Wednesday 24 July 2013

Welcome to SPSO NEWS. In this edition you will find our latest decisions on complaints about public services and the Ombudsman's commentary on this month's reports. In his newsletter, the Ombudsman highlights our work on NHS complaints in Scotland and cases involving the care of vulnerable adults.  He also provides an update on the work of our Complaints Standards Authority.



I laid two investigation reports before the Scottish Parliament today, on about a health board and one about a Commissioner.  I also laid a report on 65 decisions about all of the sectors under our remit.  All of the reports can be read on the ‘Our findings’ section of our website at www.spso.org.uk/our-findings.
 

Overview

Investigating complaints
There has been a great deal of review, scrutiny and public discussion of complaints handling in the NHS in England over the past weeks andmonths. Understandably, this causes concern in Scotland as well, among patients, relatives, carers and healthcare professionals in the many environments where people are ill and cared for.  It also highlights the role of all of us whose aim is to ensure that complaints are investigated robustly and transparently, that failings are addressed and learning from complaints is shared to prevent the problem happening again. Importantly, it also shows the need for assurance that the various organisations responsible for inspecting and improving services and dealing with complaints are talking to one another.

Our 2012/13 report on NHS complaints in Scotland is due to be published later this summer. As I have said in previous e-newsletters and elsewhere, we are taking a different approach to publishing information about our work this year. Our annual report will chart progress against our 2012/16 Strategic Plan and is devoted largely to corporate information. We will publish separate, more in-depth statistics, trends and analysis about each of the main areas under our remit over the rest of the summer and early autumn.

However, given the level of concern about NHS complaints, I want to make a number of points clear today. In 2012/13, we published the outcome of a total of 850 investigations – 806 decision reports and 44 full public reports (investigations that satisfied my public interest criteria and which we publish in detail). Of these, 330
decision reports and 34 detailed reports were about the NHS. We carry out more investigations into the health sector than any other area under our remit, in part because in health complaints we have greater powers, in that we can look at professional judgement.

We make all our reports publicly available on a regular basis, publishing around 30 decisions about the NHS each month, and drawing attention to specific issues or trends in this e-newsletter. Today, I am highlighting failings in the care of vulnerable adults in five published decision reports and one detailed investigation report.

The detailed investigation report helps me make my final point, which is about our relationship with inspectorates, regulators and others who work to improve public services. Our role is to seek redress for people at an individual level. However, if an investigation points to the possibility of a systemic issue, we can and do make broader recommendations as well as publicly alert the appropriate regulator to look into the matter. Today’s investigation report is one such example, where I have drawn issues of concern to the attention of the Mental Welfare Commission for Scotland (MWCS). In a previous report (case 201003482) I looked at an issue on which the MWCS had already conducted a review, because I decided that the SPSO’s approach of focusing on finding answers to an individual’s experience would add value.

As I said in my comments about our investigation report at the time, there can be insight and learning from the different approaches of organisations with different roles (to read my April overview see: http://www.spso.org.uk/files/webfm/Commentaries/2013/2013.04.24_SPSO_Commentary.pdf).

What is essential is that organisations share information and concerns, within the legal limits under which they operate, especially where there may be any risk to the public. Our arrangements with professional regulatory bodies, regulators and others are set out in a series of protocols and Memoranda of Understanding, which are published on our website at http://www.spso.org.uk/freedom-information/spso-publications-list/about-spso.

Vulnerable adults
A key theme of some of the reports I am publishing today is the care of vulnerable adults. I have raised this issue several times in previous e-newsletters and annual reports, highlighting a lack of awareness or misunderstanding of the Adults with Incapacity (Scotland) Act 2000. This has led to problems such as failing to assess a person’s capacity to make decisions for him/herself on admission to hospital, or to recognise a carer or family member’s role when making decisions about the treatment of a vulnerable adult.

All of the cases I highlight today came about from an overwhelming sense of frustration on the part of the family, carer or advocate as they, unsuccessfully, tried to get their concerns heard and taken into account. One complaint (case 201104966) was brought to us by an independent advocate and was about the care of a woman (Miss A) who had Down’s Syndrome, a learning difficulty and severe dementia. She had no family and no welfare guardian. The advocacy worker had been appointed to ensure that Miss A’s rights were enforced and protected.

The advocacy worker complained to us after Miss A’s death about two aspects of her care – decisions taken by staff about artificial feeding, and lack of consultation with the advocacy worker about a decision taken in advance not to resuscitate Miss A if she had a cardiac arrest. I upheld Ms C’s complaints, and a further complaint about an inaccuracy in the board's response to her complaint.While I recognise that the board have made a number of positive changes since the time of the circumstances that gave rise to this complaint, I am critical of the quality of decision-making, consideration of capacity issues and recording of these issues with respect to a most vulnerable member of society. I have also referred this case to the Mental Welfare Commission for Scotland who have an oversight role in this area.

Five decision reports published today also concern the care of vulnerable people. Like the detailed investigation report I describe above, we make these reports available on our website to raise awareness of our findings as a tool for learning and improvement.

One of the reports (case 201104503) is about an elderly woman with Alzheimer’s disease, who was taken to hospital after she broke her hip in a fall at her care home. After she was discharged she fell again and broke her arm. She did not recover, and died in hospital. Her capacity was not assessed while she was there and there was failure to communicate with her daughter who held welfare power of attorney. We also highlighted our finding about a Healthcare Inspectorate report. The board had said in their response to the original complaint that this report found that they were delivering a high standard of care to elderly patients with cognitive impairment. However, our investigation found that it had, in fact, highlighted the need for improvements in the areas of assessment and care planning. We made several recommendations as a result of this investigation, which can be read in the decision report on our website.

A second complaint (case 201200935) was about a man with dementia, for whom a brother had welfare and continuing power of attorney. The man’s capacity was not fully assessed in hospital and communication needs were not met.

A further complaint (case 201103345) was from the son and daughter of a man who died in hospital several weeks after being admitted with a urinary tract infection. The man’s daughter was unhappy that during an earlier hospital admission, no senior member of staff contacted her to discuss her father’s care, even though she held a power of attorney for her father. In particular, she was concerned about the hospital’s decision to withdraw life supporting medication during the first admission and, while we did not uphold the complaints about her father’s clinical treatment, we made a recommendation to ensure that when changes in medicines are made for patients with diminished capacity, such changes should be discussed with their carers.

Another complaint (case 201200873) concerned a woman with dementia whose sister was welfare guardian. We upheld the sister’s complaint that she was not consulted, as she should have been, by the GP about a prescription for a drug given to the woman. In a further investigation (case 201200060), we did not uphold the complaint but we made recommendations about a very unwell man with learning difficulties, who developed dementia and died in hospital.

All of these cases occurred in the health sector, but this is not the only area where this is an issue. In last year’s annual report I said ‘For the protection of both patients and staff, it remains vital that authorities across Scotland properly understand and implement this legislation.’ I again urge all relevant authorities to ensure that they and their staff are fully aware of the provisions of the Adults with Incapacity Act. They should also ensure that their procedures and processes take the Act into account, particularly around communication about the needs and care of the individual. Person-centred care should be at the heart of all such processes and too often the evidence in some of the complaints we see shows that it is not.

Read my Overview and summary of today's investigation reports here, or by accessing the links below.

Investigation Reports

‘…these complaints raise serious concerns about the quality of decision making, consideration of capacity issues and recording of these issues with respect to a most vulnerable member of society, namely an adult with life-long learning difficulties and dementia. There are a number of legal safeguards
which should have been in place for Miss A precisely because of her degree of vulnerability, and it is of considerable concern that there were significant delays in enacting these.’

Artificial feeding; do not resuscitate decisions; adults with incapacity (full report)
Lanarkshire NHS Board (Ref 201104966)

> Read full report
> Read summary

"Mr C complained about the Commissioner’s handling of Mr C’s complaint about the actions of a councillor. Specifically, he complained that the Commissioner had failed to investigate his complaint adequately and that there were errors in his Note of Decision that remained uncorrected..."

Governance; complaints handling (full report)
Public Standards Commission* (Ref 201105266)

> Read full report
> Read summary

* From 1 July 2013, the Commission for Ethical Standards in Public Life in Scotland and two existing members – the Commissioner for Public Appointments and the Public Standards Commissioner – were restructured to establish one new office of the Commissioner for Ethical Standards in Public Life in Scotland.

Complaints Standards Authority update