Health

ScottishPublicServicesOmbudsman S P S O CO M P L A I N T S R E P O RT 2013 – 14

This is one of a series of reports throughwhich we arecontinuing to put keymessages, information and analysis ofcomplaints about the health sector into the public domain.

We expect health boards to use this report to enhance theirlearning about the issues the public bring us about the NHS inScotland and about the quality of their complaints handling.We anticipate that Parliamentary committees, governmentdepartments, regulators and other improvement and scrutinybodies will use it to identify issues arising from the complaintswe see.

Equally, we hope it will prove useful tomembers of the public,and advice and advocacy groups that represent them, byproviding information about the kinds of complaints that areescalated to the SPSO, howwe handle them, and howwe putthings right though our recommendations, where we can.

October 2014

Contents

Ombudsman’s introduction 4

Casework 6

Impact 17

Case studies 20

Improving complaints standards 25

Policy and engagement 28

Health cases determined 2013/14 30

Ombudsman’sintroduction

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Building amore responsiveNHS:impact and jointworkingWhile I think this officemakes a difference in all thepublic service areaswe take complaints about, I thinkour impact is clearest in the health sector. Thesecomplaints are frequently serious and oftenharrowing. Theymay have caused significant distressbecause of a death or the poor treatment and care ofthe personwho has complained or their loved one.Peoplewho raise concerns about theway they orsomeone else felt theywere treated by theNHS are,understandably, highlymotivated tomake sure thatlessons are learned. Theywant action to be taken toensure that the same thing does not happen toanyone else.

The way we ensure that this happens whenwe find things have gone wrong is through ourrecommendations for redress and improvement.Wemade 684 recommendations to health boardslast year, well over half the total of all therecommendations wemade.

The case studies in this report give an idea of thekinds of recommendationswemake.We oftenask boards to apologise for failings, and somerecommendations gomuchwider, such as askingthem to review or change a policy, or to carry outstaff training or awareness raising.We publiciseasmany investigations aswe can, alongwith ourrecommendations, so that health boards andothers can learn fromour findings and use themto improve services.

This past year, I have been pleased to see howour work is contributing to themany initiativesunderway in Scotland to create amoreperson-centredNHS. 2013/14 saw a furtherstrengthening of our relationships with otherscrutiny and improvement bodies such as theScottish Health Council, Healthcare ImprovementScotland andNHS Education for Scotland. I welcomesuch partnership, and am confident that working intandemwith these organisations and others willhelp to ensure that the NHS in Scotland has thetools it needs to continuously improve.

I am particularly pleased that the Scottish HealthCouncil have recommended that our ComplaintsStandards Authority lead on developing amoresuccinctly modelled, standardised and person-centred complaints process for NHS Scotland.This builds on our successful work in developingstandardised complaints handling procedures forother public sector areas in Scotland and we lookforward to taking this work forward, along withother SPSO-related recommendations.

Volumes and issuesFirst, the numbers:> we received 1,379 complaints about the NHS

(almost 31% of our caseload)> this was 11.5%more complaints than last year> the rate of upheld complaints was 55%,

up from 52%> the rate of complaints coming to us too early

dropped again from 30% to 26%The issues people brought us were similar toprevious years, with GP and hospital servicestopping the list. Prison healthcare complaintsmoved up to third place, and complaints aboutdental and orthodontic services dropped. Therewas a large increase in the number of complaintsreaching us about clinical treatment and diagnosis,which is not surprising given that this is the keyservice provided by the NHS. Complaints about careof the elderly have also continued to rise – againnot surprisingly, given our aging population.

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I welcome the continuing decrease in complaintsreaching us too early. I am, however, concernedabout the small rise in upheld complaints, andparticularly about those health boards that havethe highest rates of upheld complaints. The PatientRights (Scotland) Act 2011 introduced the Charterof Patient Rights and Responsibilities. The Charterexplains that the Act gives all patients the right thatthe health care they receive will:

> consider their needs;

> consider what wouldmost benefit their healthand wellbeing;

> encourage them to take part in decisions abouttheir health and wellbeing; and

> provide themwith the information and supportto do so.

Some three years down the line, some of thecomplaints that I see indicate that there is stillmuch to do to ensure that the rights that the Actenvisages are upheld.

As I do each year, I have sent each chief executiveand board chair a letter providing their own board’sstatistics (these letters and the statistics areavailable on our website). I expect them to use thisinformation, in conjunction with other complaintsdata that they are now required to gather andpublish under the Patient Rights Act, to analysetheir complaints handling performance. Theyshould use all this information to assurethemselves of the quality of their complaintshandling procedures and the tangible learningand improved services that have resulted fromhandling complaints well.

Looking aheadFor some considerable time now, I have beenvoicingmy concern about the time it is taking forcoherent complaints procedures to be put in placefor services delivered under the integrated healthand social caremodels, where there are conflictingexisting legislation-based complaints processes.People using these services can often bevulnerable. They need to knowwhere to turn

if things gowrong. The organisations deliveringthe services and thosewith an oversight andimprovement role – the regulators, inspectoratesand scrutiny bodies – also need clarity on thisand I will continue to push for it.

Another area of concern that I have raisedrepeatedly is prisoner access to theNHScomplaints procedure. Although some action hasbeen taken to remove the barriers that prisonersare experiencing, I am very disappointed that weare continuing to find that some boards are failingto give prisoners the same access to complaintsprocesses as other people.

I have continued to find a great deal of value in oursounding boards this year. We have a customersounding board, withmembers fromadvocacy andadvice organisations across awide range of areas,including representatives of the Patient Advice andSupport Service and Patient Opinion. OurNHSsounding board ismade up ofmany differentstakeholders including a director of nursing, amember of a GP representative body, a healthboard chief executive, a health board chair, amedical director, a complaintsmanager andan infection controlmanager, aswell asrepresentatives fromHealthcare ImprovementScotland and the ScottishHealth Council. I havelistened hard to the views expressed and found thateach board facilitates two-way discussions that arefrank and insightful, and providemutual benefit insharing expertise and knowledge. I am very gratefulto all themembers for their time and input.

Over the coming year, I look forward to continuingtoworkwith others to ensure that the needs ofpeople using theNHS are central to how they arecared for, and that they feel able to voice anyconcerns they have about the decisionsmade andthe quality of the care they receive. In this way, wewill continue to have anNHS in Scotland of whichwe can be proud.

JimMartin, SPSO

Ombudsman’s introduction

Complaint numbersIn 2013/14 we received and dealt with 11.5%more complaints about health than in 2012/13.We received 1,379 (31% of total complaints)compared to 1,237 (30% of total) the year before.The rate of increase in complaints received slowedcomparedwith the 23.5% increase in 2012/13.Our sense is that these increases are not inthemselves a concern. Theymost likely reflecta positive trend in people feelingmore able tocomplain andmore hopeful that doing so willlead to change.

Premature complaintsThe rate of health complaints coming to us tooearly is always low in comparisonwith othersectors, and this year it dropped again from 30%in 2012/13 to 26%. This traditional low rate inpremature complaints can be attributed to thefact that formany years now theNHS has operatedamore streamlined complaints process than othersectors. This has now changed, however, as aresult of our complaints standards work, withother sectors catching up and implementingstandardised, simplified complaints handlingprocedures, with a subsequent reduction inpremature rates across all sectors.

Complaints investigatedWe investigate a higher proportion of complaintsabout the NHS than about any other sector (almostone in three). This is partly because of the lowpremature rate, whichmeans thatmore complaints

come to us that are ‘fit for SPSO’ (ie cases that areabout something we can consider and that areready for us to look at). Another,more significant,reason is that we have greater powers in healththan in any other sector. In other sectors, we areprecluded by the law from looking at professionaljudgement; in health, however, we have specificpowers to look at clinical judgement. Thismeanswe can consider what health professionals did andwhether this was reasonable in the circumstances.This allows us, for example, to examine the nurse’scare, the GP’s diagnosis or the surgeon’s decisionand come to a conclusion, usually with the help ofindependent specialist advice, about thereasonableness of their actions.

Upheld complaintsWeuphold complaints wherever we find fault,even if this has already been recognised by theboard.We do this to recognise the validity of thecomplainant’s experience. People come to us foran external, independent judgement about whathappened and if we find that something wentwrong it is important for the complainant that weacknowledge this. We also include in our reportshow the board or GP practice responded to theoriginal complaint and any action that they took,or plan to take, to put things right. Where a boardor practice has respondedwell, while wewilluphold the complaint, wemay also publiclycommend them for acknowledging themistakesthat happened and the action they took to resolvethis for the complainant, andwe are unlikely toneed tomake recommendations.

Public interest reportsAs a result of the higher proportion ofinvestigations, and the serious consequences ofsomething going wrong, themajority of complaintsthat we publish as ‘public interest’ reports areabout the NHS. In 2013/14, 38 of our 44 detailedpublic investigation reports were about the healthsector. They covered a range of issues, includingmental health, pressure sores, care of vulnerableadults, barriers to prisoners accessing the NHScomplaints process and record-keeping.

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Casework

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Casework

What do people complain about?The top two areas complained about remainedthe same, and the number of prison healthcarecomplaints receivedmore than doubled andmoved to third place in the table. There is asection specifically about prison complaints laterin this report. Complaints about care of theelderly in hospital rose from 58 to 86, andcomplaints about A&E doubled, but on smallnumbers (from 34 to 68). Dental and orthodonticservices was the only area where we receivedfewer complaints in 2013/14 than in the previousyear.

The top five subjects complained about remainedthe same. There was a 55% increase in thenumber of complaints reaching us about clinicaltreatment and diagnosis. This is not surprising,given that this is the key service provided by theNHS. Other areas where numbers increasedwere complaints about communication (up 22%)and appointments and admissions (up 78.5%)although these were both on verymuch smallerfigures of complaints received,meaning that anyincrease appearsmoremarked.

Top areas of health complaintsreceived 2013/14

Area of Number of As % of allcomplaint complaints health

received complaintsreceived

GPs andGPpractices 250 18

Hospitals– generalmedical 219 16

Prison healthcare 129 9

Hospitals – care ofthe elderly 86 6

Hospitals –A&E 68 5

Dental&orthodonticservices 61 4

Hospitals – gynaecology&obstetrics (maternity) 60 4

Hospitals– orthopaedics 58 4

Hospitals – psychiatry 52 4

Hospitals –general surgical 46 3

Top subjects of health complaintsreceived 2013/14

Clinical treatment/diagnosis 913

Communication/staff attitude/dignity/confidentiality 128

Appointments and admissions/waiting lists 75

Policy/administration 57

Complaints handling 43

Admission, discharge& transfer procedures 26

Continuing care 15

Nurses/nursing care 15

GP lists 12

Record-keeping 10

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Casework

We received 1,379complaints and dealt

with 1,324*

The rate of upheld complaintswas 55%, up from 52% last year,and higher than the year’s

overall rate of 50%

Key figures in health complaints 2013/14

The rate of complaints coming to us too earlydropped from 30% to 26% compared to last year

(the overall rate for all sectors is 34%)

People who receivedadvice, support andsignposting 740

Cases decided afterdetailed considerationpre-investigation 198

Wemade 684recommendations

for redressand improvement

Complaints fully investigated386, with 382**publicly reported to theparliament during the year, including38 detailed investigation reports

* There is some carry forward each year.** Some cases published in 2013/14 will have been handled in 2012/13. In a small number of cases, we do

not put information into the public domain, usually to prevent the possibility of someone being identified.

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Casework

Issues in health complaintsAswe have already highlighted, the cases reaching usabout clinical treatment and diagnosis increased by55% in 2013/14. This is a very broad subject andcomplaints were about equally broad areas of theNHS –mainly across hospital services, GPs anddentists. Of the 214 health cases in which we upheldor partly upheld the complaint, the vastmajority (156,or 73%) related to clinical treatment or diagnosis. It isworth noting, however, that a complaint about clinicaltreatment often involves other issues; for example thenursing care a person received, a concern that theirdignity was compromised or their needs not takeninto account, or that records were not properly kept.

Vulnerable peopleWe continue to receive complaints about thetreatment of vulnerable people, who often cannotspeak up for themselves. This group includes patientswith dementia or learning difficulties as well as thosein the care ofmental health services either in hospitalor, more often these days, in the community. Wherewe can, andwhere we can do sowithout breaking ourduty of confidentiality, wewill let other organisationsthatmay be able to help know about the issue.

Key case studyFailings in GP treatment and diagnosis

A young child had been suffering serioussymptoms includingweight loss, fatigue, vomiting,nausea and bone pain. His family took him to theirmedical practicemany times, where he was seenby different GPs who carried out examinations andtests. He was eventually referred to hospital,although not urgently. Hismother pressed for anearlier appointment, which he got. The child waseventually diagnosed with cancer and although hereceived treatment, he died somemonths later.

After this the practice carried out a significantevents analysis of the child’s treatment. Wewere particularly concerned that although theyapologised for an element of his treatment theysaid theywould not, with hindsight, havemanagedhis care differently, given his symptoms and theirfindings at the time. Our GPmedical adviserpointed out that there are guidelines for identifyingwarning signs of cancers, including in children,and that themedical records showed that thechild had several relevant symptoms. We alsofound that before this happened he had only beento the practice three times in six years, yet in theyear in question he had been there thirteen timesand had othermedical contacts. Our adviseridentified a number of failures in the GPs’handling of the child’s care and said that themedical records suggested that they should haveviewed his symptomswith a far higher degree ofsuspicion and recognised the significance of hissymptoms.

We recommended that the practice write to thechild’s parents apologising for the failings weidentified and offer tomeet with them to reinforcethat apology. We also said that they should provideus with evidence that the child’s case has beendiscussed with all the GPs involved, as a learningtool, and that learning points are taken forward aspart of their continuous professional development.

Case 201300703

Key case studyCapacity for decision-making

This complaint concerned the care of awomanwhohadDown’s Syndrome, a learning difficulty andsevere dementia. She had no family and nowelfareguardian, and an independent advocacyworker hadbeen appointed to ensure that her rightswereenforced and protected. Thewomanwas in hospitalseveral times. She couldn’t feed herself, andwasfed through a tube. Hospital doctors decided thatshe should not be resuscitated if her heart stopped,and staff decided to remove her feeding tube duringone admission to hospital.

After the woman died, her advocate complainedto us about these decisions. We found that thedecision to stop feeding was taken before thewoman’s dementia status was assessed. We alsofound that themedical records did not supportsome of what the board said about thebackground to that decision. The doctor in chargehad the final say on the resuscitation decision,but no-one spoke to the advocate or the woman’scarers about it to explain it or find out what shemight have wanted, which is what we wouldexpect to have happened.

Casework

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The board havemade several positive changessince this happened. However, we were veryconcerned about how they decided abouttreatment and how they dealt with thewoman’s decision-making capacity. Theyknew they were dealing with a very vulnerableperson, but there were significant delays inacting on legal safeguards that should haveprotected her. We recommended that theboard use the woman’s case to review theirpractices when caring for patients withlearning difficulties and suspected dementia,particularly in decision-making. We also askedthem to improve their record-keeping in anumber of areas. Because of our concerns,we highlighted her case to theMental WelfareCommission for Scotland.

Case 201104966

Among other failings, we found that theman’scare needswere not adequately assessed, therewere nomeaningful attempts at rehabilitationor to discharge himhome, and his dignity wasnot respected. Theman and hiswife suffereda significant personal injustice andwe alsoidentified broader failings in hospital staff’sgeneral understanding of peoples’ rightsunder the relevant legislation (the Adultswith Incapacity (Scotland) Act). To redressthe personal injustice as far as possible, werecommended that the board apologise tothe couple and that, if his wife agreed, theythoroughly assess theman to find out whetherhewould benefit fromphysiotherapy and if so,arrange this.We alsomade recommendationsto improve staff training in the care of peoplewith dementia, and asked the board to audittheward’s compliancewith the legislation.

Case 201204498

Key case study

Lack of assessment of care needsand rehabilitation

This case raised important issues under theCharter of Rights for peoplewith dementia andtheir carers in Scotland. Amanwas taken tohospital after a seizure. He had early onsetdementia, and sight and hearing difficulties.He had a stroke in hospital andwas dischargedto a care home, where hewas given nophysiotherapy care. His wife felt that hewas leftto vegetate and said that, despite her havingwelfare power of attorney for her husband, thehospital had not included herwhenmakingdecisions about his care and treatment.

The care of older people is another area wherepatientsmay be particularly vulnerable, and aboutwhich we regularly receive complaints. During theyear, we upheld or partly upheld complaints in 31cases that we recorded as being directly about careof the elderly. We recordedmanymore casesinvolving older people’s care and treatment.

In another example an elderlymanwas not properlyassessed and his family were not communicatedwith properly (case 201202679). Themanwas 87years old andwas admitted to hospital after fallingat home.While he was in hospital, he sufferedfurther falls and fractured his hip. He died inhospital nine days after surgery on his hip and,because of a delay in the death certificate beingissued, funeral arrangements had to be postponed,further adding to his family’s distress. We upheld thefamily’s complaint that the board did not assess theman’s risk of falling when hewas admitted, or oftenenough during his stay, even though hewas knownto be at high risk of this and his family hadwarnedstaff about it. We also found that food and fluidintakemanagement andmonitoring wereinsufficient and that staff did not communicateeffectively with theman’s family during his care andafter his death. Wemade eight recommendationsfor improvement to the board concerned, includingthat they review their falls risk assessment policyand procedures; ensure that staff are trained inusing this and inmonitoring patients considered tobe at risk, and ensure that they remind staff of theimportance of food and fluidmanagement andcommunicating effectively with patients and theirfamilies.

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Casework

Nursing careConcerns about nursing care are often an underlyingissue in broader complaints about hospital careand treatment. Areas where we have come acrossproblems include assessing patients for risks, suchas their risk of falling or of developing pressureulcers, and the steps taken tominimise that risk.When reporting the key case study described here,the Ombudsman issued a strongmessage in hismonthly commentary, stating that pressure ulcersshould be a thing of the past in Scottish hospitals.Ulcers are often avoidable if the patient is correctlyassessed, proper equipment provided andmonitoringcarried out. Sadly, once they occur, healing andtreatment can be very difficult, as this example shows,where awomanexperienced significant complicationsbecause of pressure ulcers, whichmeant that shecould not return home and had to remain in hospital.

In another casewe found that an elderly woman, whohas since died, was not properly assessedwhen shewas admitted to hospital (case 201204018). Staff hadused a risk assessment tool, but had not scored hercorrectly on this when assessing her risk of falling.Thismeant that she did not get the intensive care planthat she needed.Wewere also concerned that whenthe board investigated the complaint they did not spotthat the scoringwaswrong.We recommended, amongother things, that the board should apologise to thewoman’s family and look again at the assessmentprocess to ensure that in future staff exercise clinicaljudgementwhen assessing risk, and keep accuraterecords.

CommunicationWe all know that good communication betweenhealthcare professionals and patients, clients andrelatives is a key factor in howwe experiencehealthcare. When people are properly involved andengaged in care and treatment, they aremore likelyto be satisfiedwith the care provided. The valueof connection to and compassion from anotherhuman being whenwe are vulnerable cannot beunderestimated. It is, therefore, no surprise thatfailings in communication continue to feature stronglyinmany of the complaints that people bring us.

Key case studyPoor nursing care

Awomanwho is paraplegic was admitted tohospital with severe headache and neck pain.She was there for seventeen days, being treatedformeningitis. When she came home, herhusband found that she had developed extensiveand serious pressure ulcers, and he contactedthe district nurse for help in dressing these. Thenurse said she did not know that the womanhad them. The woman had to return to hospitalbecause the ulcers and associated complicationsmeant she could not be nursed at home, andshe was still in hospital when we investigatedthe complaint some time later. Her husbandcomplained, among other things, that there wasno discussion about arrangements for his wife’scare at home or equipment needed tomanageher pressure ulcers, although a hospital bedwas brought there some two weeks after sheleft hospital. Our nursing adviser said thatno-one seemed to consider the fact that thewomanwas paraplegic or that she was acutelyill, and there was little evidence of what wasdone to reduce the risk of pressure ulcers.Communication between hospital andcommunity nursing staff was poor, andmeantthat the district nurse lacked key informationand equipment.

The woman should not have been discharged untila suitable bed had been provided for her returnhome.

The board concerned had acknowledged that theirrisk assessment for pressure soreswas incorrect,therewas no tissue viability nurse service, andtherewere communication issues and concernsaround the discharge arrangements. They providedan action plan to address the issues they found inthe complaint. This was appropriate but we foundthe key problem to be a lack of cohesion betweenthe board’s very clear policies andwhat staffactually did. Staff carried out only parts of thepolicies, whichmeant that what they didwasn’teffective.Wemade a number of recommendations,including that the board apologise to the couple,provide staff training on proper implementation ofpolicies, including recording the actions taken; andprovide uswith evidence of what they have done toimplement their action plan.

Case 201103459

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Casework

We receive complaints that expressmanyemotions such as frustration, anger, sadnessand fear. We hear about people being deeplydisappointed and upset with the level ofinformation given and shared. Andwe also hearabout information being given too late, withimportant consequences. Below are twoexamples of such complaints, where therewas a lack of communication with the familyand between healthcare staff. The failingsresulted in the families not being contactedor consulted aboutmajor decisions.

In the first, a woman’s father was taken to hospitalwhen hewas very unwell with pneumonia andkidney damage (case 201301771). He also had anabdominal aortic aneurysm (a bulge in a bloodvessel caused by a weakness in its wall). At first,he respondedwell to treatment, but his conditiondeteriorated and he died. His deterioration wasconsistent with the aneurysmhaving burst. Hisdaughter complained it took too long to find outthat this had happened, and that staff did notcommunicate adequately with the family.

We found that theman’s treatment wasreasonable, but we upheld the complaint aboutcommunication. Conversations between staff andrelatives were not documented and there was littleevidence to suggest that the family weremadeaware of the treatment being carried out, or wereinvolved in conversations about theman’s care.Our nursing adviser said that they should havebeen contacted sooner about his deterioratingcondition, and should have been included inmajordecisions about his treatment. We recommendedthat the board apologise to the family for thecommunications failures and remind staff toinform relatives about and involve them in thepatient's care, and to properly record discussionswith them.

In the second case, amanwent to A&Ewithstomach pains (case 201300003). Staff decided thathe should be transferredwithin the hospital forfurther assessment, but this did not happen for

some eleven hours. After he was transferred, hebecame unwell and died. His wife had been athome some sixtymiles away, and could not get tothe hospital before her husband died. Shecomplained to us about his care and treatmentand about what happened after she arrived atthe hospital.

Among other things, our nursing adviser said thatnursing staff should have told his wife how ill themanwaswhen they phoned to tell her that he hadbeen transferred to the high dependency unit.The fact that he had been transferred there in itselfindicated that she should have been called to thehospital. We found that she had been treated witha fundamental lack of sensitivity, particularlywhen seeing her late husband after he died. Staffhad not properly cared for him after death and,understandably, she found this extremelydistressing. She told us that, when she saw him,he looked as if he had died in extreme pain andshe has been unable to remove that image fromhermind. The chief executive had apologisedpersonally for what had happened, but wemade anumber of recommendations including ensuringthat staff are aware of their responsibilities, both inpreserving dignity in death and in being sensitive tothe needs and feelings of familymembers in sucha situation. As guidance in this area1makes clear,caring for a person at the end of their life, and afterdeath, is enormously important and a privilege.There is only one chance to get it right.

In this case, themanwas clearly dying, yet hisfamily were not told andwere unable to preparefor his death. Therewas evidence in the notes thatboth the nursing andmedical staff knewhewasnearing the end of his life, yet no one clinician tookresponsibility to call his family. Families should begiven the opportunity to bewith their loved ones iftheywish, as being unable to say goodbye can affectthe grieving process. Healthcare professionals alsohave a duty to consult familieswhen patients aredeteriorating or nearing the end of their life. Theseconversations are important and should includepreparing families for death and dying.

1Guidance for staff responsible for care after death www.nhsiq.nhs.uk/media/2426968/care_after_death___guidance.pdf

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Casework

Waiting lists and delays inreceiving treatment

Wedealt with 71 complaints about delay inreceiving appointments or treatment in 2013/14.In some cases, the problemswere serious.One such examplewas of a youngmanwithmental health problemswhowas twice on thewaitinglist for treatment (case 201204084). Hewas not,however, seen as both times the board removed himfrom the list because hewas either being investigatedby the police orwas awaiting trial. The board said thatthey did this in accordancewith their usual protocol.We took independent advice on the case fromaconsultant forensic psychiatrist, who said that theboard’s protocol went against theNHS policy ofindividualised care according to need. The youngman’srequirements and circumstances had not been properlytaken into consideration and he had received notreatment for his significant psychological needs. Aswell as apologising andmaking sure that the youngman’s outstandingmental health needs are nowaddressed, we said that the board should look againat their protocol in terms of theHealthcare QualityStrategy for NHSScotland 2010.

Inmany cases, however, we found that nothing hadgonewrong. For example, awoman complained thatshewas not immediately offered physiotherapy aftershewas discharged fromhospital (case 201304536).The board explained that they provide physiotherapyadvice before discharge and the patient shouldcontinuewith these exercises until their normalsix week review.We found that this practice iscommonly used throughout theNHS, and that stafffollowed normal procedures. In another case, amancomplained of delay in carrying out his knee surgery,and that this breachedwaiting times (case 201203486).Therewas a gap between his first consultantappointment and the second (at which the consultantdecided to go aheadwith surgery). We found, however,that this was because tests were needed tomake surethat surgerywas the right option, and because of thecomplexity of his operation. Thewaiting time target onlyapplied once it was certain that themanwould behaving surgery, and once this decisionwasmade, theoperationwas carried out in threeweeks.

ApologyIt is possible that when things gowrong staffmay

be concerned about apologising. Howeverwhen staffdomakemistakes, early communication is vital. Being ableto say ‘I am truly sorry…’ allows amember of staff tomakea connection as a fellow human being and can be the firststep in resolving an issue.We encourageNHS staff at all

levels to apologisewhen things gowrong.

The quality of written apologies that boards andGPpractices provide to complainants can be variable. Some

are clear, empathetic and personal, others sound formulaicand formal. To support boards inmakingmeaningful

apologies, we have produced SPSOguidanceon apology andwe offer training in this area aswell.

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Casework

Record-keepingA regular learning point from our NHSinvestigations is the importancewe place uponmedical records as a primary source of evidence. Itis essential that clinical and nursing staff accuratelyrecord what has been done, or not done, both fromamedical care and a communication point of view.Equally importantly, the record should showwhyparticular action was taken or not taken, especiallywhen standard practice is not being followed.

In one example, a cancer patient was undergoingtreatment and had to have a Hickman Line (a tubefor administering chemotherapy) inserted (case201203628). He complained that this caused hima great deal of pain. We found no evidence thatthe procedure was not carried out properly. Ourmedical adviser said that patients will experiencediffering levels of pain and there was no evidencethat anything went wrong. However, the adviserpointed out that nothing waswritten in themedicalrecords at the time about the problems themanexperienced. The radiologist who performed theprocedure had spoken to theman afterwards, andagreed tomake a record in the clinical notes and toput an alert on the electronic records saying that heneeded sedation for this in future. This, however,did not happen andwhen theman had to beadmitted for a further line to be inserted hewas,understandably, distressed that the teamwere notaware of his experience. Because of this, althoughwe did not uphold the complaint about theprocedure, wemade recommendations aboutrecord-keeping.

In a different example, amanwent to A&Ewith abadly cut hand (case 201203387). Hewas assessedby an emergency nurse practitioner, who said hehad superficial cuts, and treated themby closingthemwith adhesive strips. Over the next year orso theman continued to have problemswith hishand, for which hewas reviewed by his GP andorthopaedic specialists and discharged on eachoccasion. He complained to us that his finger wasbent and painful and that the nurse should haveconducted amore thorough assessment or askeda doctor for advice.

We found that the record-keeping of the initialassessment was not of a reasonable standard.It did not show that the nurse carried out a full

examination of the injury including ofmovementand the wound base of the cuts. Our nursing advisersaid that it was difficult to know from the records ifthere was evidence of a further injury that wouldhavemeant theman should have been referred to aspecialist. Wewere happy that the follow-uptreatment was reasonable, but upheld thecomplaint about his treatment in A&E.

Prison healthcare

Nine of the 14 regional health boards in Scotlandhave responsibility for the healthcare of prisoners.This responsibilitymoved to them from the ScottishPrison Service in 2011, and since thenwe have beenthe final stage for prisonerswith complaints abouttheir healthcare in prison. As in other areas ofhealthcare,most of the complaints we received anddealt withwere about clinical treatment anddiagnosis.

Althoughwe received few complaints directly aboutcomplaints handling, we did in a number of casesfind failures in this in addition to themain issuecomplained about.We also identified the issue offailure to follow theNHS process, and this featuresas a case study later in this section (case 201203374).

We determined 122 prisoner complaints abouthealthcare in 2013/14. Of thesewe investigated 32in detail. We partly or fully upheld 17 and did notuphold 12.

Prison healthcare cases receivedby subject 2013/14

Clinical treatment/diagnosis 104

Appointment and admissions/waiting lists 8

Complaints handling 8

Communication/staff attitude/dignity/confidentiality 6

Policy/administration 2

Nurses/nursing care 1

Total 129

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Casework

One themain reasons prisoners complain to us isthat they have been prescribed a differentmedicinefrom the one that they were prescribed when theywere in the community. This ismost commonlymedicine used to treat pain or a sleeping disorder.We usually ask our clinical advisers to look at thesecases and provide independent advice. While in themajority of cases they agreedwith the prison’sassessment that it was reasonable for the prisonerto be prescribed the differentmedicine, in a fewcases our advisers identified that the person’sneedswere not properly considered.

An example of each type of case follows – in thefirst, where we did not uphold the complaint, aprisoner complained about the drug prescribedfor his sleeping disorder (case 201300723). Hewasunhappy that his prescription for this was reduced,then stopped. Hewas given an alternative but saidthat it did not agree with him. Our adviser saidthat the prison health centre acted reasonably inreducing the drug, which is in fact only licensedfor short term use, and pointed out that themanwas aware of this when it was first prescribed.There was also evidence that he was reviewedappropriately, andwas told several times that theprescription needed to be reduced.

In a casewhere we did uphold the complaint, aprisoner told us that the prison health centrestopped his painmedication (case 201302414).He said hewas prescribed this in the community,and it was the only one that helpedwith his pain.The community GP had confirmed this to the prisonhealth centre, but staff there had decided he did notneed it and prescribed differentmedication.Our adviser said that they did not appear to haveassessed the circumstances in detail, and that theoriginalmedication was in fact likely to be suitablefor that type of pain. The information suggested theman had tried various types of pain relief but theyhad all been unsuitable. We recommended that theboard review his clinical need for the pain relief herequested.

Another feature we noted was an increase incomplaints about delay in or failure to provide bothmedical and dental care. One of the issues thatseems to have underpinned this is that whenresponsibility for these complaints changed therewere no guidelines in place aimed specifically atthe treatment of prisoners. This has now beenaddressed, with the Scottish Government draftingprinciples for treatment, and boards withresponsibility for prison healthcare reviewingtheir practices.

Key case studyPrison healthcare

A prisoner said that the prison dental hygienistdid not see himquickly enough, and that whenhe reported a broken tooth it was nearly fourmonths before he saw a dentist. The board toldus that when they took over responsibility forprison healthcare they had no guidelines for thetreatment of prisoners but this was now in hand.They also said that the prison had audited theirpractice against the board's new dental servicesstandard statement.

The hygienist had recommended that themanbe seen again after threemonths, which ouradviser saidwas appropriate, andwe could notfind out why it took elevenmonths for this tohappen. Theman’s gumdisease got worsewhile hewaswaiting to be seen. It also took toolong for him to see a dentist, whichwas likely tohave contributed to his tooth decay and thepossibility that hemight lose a tooth.Wewereconcerned that the board did not identify thiswhile investigating his complaint. Aswell asasking the board to apologise to theman for thedelays, we asked them to showus evidence ofthe audit they carried out.

Case 201204744

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Casework

In another case, a prisoner normally attended theprison health centre two or three times amonth (case201202627). At one point he asked several times tosee a doctor but was only given reply slips inresponse. These either asked formore informationor said he did not need an appointment as hismedicationwas correct. The board told us that doctorappointments aremade after referral by a nurse.They said the doctor knew about the requests and haddecided he did not need to see theman.We foundthat the prisoner’smedical treatmentwas correct,but that hewas not given a doctor’s appointment untilsome fivemonths after asking.

Although it is reasonable for a nurse to assess theneed for the appointment, we thought it unreasonableto repeatedly block access, particularly if a patientthought their condition had changed.We said thatprison healthcare staff should bemade aware of ourview that it would have been better for the doctor tohave seen the prisoner to discuss this, and explainwhat happened.

Prisoner access to theNHScomplaints process

Through our investigations (for example cases201203514 and 201203374) we have highlightedserious concerns about prisoners’ access to theNHScomplaints procedure.We have found that thereappear to be twomain obstacles. The first is thatsome prisoners find it difficult to get beyond thefeedback stage. They say that when theywant tocomplain, they are given a feedback form, and thatcomplaints forms are not being provided. Others saythat, because ofmisunderstanding by prisonmedicalcentres about the process that should be used, theyare effectively forced to go through an additional‘feedback’ stage before they can reach thecomplaints stage.

This is at oddswith the Scottish GovernmentCan Ihelp you? guidance fromwhich it is clear that NHSusers are not required to complete a feedbackprocess before accessing the complaints procedure,and that the same applies to those receivingNHScare and treatment in prison.

In the policy and engagement section, we outlineinmore detail how andwherewe have raisedthese concerns.

Key case studyPrison complaints handling

A prisoner was unhappy with how hishealthcare complaints were treated. He hadsent the board a lot of feedback forms and acomplaint form. Although the amount ofwork involvedmeant that these would havetaken time to deal with, we found that theboard did not handle them properly. We saidthey should apologise and ensure that theirlocal process is in line with the guidance.

Of evenmore concern, however, was thatwe found that prisoners’ access to thecomplaints process was restricted. Althoughthe board said that they thought forms wereavailable to those who wanted to complain,and that prisoners could write directly to theboard with a complaint, we found thatprisoners normally had to complete a nursereferral form, then ask for a complaintsform. Even then, they sometimes onlyreceived a feedback form, unless they saidthat they didn’t want one. Thismeant that insome cases the feedback process was usedas an extra level of the NHS complaintsprocess. NHS users don’t have to do thisbefore accessing the complaints process,and this should still be the case when peopleare in prison. We recommended that theboardmake sure that prisoners could infuture have easy access to NHS complaintforms.

Case 201203374

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This section outlines what we have done toensure that the outcomes of our consideration ofcomplaints, in particular our recommendations,were relevant, joined-up and drove improvementsin public services. We also highlight howwe haveshared strategic lessons from complaints andwhat we have done to further strengthen ourrelationships with advocacy and advice groupsthat support complainants.

Tracking and following uprecommendationsIn 2013/14 wemade 684 recommendations aboutthe NHS in Scotland, up from 557 the previous year.As the case studies we highlight in this reportshow, we use recommendations to put things right,as far aswe can. Theymay include asking boards to:

> recognise the impact the injustice hascaused – for example through a letterof explanation and apology

> prevent the same thing happening again,andwhere relevant prevent it happeningto other people – for example ensuring thatstaff receive training to understand theirobligations under Adults with Incapacitylegislation, or that they are aware of andimplement appropriate falls preventionmeasures

> provide remedy and redress to put the personback in the situation they would have been inhad the injustice not happened – for examplerepeating an assessment of a person’s needs

> identify systemic issues where we seerepeat failings – for example undertaking anaudit of hospital wards to ensure that pressureulcer care andmanagement is in line withnational guidance.

We are rigorous in asking boards for evidenceof implementation by the deadline we set.Evidence includes copies of apology lettersdemonstrating that they satisfy our guidanceonmeaningful apology; copies of the newpolicy/procedure or review/audit we have askedfor, with the action plan for implementation;documentation showing that the staff training weasked for has been carried out or that findingsfrom our investigation have been sharedwiththe relevant staff and reminders have beencommunicated.

Where appropriate, wewill ask one of ourindependent advisers to assess this evidenceas well. This can happenwith any of ourrecommendations, but we do so particularlywhere we have identified systemic issues.If we find that an organisation has not providedrobust evidence, we go back to themuntil therecommendation has been implemented to oursatisfaction. We also liaise with the ScottishGovernment Health and Social Care Directorate,which tracks recommendations within the healthsector, andwe see this as a progressivemodelfor other sectors to follow.

Impact

Sharing strategic lessons

Through our recommendationswe try to fix thingsfor people and ensure that theNHS learns lessonsfrom complaints andmonitors improvements.While it is ultimately for health boards themselves(supported and driven by regulators and otherimprovement and scrutiny bodies) to bring aboutchange on the ground, our recommendations aresignificant tools that can help bring about thatchange.

We see our role as identifying failings andmakingrecommendations that put organisations backon the right track.We see it as the role of otherscrutiny bodies to regularly review processesand ensure that organisations are on that trackon an ongoing basis. To put it anotherway, ourinvestigation is a red flag that shouldmake anorganisation sit up, take notice andmake changes.Regulators and other improvement and scrutinybodies carry out green flag checks in a continuousand systematic way that show that the organisationare acting properly.

There are threemainways inwhichwe sharelearning:

> putting information, including analysis andtrends, into the public domain;

> working alongside regulators and otherimprovement and scrutiny bodies to ensure thatpeople’s concerns are fully addressed and theydo not fall between the cracks; and

> encouraging regulators and other improvementand scrutiny bodies to build key aspects of goodcomplaints handling into their workwherepossible, to help drive a valuing complaintsculture across the public sector.

Publishing information

Weshare learning from the complaints we seethrough:

> publishing a significant volume of decisionsand statistics about sectors and individualservice providers on ourwebsite

> e-newsletters, sectoral reports, annual lettersand our Valuing Complaints website

> consultation and inquiry responses

> providingwritten and oral evidence toparliamentary committees and others

> participating inworking groups

> conferences,meetings, presentations, visitsand so on.

Our annual letters to the health sector2 providedetails of the complaints we received and dealtwith, alongwith premature and uphold rates,comparedwith the previous year. Healthcareproviders and other organisations in the sectoruse these statistics to help assess complaintsperformance.

Aswe reported last year, we alsoworkedwithindividual organisations, some in the health sector,that we identified as having both high volumes ofcomplaints reaching us and high uphold rates afterinvestigation. Having analysed the reasons for theselast year, we are continuing toworkwith a smallnumber of organisationswherewe feel a greaterstrategic focus on good complaints handlingwillhelp them reduce both the volume of complaintsand their uphold rates.

Maximising the impactWeshare the outcomes of our investigationswithregulators and other scrutiny and improvementbodies, tomaximise the change that can comeabout fromour findings and recommendations.An example of the interrelatedness of ourworkwashighlighted in our April 2013 commentary about thecare and treatment provided to a youngman beforehe committed suicide (case 201003482). TheMentalWelfareCommission forScotland (MWCS) hadconducted a review into theman’s death and usedthe case to raise broad concerns about how servicesrespond to young peoplewithmultiple problems.Whenwe investigated the case, we did so fromourspecific standpoint of looking at the individualexperience of the personwho had brought thecomplaint, in this case the father of the youngman.

Given our different roles and remits, theMWCSreview and our investigation examined somedifferent areas. However, the two reportscomplemented one another inmanyways,and several of the conclusionswere similar.

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Impact

2 http://www.spso.org.uk/statistics-2013-14#letters

Wehave a duty to alert the appropriate authority ifwe see serious failings andmay also do so if ourinvestigation points to the possibility of a systemicissue. In these caseswemay pass on information toprofessional regulatory bodies such as theGeneralMedical Council. We have arrangementswithregulators and others set out in protocols andmemoranda of understanding, which are publishedon ourwebsite.3

Encouraging good complaints handlingThe key elements that we encourage regulators andother scrutiny and improvement bodies to ensureare built in are:

> clear accessibility and visibility of the complaintsprocedure and related information. This includesclear signposting and support for thosewithneeds or difficulties in accessing the system, aswell as ensuring that real or perceived barriersto complaining have been identified andremoved

> a focus on resolving things early at the frontline,including ensuring apologies are given freelyand action takenwhere things gowrong

> recording all complaints and reporting thisregularly in linewithmodel complaints handlingprocedures or other requirements such as thePatient Rights Act

> learning from service failures, with systems inplace to analyse and report on complaintsoutcomes, trends and actions taken. This wouldinclude seeking opportunities to share learningacross the relevant sector.

> ensuring that processes are in place to identifyand respond immediately to critical or systemicservice failures or risks identified fromcomplaints

> strong, visible leadership on complaints fromsenior staff, including support and training anda recognition of the importance of effectivecomplaints handling to good governance.

Engagingwith advice and advocacyworkers

Peoplewhomake complaints to us are oftensupported by advice and advocacyworkers, inparticular by Patient Advice and Support Service(PASS) advisers. To ensure goodmutualunderstanding of the serviceswe each provide,wemet regularly with Citizens Advice Scotlandand PASS coordinators to discuss how to raiseawareness of any areas of concern orways toresolve issues that the public brought us.In 2013/14, we developed a guide to all our keyinformation leaflets for bureaumanagers, andan e-learningmodule about the SPSO for bureaustaff and PASS advisers. Thismaterial is alsoavailable through the Scottish IndependentAdvocacy Alliance.

Wewere pleased that the independent feedbackwebsite Patient Opinion continued to grow, andwewelcome their emphasis on the positive aswell asthe negative experiences of people using theNHS.We also supported thework of theNHSComplaintsPersonnel Association Scotland (NCPAS) throughattending theirmeetings as observers.We providedinput about the complaints handling issues that wesaw and received valuable feedback about ourservice and about the challenges faced byNHScomplaints handlers.

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Impact

3http://www.spso.org.uk/memoranda-understanding

PAGE 20

This is a selection of case studies from investigations we published for 2013/14.

Some illustrate the double injustice that can happenwhen a poorly delivered service iscompounded by poor complaints handling. Other case studies are included to show someof the positive actions that organisations take in response to complaints. To share this goodpractice, in the report on our website we normally highlight where an organisation hastaken such action. Others are included as examples of where organisations have delivereda service and investigated the complaint properly.

These case studies are brief summaries andmay not contain all the information wepublished about the complaints. You can findmore information online atwww.spso.org.uk/decision-reports.

Case studies

Awoman had power of attorney tomake decisions for her late brother, who had profoundlearning and communication difficulties. He was admitted to hospital, where he died threedays later from a blood infection. The woman told us that hospital staff did not discuss hiscare and treatment with her. She said that when her brother deteriorated, she could haveprovided important information about his normal condition, which could have informedhow he was treated. The board apologised that staff did not act on changes in her brother'smedical condition but said this was not due to his learning disabilities.

The board have a good best practice guide in linewith the principles of the Adults withIncapacity Act (Scotland) Act 2000. It says that aswell as the views of the individual, staffshould as far as possible take account of the views of family and carers. However, the guidewas not followed in this case. Thewomanwas not involved in the decision-making processand,more importantly, her information about her brother’s deteriorationwas not takenseriously. We said that the board should apologise to her, remind staff of the best practiceguidance andmake sure it is used for relevant patients.

Case 201304515

Adults with incapacity – board’s guide not followed

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Amedical practice suddenly removed a woman and her elderly mother from their list ofpatients, because of the woman’s behaviour. They did not warn her that this was going tohappen, nor did they invite her to discuss it with them. The practice said that they believedthey had followed procedures because they told the health board about the removal. Wefound, however, that they had not followed relevant guidance and the NHS General MedicalServices Contract, which says that deregistration should only be a last resort. Medicalpractices are entitled to remove patients from their list, but should only do so after warningthe patient that their behaviour is giving cause for concern, that they have to improve itand that if the patient doesn’t, they risk being deregistered. The only exception to this iswhere violence is involved, which can trigger immediate deregistration. As this was clearlynot the case here, we upheld the complaint and recommended that the practice apologiseto the family and ensure that staff understand what they need to do if something like thishappens in future.

Case 201300401

Inappropriate removal from GP list

Case studies

Awoman complained that her dentist didn’t give her enough information about availabletreatment options and costs. She said that thismeant that shewas treated as a privatepatient rather than by theNHS.We found, however, that the dentist gave her awrittenestimate of the cost of treatment. Our dental adviser also examined the records, andconfirmed that she received the appropriate treatment and had consented to it being providedprivately. The dentist had correctly explained the options, and had also explained that thetreatment thewomanwanted could not be provided on theNHSwithout a sixmonth delay.Our adviser also pointed out that therewas no guarantee that the dentist could have providedit on theNHS, as hewould first have had to obtain permission to do so.

Case 201104023

Communicating treatment options

Case studies

Amother complained about delays in providing dental treatment to her profoundly disableddaughter. She said that after her daughterwent to the dentist it was sevenmonths before shereceived treatment and that, because of her disability, her daughter received a poorer standardof care than that given to the general population. She also complained that the board did not dealwith her complaint properly.

After taking independent advice fromour dental adviser on the care and treatment provided, wefound that themother had initially questioned both the treatment and the approach recommendedby the dentist. Because of this, the boardwere in the unusual position of having to have twodentists present during the treatment, and also had to satisfy themselves that what was beingagreedwith themotherwas in accordancewith the policieswithwhich they had to comply.These complex discussions and additional arrangements created understandable, and notunreasonable, delay. However, after an approachwas agreed upon it was threemonths before thiswas confirmed to the patient and hermother, whichwe did find unreasonable.We also found thatthe board showed a similar lack of urgency in responding to the complaint.We recommended thatthey apologise, confirm that they have put a protocol in place to avoid this happening again andremind staff of the importance of following the complaints policy.

Case 201300258

Delays in treating patient with profound disabilities

Aman’sGP referred him to a health board'sweightmanagement service in August 2009. They lostthe paperwork and theGP sent it again in February 2010. The board told theman that hewould bepsychologically assessedwithin a couple ofmonths, but this did not then happen for a year. InOctober 2011, it was confirmed that hemet the criteria to be assessed for surgery, forwhich hewould be referred to another board. His GP referred him there, but nothing happened. Thiswasbecause referralswere not being accepted because of the level of demand for the service, butno-one explained this to him.Meanwhile in July 2012 newcriteriawere put in place and inOctoberthat year the board told theman that he did notmeet these andwas no longer eligible to be referred.

Our investigation found that, but for the loss of the referral and the delay in psychologicalassessment, themanwould have been assessed for surgery under the criteria in place before July2012.We said that the board should have followed through on their agreement to further assesshis suitability, and that they should now consider prioritising this and apologise to him for the delayand lack of information.

Case 201202880

Delay in assessing for and providing weight-loss surgery

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Case studies

Awoman had experienced severe breathlessness, and had collapsed several times at home.During one of these episodes an ambulancewas called, but was cancelledwhen she becamemore alert. Another ambulancewas called later when she collapsed again. The ambulance crewhelped her into bed, but said that therewas notmuchmore that could be done at that point, even ifthey took her to hospital. She continued to strugglewith her breathing and in the early hours of thefollowingmorning, an ambulance took her to hospital. Shortly after arriving there, she collapsedand, despite attempts to revive her, she died. Thewomanwas found to have a pulmonaryembolism (a blockage in the artery that transports blood to the lungs). Her father complained tous because he thought that shemight have survived had an ambulance crew taken her to hospitalearlier, or had the crew that did eventually take her to hospital actedwithmore urgency.

We found that the ambulance crews obtained relevant information about thewoman's recentsymptoms andmade thorough examinations. Ourmedical adviser said that thewomanwasdisplaying two symptoms that could indicate pulmonary embolism, but that thesewere alsosymptoms ofmore common illnesses, including viral infection, which is what her GP thought shehad. Althoughwith hindsight it was clear that her symptomswere related to a serious underlyingcondition, this would not have been clear to the ambulance crews at the time.

Case 201300911

Clinical treatment and diagnosis by ambulance team

Aman,whohad been out for a drinkwith friends, fell downstairs at home. Hiswife found himunconscious and finding it very hard to breathe.When an ambulance arrived she said the crewdidn’tseem towant to take him to hospital and she overheard them talking about ‘drunks’. She said theyonly took himbecause his blood pressurewas low. The crew transferred theman to awheelchair totake him to the ambulance. He ended up paralysed, and hiswife thought that this had something todowith theway the ambulance crew transferred him.

We couldn’t saywhetherwhat the ambulance crew did had any effect onwhat eventuallyhappened. But we found that once they realised howhe had fallen, and that he had beenunconscious, they should have immobilised him as soon as possible, and they didn’t do that.The ambulance service’s response to the complaint also didn’t reflect the seriousness of thisallegation and suggested that the staff involvedweren’t interviewed.Much later, wewere told thatone of themhad in fact left and the other had been disciplined.Wewere very concerned that theambulance service did not send us all the information at the start, and that they gave us themissing details so late. We said they should have their complaints process externally audited tomake sure it was fit for purpose.We also said they should apologise to theman and his wifebecause hewasn’t properly immobilised and because their investigationwasn’t good enough.

Case 201301204

Ambulance transfer and complaints handling

Case studies

A youngmanwith a history ofmental health problemsand drug/alcohol abuse had been trying tosort out his problems, and had been drug-free for some time.However, he relapsed, afterwhichhe became very distressed and pleadedwith his parents to help him. They took him toA&E,and told a doctor that he had expressed suicidal thoughts. The doctor asked an on-callmentalhealthcare nurse tomake a psychiatric review, but the nurse said that the youngmanwas toointoxicated. Hewas discharged, andwas found dead fromanaccidental overdose three days later.The youngman’s parents complained that the care and treatment providedwas inadequate – theythought that he should have been admitted to hospital.

The board said that there is a national gap in service provision in such cases, and ourmedicaladvisers agreed that this is true for patientswho presentwith both substancemisuse andmentalhealth problems. Ourmental health adviser also pointed out, however, that the on-call nursewrotenothing in themedical notes. The nurse laterwrote to theman’sGP saying that amental healthassessmentwas needed, as he couldn’t assess the youngmanbecause hewas unable towake him.We foundno evidence of this, however, and it contradictedmedical evidence in the notes that theyoungmanwas conscious and alert an hour before. Our adviser said that the nurse should havemade every effort towake and assess him, and appeared to have disregarded the parents’ concernsabout themention of suicide. The adviser pointed out that therewas no physicalmedical reason toadmit the youngman to hospital, but the lack of psychiatric assessmentmeant that therewas noevidence aboutwhether hewasmentally fit for discharge.

We recognised that this was a difficult situation but upheld the complaint about his care andtreatment because the youngmanwas dischargedwithout amental health assessment.We alsofound that the board’s complaints handlingwas poor, as therewas delay, and a lack of empathytowards the youngman’s parents.We recommended that the board apologise to them for thesefailings, and create a protocol for dealingwith patients who attend A&Ewith issues relating toboth substancemisuse andmental health.

Case 201203602

Mental health assessment and complaints handling

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PAGE 25

Improvingcomplaints standards

4 www.scottishhealthcouncil.org/publications/research/review_of_nhs_feedback.aspx5 www.scottishhealthcouncil.org/publications/research/listening_and_learning.aspx

NHScomplaints handlingInMarch 2012, the Scottish Government revised theirCan I Help You? guidance on theNHS’ standardisedcomplaints handling framework. In linewith this,since 1 April 2012NHS boards in Scotland have beenrequired to produce an annual report on their use offeedback, comments, concerns and complaints.The ScottishHealth Council (SHC) undertook areview4 of the first reports published for 2012/13,comparing how boards responded to the newrequirements and identifying potential areas forfuture improvements in reporting.

The SHC concluded that ‘The reports from theNHSBoards vary significantly in terms of both format andcontent. SomeNHSBoards did not produce all therequired information, some producedwhat wasrequired, and otherswent beyond this to provide afuller account of feedback, comments, concerns andcomplaints on their services. In future itmay proveuseful to develop a framework for howNHSBoardsreport this information.’

Following this, the Scottish Government initiateda review of feedback and complaints in theNHSthrough the SHC andHealthcare ImprovementScotland. The review involved visits to all 21 boardstomeet seniormanagement teams and thoseresponsible for complaints and also sought theviews of patients on feedback and complaintsarrangements.

Their report Listening and Learning5was publishedin April 2014. Itmade a number of specificrecommendations to the SPSO’s ComplaintsStandards Authority. Since the report’s publication, wehave been involved in discussionswith the ScottishGovernment, SHC and others on taking forward theserecommendations andwe look forward toworking inpartnershipwith the sector in doing so. Our aimwillbe to align theNHSmodel asmuch as possiblewiththemodel CHPswe have developed in other sectors,within the framework of the Patients Rights Act andassociated requirements.

SHCListeningandLearningreport recommendations

1 TheComplaints Standards Authority hasdeveloped a number ofmodelled complaintsprocesses across other areas of the publicsector. As experts in that area, they shouldlead on the development of amore succinctlymodelled, standardised and person-centredcomplaints process forNHSScotland, incollaborationwith the public, NHSBoardsand the ScottishHealth Council. This shouldbuild on the requirements in the guidanceand legislation but articulatemore clearlythe outcomes expected and the indicatorsandmeasures that will demonstrate qualityalongside timeliness.

2 Explicit reference should bemade in thatprocess to address the following.

> Assist the staffmanaging feedback,comments, concerns and complaints tobetter understand the definitions of each.

> Ensure that service users, carers andfamilies can be involved to the leveltheywish.

> Encourage early resolution and frontline ownership.

> Ensure that the focus on improvementsas a result of the learning fromall typesof improvement is clear.

> Ensure that the processes for complexcomplaints are integratedwith themanagement of serious and adverseevents.

> Focus on quality alongside timeliness.

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Improving complaints standards

TrainingListening and Learning also identified a role forthe SPSO’s training unit. The report said:

‘The range of trainingmade available recently viaNHS Education for Scotland and the ScottishPublic Services Ombudsman has been extremelyhelpful and supportive to NHS Boards andindependent contractors in enabling them toensure their staff can respond to feedback andcomplaints and use this as ameans of deliveringservice improvements. The blended learningapproach taken of e-learning, master classes andface-to-face training has enabled learning rightacross organisations from the boardroom to theward or clinic and also for individual practice.’

E-learning

The SHC report highlighted that to date around3,000NHS staffmembers had undertaken e-learningmodules developed by SPSO andNHSEducation for Scotland (NES), and that evaluation ofthesewas positive.

Our e-learning partnershipwithNES began in 2012and in 2012/13we jointly developedmodules forfrontlineNHS staff. In 2013/14, we built on this,developing an e-learningmodule on investigationskills. This helps participants explore the complaintinvestigation journey fromfirst receipt through tothe final decision. It also dealswith how lessonsfrom complaints can be learned and shared, andincludes examples of good practice.

All our e-learning trainingmaterials are currentlyfree and available to all public sector organisations.TheNHS in England are adapting themodules foruse in training their staff.

SHCListeningandLearningreport recommendations

> NHSEducation for Scotland/Scottish PublicServices Ombudsman online e-learningmodules are recognised as an essential basictraining requirement for all staff providingdirect services for patients, as a priority.

> Power of Apology training ismade a priorityfor those staff with responsibility formanaging, co-ordinating and contributingto complaints responses. Considerationshould be given to central funding tosupport the attendance and delivery of thislocally/nationally as required.

NHSEducation for Scotland should:

> Ensure that the new complaints investigationskills e-learningmodule is publicisedand disseminated acrossNHSScotland forstaff who are investigating complaintsincluding thosewho are involved in preparingandwriting complaints responses. Thismayinclude the provision of face-to-face training tosupplement the e-learning, where necessary.

Direct delivery courses

In 2013/14we provided four direct delivery coursesto health organisations, ourmain focus having beenon other sectors.We do, however, anticipate furtherdemand from theNHS in the future following theSHC report’s recommendations on training andon developing theNHS complaints process.

In addition to the direct delivery courses, wedeveloped tailoredmaterials for GPs and dentists.With the support of NES, we created audio casestudies as a training tool for practicemanagers.SPSO trainers also deliveredworkshops on how touse thematerial to over 200 GP and dental practicemanagers, who could then cascade the learningthroughout their own practices.

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Improving complaints standards

Accountability and governance– creating the right culture

Listening and Learning also drew attention to theOmbudsman’smaster classes on complaints aspart of corporate governance and responsibility forexecutive and non-executive boardmembers.Wedeveloped these in partnershipwithNES and ranthem inNovember andDecember 2013. Theyweredesigned to support these boardmembers andsenior level staff by raising awareness of theimportance of robust complaints and feedbackarrangements in improving the care andexperiences for peoplewho use their services.They focused on the value of complaints asindicators of performance, service quality and riskand used lessons from the Francis report on thefailures at NHSMid-Staffordshire to highlight therisks of not including complaints informationas a core part of a board’s approach to gainingassurance about the service being provided.A video recording of the session is available ontheNESwebsite alongside all the other tools thatwe have developed forNHSScotland staff.

Participants reported that the sessions hadsignificant impact and the Ombudsman has sincedelivered a number of tailored sessions to individualNHS boards. This reflects how vitally important it isthat the leaders of organisations create and embeda culture of person-centredness, transparency andcandour, where complaints arewelcomed andvalued, wherever they come from.

Formore about our training activities, visitwww.spsotraining.org.uk

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In 2013/14we strengthened our linkswith otherscrutiny, regulatory and improvement agencies, aswell aswithNHS boards and other stakeholders, inorder tomaximise the learning from the complaintspeople bring us. In the previous sectionwe outlinedthework that wewill be taking forwardwith theScottishHealth Council and others to improve theNHS complaints procedure andwider aspects ofcomplaints handling. Other key interactionswithstakeholder agencies are described below.

Adverse eventsworking groupWe took part in Healthcare Improvement Scotland(HIS)’s working group looking at new guidance foradverse incident reviews. Therewere areas ofclearmutual learning – for example, the groupnoted a significant overlap in the skills needed toinvestigate complaints and to review adverseevents, and looked at supportingNHS boards totranslate learning into service improvement andto share outcomes across services and boards.Theworking group reported inMay 2014, andweare continuing toworkwith HIS to take forward therecommendation to align learning from complaintsand adverse events.

Sounding boardsWewant to involve the public and theorganisations that we investigate in helping usimprove our service. We also want to understandthe challenges faced by the NHS, and ensure thatour recommendations are clear and relevant.To support this aim, we set up two soundingboards in 2013/14.

The customer sounding board ismade up ofmembers of different public service user groupsincluding Age Scotland, Alliance Scotland, a prisonvisiting committee, Citizens Advice Scotland,Patient Opinion Scotland and the Scottish

Independent Advocacy Alliance. We welcomedtheir input to the information we give customersabout our service and on initiatives such as ourproposed revised service standards. The soundingboard also discussedmore general themes suchas social media and other routes for feedback andcomplaints, people’s experience of health andsocial care integration complaints pathways andprisoner access to complaints processes.

In 2013/14, our NHS sounding boardmet twice,following its inaugural meeting in March 2013.It is made up of senior NHS professionals fromacross Scotland, including representatives ofchairs of boards, chief executives, medical andnursing directors and complaints handlers.The sounding board allows for frank, two-waydiscussions about our role and effectiveness.It helps us listen to where we can improve ourservice, and provides a constructive environmentfor discussion and better understanding of issues,away from the consideration of individual cases.At its most recentmeeting, areas discussedincluded the Scottish Health Council’s reviewof complaints and feedback; the key role ofgovernance and culture in complaints handling;SPSO’s NHS training; how the SPSO usesindependent professional advice; prisonerhealthcare; health and social care integration;and redress and apology.

Evidence to committees andconsultation responsesThe complaints that people bring us provide avaluable source of information about their directexperiences of using health services andcomplaints systems.We use this knowledgeto informour responses to inquiries andconsultations.

Policy and engagement

Formore information visitwww.spso.org.uk/sounding-boards

PAGE 29

Policy and engagement

Health and social care integration

In October 2013, Parliament’s Health and SportCommittee invited us to give evidence about therole of regulators and complaints bodies in relationto integration.We highlighted how important it isfor the complaints route to be clear and accessibleto service users, and for there to be no legislativebarriers that restrict the ability of public bodiesto investigate and respond to complaints in ajoined-upway.We remain concerned that it is stillunclear how complaints about the newbodiesand integrated serviceswill be handled, andwecontinue to raise this issue. These concerns are allthe stronger because people using health andsocial care services can often be vulnerable.

At the evidence session, the Ombudsmanexpressed his concern about the time it is takingfor simple, coherent and effective complaintsprocedures to be put in place. He commented‘...If we are serious about integration, all aspects […]should be looked at, which should includecomplaints. It is amatter of some urgency. I wouldnot want a system to be put in place and then havea lag on the complaints side that causes people tobecome frustrated with the system and begin tolose confidence in it. I urge people to think carefullyabout that.’

Wehighlighted the need for clarity aroundcomplaints in two other policy areas in 2013/14.Thesewere in our responses to separate ScottishGovernment consultations on guidance in relationto self-directed support and to the delegation ofsome local authority functions undermentalhealth and adults with incapacity legislation.

Barriers to prisoners raising complaints

Following the transfer of responsibility ofhealthcare in prisons to theNHS, we identifiedsome barriers to prisoners raising complaints.We raised these concerns early on,most publicly inJanuary 2013when the Ombudsman gave evidenceto theHealth and Sport Committee. In aMay 2013

investigation (case 201203514) we found that aprisoner had been unreasonably denied access tothe process.We commented in our newsletter andsubsequent evidence to theHealth Committeethat: ‘It is now 18months since the transfer ofresponsibility and it is high time that these issueswere fully addressed.’

In October 2013, we highlighted the same issuesappearing in a different health board – this featuresas one of our case studies elsewhere in this report(case 201203374). In written evidence to theHealthCommittee before a second appearance there inFebruary 2014, we said that while we appreciatedtherewould be a time lagwhile problems are ironedout, wewould be very disappointed if wewerecontinuing to report on access issues into 2014.

We receive dozens of contacts fromprisonersacross the Scottish prison estate. Like everyonewho is concerned about their health, some of theprisoners phoning our office are, aswell as needingmedical attention, very anxious and upset. Thosefeelings are compounded by frustration at beingunable to access theNHS complaints procedure.We have been advised by Scottish Prison Servicestaff that this can lead to potentially difficultsituations arising.We have shared this warningwith Scottish Government officials andwerepleased to see some progress in the formofreminders to relevant health boards about thecorrect process and the need for complaints formsto bemade available.

It is clear fromdiscussionswith somehealthboards that access by prisoners to theNHScomplaints process remains problematic. It isworth noting that the numbers of complaints wereceive remainswell below the levels escalated toScottishMinisters under the previous complaintssystem. It is also clear to us that the quality ofhealth boards’ responses to complaints fromprisoners is variable.We are continuing to raisethis with the boards concerned.

Formore information see www.spso.org.uk/consultations-and-inquiries

PAGE 30

Statistics

Further information is available atwww.spso.org.uk/statistics

Stage

Outcome

Adv

ice

Not

duly

mad

eor

with

draw

n4

111

220

330

52

20

03

34

120

130

331

Out

ofju

risdi

ctio

n(d

iscr

etio

nary

)1

00

174

00

10

00

00

00

02

025

Out

ofju

risdi

ctio

n(n

on-d

iscr

etio

nary

)0

00

54

31

00

00

00

31

01

119

Out

com

eno

tach

ieva

ble

32

430

90

31

11

11

00

80

11

66

Pre

mat

ure

111

2516

228

015

42

00

33

221

02

1829

7

Res

olve

d0

00

00

01

00

00

00

01

00

02

Total

194

40434

783

258

51

17

69

430

750

740

Early

Res

olut

ion

1N

otdu

lym

ade

orw

ithdr

awn

20

323

130

03

10

01

00

20

10

49

Out

ofju

risdi

ctio

n(d

iscr

etio

nary

)0

01

174

02

01

00

00

00

01

026

Out

ofju

risdi

ctio

n(n

on-d

iscr

etio

nary

)0

00

63

00

00

00

10

13

10

015

Out

com

eno

tach

ieva

ble

00

321

50

11

10

11

11

10

00

37

Pre

mat

ure

10

536

40

31

00

00

10

20

00

53

Res

olve

d1

00

103

01

10

00

00

11

00

018

Total

40

12113

320

76

30

13

23

91

20

198

Early

Res

olut

ion

2Fu

llyup

held

01

25

40

21

00

02

00

00

00

17

Som

eup

held

00

12

00

00

00

00

10

00

00

4

Not

uphe

ld1

06

246

02

00

00

01

11

00

042

Not

duly

mad

eor

with

draw

n0

00

50

01

00

00

01

00

00

07

Res

olve

d0

00

00

00

00

00

00

00

00

00

Total

11

936

100

51

00

02

31

10

00

70

Inve

stig

atio

n1

Fully

uphe

ld3

07

534

02

01

00

00

02

01

073

Som

eup

held

42

063

50

10

00

00

40

20

10

82

Not

uphe

ld0

03

998

01

10

00

01

02

00

011

5

Not

duly

mad

eor

with

draw

n0

00

70

00

00

00

00

00

00

07

Res

olve

d0

00

10

00

00

00

00

00

00

01

Total

72

10223

170

41

10

00

50

60

20

278

Inve

stig

atio

n2

Fully

uphe

ld0

00

230

03

00

00

01

00

00

027

Som

eup

held

10

010

00

00

00

00

00

00

00

11

Not

uphe

ld0

00

00

00

00

00

00

00

00

00

Total

10

033

00

30

00

00

10

00

00

38

Totalcom

plaints

327

71839

137

344

169

12

1217

1359

111

501,324

Admission,discharge&transfer

Appliances,equipment&premises

Appointments/admissions

Clinicaltreatment/diagnosis

Communication,staffattitude,dignity,confidentiality

ComplaintsbyNHSstaff

Complaintshandling

Continuingcare

Failure/delayinsendingambulance

Hotelservices(food,laundry)

Hygiene,cleanliness&infectioncontrol

Lists

Nurses/nursingcare

Other

Policy/administration

Pre-contractual/commercialmatters

Record-keeping

Subjectunknown/outofjurisdiction

Total

Health

casesde

term

ined

2013/14

SPSO4 Melville StreetEdinburghEH3 7NS

Tel 0800 377 7330Fax 0800 377 7331Web www.spso.org.ukCSA www.valuingcomplaints.org.uk