Wednesday 26 March 2014

Welcome to SPSO News. In his overview, the Ombudsman draws attention to ways in which we are supporting the NHS to improve the quality of their complaints investigations. He also highlights two recent sounding board meetings (for local government and customers) and the SPSO's continuing recognition as an Investor in People. We also provide an update from the Complaints Standards Authority about our work with different sectors including local government, further education and the NHS. 



I laid three investigation reports about the NHS and a report on 73 decisions about all of the sectors under our remit before the Scottish Parliament today. All the reports can be read on the ‘Our findings’ section of our website at www.spso.org.uk/our-findings and via links within this email.

Overview

Investigation reports
The three main reports I am laying today are about the NHS. As is so often the case, the events described had devastating consequences for the people involved. The reports also contain lessons for the NHS in Scotland as a whole, particularly in relation to the quality of their investigations into what went wrong.

Each complaint I report today had, rightly, undergone an investigation before reaching our office. However, in each case, I found significant failings not only in the clinical care or treatment provided, but also in the investigations themselves, which is a concern and is something which contributes to the high level of health complaints upheld by my office. I want to emphasise the recommendations we are making to those organisations to improve their individual practices. I also want to mention the work we are supporting to build a national approach to learning from adverse events, and our NHS complaints training activities. 
 
In one report (case 201301204), I express great concern about aspects of the ambulance service’s internal investigation process into how paramedics treated a man after he fell at home. To address the failings I found, I have made a far-reaching recommendation, requiring the ambulance service to externally audit their complaints handling processes to ensure that they are sufficiently robust and fit for purpose. 
 
In my report about a health board (case 201205005), as well as clinical issues, I found failings in the way the board carried out their critical incident review. The family of a woman who died of ovarian cancer were not told that the review was taking place and did not see a copy of the report of the review until almost a year after it was carried out. There was also significant delay before the board met with the family, and one of the seven recommendations that I made in this case related to that.
 
In my report about a GP practice (case 201300703), which was about the care of a child who later died, my adviser expressed concerns that one of the conclusions from the practice’s significant event analysis (SEA) had not been conveyed to the child’s mother. My adviser was also concerned that, after carrying out the SEA, the practice said that they would not in hindsight have managed the child’s care in a different way. My adviser expressed concern about what would happen if a similar situation happened again. My recommendations in this case focused on apology, and learning for the GPs concerned.

Supporting improvement
The findings of our reports can also be a very useful tool for improvement agencies.  We are pleased to support Health Improvement Scotland’s work to build a national approach to learning from adverse events through reporting and review.  HIS published the framework for a national approach in September 2013, and invited SPSO to join one of the work streams they identified, which is about learning and improvement. The work of the learning and improvement group and its findings will be fed back at a National Learning Event later this year.  I look forward to continuing to contribute to this work, through highlighting the findings of our investigations and sharing our expertise in complaints handling.
 
Another way we support improvement is through NHS complaints training.  As part of our two-year package of training for the NHS, delivered in partnership with NHS Education for Scotland (NES), we have recently developed with NES an e-learning module on investigation skills for NHS staff who investigate complaints. The modules will be made available to NHS Boards in the coming weeks.  They will  be accessible from the Little Things Make a Big Difference website (a website for NHS frontline staff) along with other feedback and complaints resources.

Listening to service users
As I have reported before, we have set up a series of sounding boards to provide feedback on the way that the SPSO is performing and the opportunity to discuss key issues in complaints and public services.  Following the introduction of NHS and customer sounding boards last year, a third sounding board is now in place for the local government sector.
 
Attendees have found that the meetings provide an excellent forum for discussing both the service provided by SPSO and wider complaints handling issues. Key subjects include access to complaints procedures, using complaints information to improve services and benchmarking of performance as well as forthcoming developments in areas such as social work and the Scottish Welfare Fund. Each sounding board will continue to meet approximately three times a year.
 
Local government sounding board
We held the inaugural meeting of this sounding board on 12 March. The chair of SOLACE (Local Authority Chief Executives) and the Ombudsman jointly issued the invitations. Representatives on the group include SOLAR (Local Authority Lawyers), ADES (Directors of Education), ADSW (Directors of Social Work), HoP (Heads of Planning), CIPFA (Chartered Institute of Public Finance and Accountancy), the Improvement Service and the chair of the local authority complaints handlers’ network.
 
Discussions focused on the successful implementation and operation of the local government model complaints handling procedure, and the shifting focus to consistent reporting and benchmarking of complaints performance and learning from complaints, including how to align the roles of the Improvement Service, the local authority complaints handlers’ network and others with a role in supporting improvement.  We also discussed progress in relation to social work complaints and the Scottish Welfare Fund.
 
Customer sounding board
This sounding board is made up of representatives from Citizens Advice Scotland, Consumer Futures, Patient Opinion Scotland, the Tenant Participation Advisory Service, Alliance Scotland, Age Scotland, a prison visiting committee (Cornton Vale), and the Scottish Independent Advocacy Alliance.  
 
At the second meeting, held on 19 March, the sounding board was invited to input on service improvements that the SPSO is currently reviewing, and discussed social media and other routes for feedback and complaints. There was also debate about people’s experience of health and social care integration complaints pathways, prisoner access to complaints processes and the Scottish Welfare Fund.
 
Investors in People
I am very pleased to report that we have continued to be recognised as an Investor in People. We achieved IIP recognition in March 2011, and the three year review was carried out earlier this month through an external independent assessment visit. The broad aims were to seek confirmation of good practice and identify development areas to support continuous improvement against the 39 core evidence requirements (Investors in People Standard) with particular focus on:

• delivering a high quality service with clear values and standards of performance defined and addressed through effective communication and consultation
• achieving and maintaining a clear and consistent approach to leading and managing people with an approachable, supportive and motivational style
• being recognised as a learning organisation as a result of the commitment to meeting the learning and development needs of people to build individual, team and organisational capability.

Once the assessor’s report has been finalised, it will be published on our website.
 
Read my Overview and summary of today's investigation reports here, or via the links below.

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"Although it is not possible to say whether earlier diagnosis would have made the outcome any different, it could have meant that Ms A had earlier access to proper relief for her symptoms, and she and her family would have had more time to prepare for the outcome."

Clinical treatment; diagnosis
Tayside NHS Board (201205005)

> Read full report (PDF)
> Read summary (PDF)

"Mrs C complained that the ambulance service failed to ensure that paramedics used a stretcher and neck brace when transferring her husband to hospital after a fall. Mr C is now paraplegic, and Mrs C believes that the action of the ambulance staff contributed to her husband's paralysis."

Clinical treatment; diagnosis
Scottish Ambulance Service (201301204)

> Read full report (PDF)
> Read summary (PDF)

"...the guideline outlines that there should be an urgent referral where there is no clear diagnosis after about three visits with same problem, and the parent’s knowledge of the child should be taken into account.  It also includes a list of symptoms, including several that Master A clearly had."

Clinical treatment; diagnosis
A GP practice in Fife NHS Board area (201300703)

> Read full report (PDF)
> Read summary (PDF)

Complaints Standards Authority

• local authorities: the next complaints handling network meeting focusing on benchmarking
• further education: the first meeting of the FE complaints handling advisory group
• Scottish Government, Scottish Parliament & associated public authorities in Scotland: reminder of the CHP implementation support available
• NHS complaints handling: our involvement in the Scottish Health Council's review of complaints handling