these complaints have been fed back to relevant staff in a supportive way (e.g. a record of a meeting with staff; or feedback given at one-to-one sessions).

Evidence that the Council have considered any training needs for social work staff in relation to making sure that Looked After Children with complex needs can make informed choices.

By: 22 October 2020
6. Under complaint (b) we found that the Council largely engaged with Ms C via email rather than holding meetings outwith the formal Looked After Child Review process. The Council should engage in a meaningful way, including holding meetings with parents/guardians, outwith the formal Looked After Child Review process, when planning the future care for Looked After Children with complex needs.

Evidence that the findings on these complaints have been fed back to relevant staff in a supportive way (e.g. a record of a meeting with staff; or feedback given at one-to-one sessions).

By: 22 October 2020
7. Under complaint (b) we found that Ms C was not provided with information on how to make a Continuing Care request when she requested this. Information on how to make a Continuing Care request should be provided to individuals when they request it.

Evidence that the findings on these complaints have been fed back to relevant staff in a supportive way (e.g. a record of a meeting with staff; or feedback given at one-to-one sessions).

By: 22 October 2020
8.

Under complaint (b) we found that:

  • an invite to a Looked After Child Review was sent three days before the Review was due to take place.
  • there was a delay in the Looked After Child Review minutes being available and there was a delay in these being sent to Ms C.

Invites to Looked After Child Reviews should be distributed in a timely way.

Minutes of Looked After Child Review should be typed up and distributed in a timely way.

Evidence that the Council have a system in place to timeously:

  • distribute invites to Looked After Child Reviews.
  • type up and distribute minutes of Looked After Child Reviews.

By: 22 October 2020

We are asking the Council to improve their complaints handling:

Rec. number

What we found

Outcome needed

What we need to see
9

Under complaint (c) we found that:

  • there was an unreasonable delay in Ms C receiving a complaint response.
  • the Council’s complaint response was copied directly from an email that had been sent to Ms C before she submitted her complaint.
  • there was no evidence that the Council had investigated Ms C’s complaints.
  • the Council’s complaint response did not address all the complaints that Ms C made to the Council or indicate whether her complaints were upheld or not upheld.

The necessary systems should be in place to ensure that complaints are handled in line with the Moray Council’s complaint handling procedure and the Model Complaints Handling Procedure and that all staff responsible for dealing with complaints should be aware of their responsibilities in this respect.

Evidence that the findings on these complaints have been fed back to relevant staff in a supportive way (e.g. a record of a meeting with staff; or feedback given at one-to-one sessions).

Evidence that the Council’s systems demonstrate senior level/governance responsibility for complaint handling.

By: 22 October 2020

Feedback

Points to note:

I note that the Ordinary Residence Policy and Procedure on the Council’s website appears to be out of date. The SPSO appear to have been provided with the most up to date copy of this policy and procedure. The Council may wish to consider updating this on their website.

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