Welcome to SPSO News. Today we are laying 71 reports before the Scottish Parliament. One of these is a full investigation report about the NHS. This overview contains:
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All of the decisions that we are publishing today can be found on our website at: www.spso.org.uk/our-findings.
Overview
Read the Ombudsman's Commentary in full (PDF, 215KB)
Last month (in May), we received 401 complaints. We determined 413 complaints and of these we:
- gave advice on 197 complaints
- considered 144 complaints at our early resolution stage
- decided 72 complaints at our investigation stage
We made a total of 115 recommendations.
Key casework outcomes
Consent and DNACPR
I am highlighting today the application of do not attempt cardiopulmonary resuscitation (DNACPR) orders, which features in four of today’s decisions. In one (
201507639) I found that staff had acted in accordance with the guidance on this area, which is clear that a patient with capacity can consent to or refuse CPR, and that if they lack capacity the decision rests not with the next of kin but with a legally appointed proxy or with the lead clinician. In another case (
201406607) however, I found that, among other failings, a man had not been properly involved in the decision about his mother’s DNAPCR status, despite him holding welfare power of attorney. In case
201507581, we were critical of the failure to complete a DNACPR form and the low level of detail in the medical notes surrounding the decision. In the final case (
201508900), we identified a communication issue in relation to the decision not to resuscitate, and we noted that Healthcare Improvement Scotland had since inspected the hospital and identified a similar issue. We made a number of recommendations to address the failings we identified.
Anti-coagulant therapy
Today’s full investigation report (
201507970) concludes that a hospital failed to provide a patient with appropriate anti-coagulant therapy following a hip replacement operation. The patient was given aspirin to take, and around two weeks later he was readmitted to hospital with a pulmonary embolism (a clot in the blood vessel that transports blood from the heart to the lungs).
There are national guidelines, issued by the Scottish Intercollegiate Guidelines Network (SIGN) and the National Institute for Health and Care Excellence (NICE), which relate to the use of treatments to prevent VTE (the formation of blood clots in the vein). These guidelines state that aspirin is not considered an adequate treatment for reducing the risk of VTE for patients in hospitals. I am very concerned not only that the relevant guidelines were not followed in this case, but also about the board’s practice in general. It remains unclear to me if the board have a coherent policy that is being followed within the hospital and beyond. As a result, an urgent review is required. I have also written to the Chief Medical Officer to draw their attention to my concerns about the use of aspirin and its potential implications for patient safety which have come to light in the course of this investigation.
Unmet communication needs
Another case that has wider learning relates to the way the consultation booking process and the consultation itself failed to meet the needs of a woman with autism, dyslexia, Asperger’s syndrome and anxiety (
201401536). It was unclear to me that the process around the consultation booking and consultation procedure adequately met the needs of individuals with disabilities. Our investigation found that the process, whereby the referral was read just before the patient was seen, did not enable the board to plan ahead and make reasonable adjustments once a patient’s needs were known. I took independent advice on this case from an equalities adviser and have written to the Equality and Human Rights Commission for Scotland to highlight our findings as well as informing the Chief Medical Officer of my concerns.
Neighbour nuisance
In one of the local authority decisions, we found that the council had followed their anti-social behaviour policy, including visiting the property, trying to get the parties involved to fill in diaries or provide statements, offering to install noise monitoring equipment and working directly with the tenants concerned (
201508513). We found that the council acted swiftly, and we did not uphold the complaint.
Prisoner property
While this investigation (
201502781) was about an individual prisoner’s claim for compensation when an item of property went missing, we found that there was a general lack of awareness of the procedure that staff were supposed to follow. Our recommendation therefore addressed the failings in this case, and also asked the prison service to provide us with details of the outcome of the stated reviews being carried out to their processes of recording prisoner property and assessing claims of lost property.
Learning and Improvement Unit (LIU)
Resourcing and recruitment for this new one year pilot project is now in place. Its purpose is to increase the impact our work has in supporting public service improvement. It aims to further the effectiveness of our recommendations by enabling authorities to use our work to learn from complaints to improve the delivery of frontline services. It will also benefit SPSO by improving our efficiency. The LIU was proposed in our 2016-2020 draft strategic plan which went to public consultation. It was the most commented on aspect of the plan, and received significant support from respondents, who were mostly public authorities and advice/advocacy organisations. We were successful in applying for one year funding for the unit for 2016-17.
Learning and improvement statement
Provisions in the Public Services Reform (Scotland) Act 2010 gave SPSO the duty of promoting of best practice in complaints handling. This explicitly includes monitoring practice, identifying trends in practice, promoting best practice, and encouraging co-operation and sharing of best practice.
As we did last year, in order to promote best practice in learning from complaints we will again be asking authorities in the main sectors we receive complaints about to confirm that SPSO complaints are reviewed at a senior level (such as the appropriate scrutiny/ governance/ performance committees) by returning a learning and improvement statement to us. This builds on the model complaints handling procedures that set out the importance of authorities demonstrating how they ‘systematically review complaints performance reports to improve service delivery’. As we informed members of our local authority sounding board at our June meeting, the statement will be included in our annual letters to authorities, which we will issue later this summer.
Social work complaints
The Public Services Reform (Social Work Complaints Procedure) (Scotland) Order 2016 abolishes the existing social work complaints process. It also contains provisions to allow the SPSO to consider the professional judgement exercised on behalf of local authorities and allows for the sharing of information between the SPSO, Care Inspectorate and the Scottish Social Services Council when appropriate.
The order comes into force on 1 April 2017. The abolition of the current system means that we are now starting work to develop a process for social work complaints that aligns with the current model CHPs in use across the public sector. We will work closely with the Government, local authorities (including social work professionals), third sector, advocacy groups and other key stakeholders both in developing the new process and preparing for our new role. We will also consult with stakeholders as we plan for the effective implementation of this new area of jurisdiction.
Scottish Welfare Fund
We are approaching the end of our third month in our new role as SWF independent reviewer and the team is gaining experience in dealing with a diverse caseload, covering a broad range of applicant circumstances.
Casework outcomes
One of the key arising themes we have considered in recent weeks is around the qualifying criteria ‘to enable qualifying individual to maintain a settled home where that individual, or another individual in the same household, is facing exceptional pressure’. In one such case, an applicant applied to the fund for clothing, carpets and a bed as she could not afford these items. She advised that she had a bed on hire purchase but this was causing hardship and didn’t suit her needs. The council considered that the applicant did not meet the criteria of being under exceptional pressure. We contacted the applicant and obtained further information about her circumstances and the pressure her family was facing. This included health problems and disabilities experienced by herself and one of her adult children. The applicant also advised that she had financial problems exacerbated by her hire purchase payments and on one occasion she was unable to pay for electricity for several days which meant that she couldn’t use her oxygen machine. She also advised that the lack of flooring was having an impact on her mental health. On this basis we considered her family could be deemed to be under exceptional pressure and upheld her review. We awarded her the flooring and bed, although we did not award clothing as we deemed this to be an ongoing need.
In another case, a young man applied to the fund for items for his new tenancy. He was planning to move in with his girlfriend, who was experiencing difficulties at home. Prior to being allocated his tenancy, the applicant was living with family and shared a room with a relative who had disabilities. The council did not make an award as they considered that the couple did not face exceptional pressure in their new tenancy. We agreed with this assessment as while the couple’s situation had been very difficult, they did not have any ongoing health problems or other factors that we considered could class them as being under exceptional pressure in their new home.
Engagement and awareness-raising
The team has continued its engagement with the third sector this month, including presenting at various events for advice workers including the CPAG conference. Our first third sector sounding board since the launch of the service took place on 8 June during which valuable insights were gained into the needs of specific groups when accessing the fund. On the same day, we held our local authority sounding board and this was extremely well attended with representatives from 19 councils attending. In addition, we participated in regional Scottish Government workshops for SWF decision makers as part of their SWF Continuous Improvement Strategy. The team plans to carry out further engagement with key stakeholders throughout the year as the service develops.
Complaints Standards Authority (CSA)
Further Education
The complaints handling advisory group held its annual ‘Improving Complaints Handling’ event in April. Delegates were updated on the key findings of the sector’s complaints performance for 2014-15. It was recognised that learning from complaints, and the ability to demonstrate this learning, should be a priority area for the sector moving forward. Delegates also enjoyed a presentation on the advisory group’s work on developing standardised complaints categories for colleges. It was agreed that the sector would move to adopt the standardised categories from the start of the next academic year. Other sessions included case studies on complaints management processes and an update on measuring and driving improvements through customer satisfaction feedback.
A further session featured ‘An Introduction to the Complaints Improvement Framework’. Edinburgh College reported that they had trialled the framework to better understand their complaints handling performance. As a result the college developed a complaints improvement plan. Delegates then participated in workshops to consider the six areas of good practice to identify the priority areas to be addressed by the advisory group over the next year.
Feedback on the event was extremely positive in respect of the excellent work this network is doing to identify and share best practices in complaints handling. We encourage any college that wants to know more about the advisory group to contact us at CSA@spso.org.uk
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Local Government
The local government complaints handlers network met in June. Members enjoyed a presentation from Patient Opinion/Care Opinion. Patient Opinion is about honest and meaningful conversations between patients and health services. The basic principle is that people share their story of using a health service online. The story is sent to staff in the appropriate organisation so that they may learn from the experience. Care Opinion in Scotland adopts a similar approach to telling stories through a website where service users and carers can safely share their experience of care at registered care providers. Knowledge of this resource was felt to be particularly valuable to those organisations providing integrated care services.
We presented a session on the forthcoming changes in respect of social work complaints and responded to questions about how the changes would impact on local authorities. Other sessions included an examination of how well prepared the network is to face future challenges, and discussions on the priorities for the network over the next year.
Members unanimously agreed to a proposal that the network be co-chaired by South Lanarkshire Council and Fife Council. Members also acknowledged the need to provide additional support to the network in relation to the administration and facilitation of meetings.
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NHS
Our work to develop a revised NHS model complaints handling procedure (CHP) continues to make good progress. The project is led by a steering group (chaired by CSA) and supported by three discrete working groups, each tasked with developing key parts of the revised procedure. These are the CHP development group; the data recording and reporting group; and the learning and training group.
The June meeting of the steering group considered outputs of each working group. The draft model CHP and supporting documents, together with the final reports from the data recording and reporting group and the learning and training group, were agreed by the steering group. We will now work closely with the Scottish Government to prepare the draft procedure for publication. We will also engage with NHS Education Scotland (NES) through the learning and training group to provide a program of activities to support NHS organisations as we move towards planning for the implementation phase. The NHS model CHP will be implemented by NHS Scotland from April 2017.
For all previous updates, and for more information about CHPs, visit our dedicated website www.valuingcomplaints.org.uk.
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SPSO Training Events
Upcoming courses (all based in central Edinburgh)
Complaint investigation skills (stage 2 of the model CHP)
1-day open course
Tuesday 29 November
Managing Difficult Behaviour
Wednesday 28 September
These are open to staff from all sectors under the SPSO’s jurisdiction. Full course details are available on the SPSO Training Unit website.
For general information see our flyer: SPSO Training 2016 (PDF, 40KB)
For more information and to book spaces, please contact training@spso.org.uk
Jim Martin, Ombudsman | 22 June 2016
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