Welcome to SPSO News. In his overview, the Ombudsman highlights:
• gave advice on 210 complaints
• considered 163 complaints at our early resolution stage
• decided 74 complaints at our investigation stage
We made a total of 126 recommendations.
Overview
Complaints and professional conduct
I was interested to note earlier this month that a Nursing and Midwifery Council (NMC) panel found that poor complaints handling potentially put patients at risk. They found a nurse guilty of misconduct for failing to declare that she was a friend of a nurse involved in a complaint. They said that the nurse had ‘failed to acknowledge the potential harm that patients could have suffered when she failed to objectively decide if a complaint had any merit.’
The report went on to say: ‘Whilst there were no concerns relating to [her] clinical practice, the panel considered that not dealing with the complaints efficiently, effectively and in a timely manner had the potential to put patients at unwarranted risk of harm.’ The NMC report can be read here.
Two of today’s investigations (201404767 and 201404874) involve inadequate handling of complaints, as well as clinical failings and poor nursing practice relating to the care of elderly women with dementia. I found that the nursing care was unreasonable in many areas – personal care, skin care, eating and drinking, assessment of falls risk, monitoring on the ward, care plans, record-keeping, communication with patients’ families including where the family held welfare power of attorney, discussions of confidential patient information, compassion and end of life care. I would urge nursing leaders to look at these two reports and particularly at the recommendations made which aim to ensure learning and prevent recurrence. Among the recommendations, I ask the boards to review nursing care and leadership on the relevant wards and to carry out a significant event analysis. We can only improve if we look at what happened and why, asking ourselves what went wrong in the interaction between the procedures and the people responsible for implementing them, ie what were the human factors? Complaints are a vital part of that learning loop.
Saying sorry right
The two other reports highlight clinical failings. One investigation (201405155) concerns insufficient care taken to assess a woman’s cardiac disease and blood loss. The other investigation (201406099) is into a man’s complaint about the toxic reaction he suffered after a second cycle of chemotherapy. In both cases, among other recommendations, I require the boards to ensure that the health professionals concerned take the failings into account in their annual appraisals/educational supervision.
In all four of today’s reports, as is often the case in NHS investigations, I ask the boards to apologise to the patients or their families. I would like to make the point that the apology should be made not for my benefit - and certainly not for the benefit of the media - but should be a sincere and heartfelt apology to the patient or their family. It must be genuine, focus on the harm caused to the people concerned, and say what the board is doing or has done to try to put things right.
Getting apology right is so important that we have published guidance on apology which can be read here.
Promoting good practice through learning and improvement
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, encouraging co-operation and sharing of best practice. This gives the Ombudsman the statutory authority to require relevant authorities to comply with any requirements the SPSO may make in relation to the promotion of best practice in complaints handling.
The model complaints handling procedures (CHPs) which were consulted on and developed in partnership with public authorities requires them to report and demonstrate learning from complaints. This is supported by the performance indicators which were developed in 2013/14. Among the requirements are that authorities show how they ‘systematically review complaints performance reports to improve service delivery’. Local authorities were the first sector to implement the model CHP and all councils reported against the indicators in 2013/14. Many councils and other authorities in our remit are exemplars in reviewing complaints information effectively at a senior level (such as the appropriate scrutiny/ governance/ performance committees). To extend this best practice, we have asked authorities from across the main sectors in which we work to confirm that SPSO complaints are similarly reviewed at a senior level by returning a learning and improvement statement to us.
Another area of good practice which is already in existence in many authorities is good complaints file management. We routinely ask all authorities to provide all the information relating to a complaint at the start of our investigation (not on every complaint, only on the ones that we have established are appropriate to be taken forward by us). To support them in this, we have now developed a self-assessment complaints handling reflective learning form. This should not create any extra work, as these are complaints that the authorities have already completed. In response to feedback at our sounding boards, we also extended the deadline for providing the complete complaints file by 10 working days.
Both the reflective learning form and the learning and improvement statement should provide the authorities themselves, and us, with assurance that complaints file management is of a high standard and that the learning from complaints is reviewed at a senior level and used to drive improvement.
Scottish Welfare Fund
Our consultation about our proposed implementation of our new Scottish Welfare Fund role closed on November 27. We received 24 responses, with the majority from local government and a significant number from the third sector. The responses are now being analysed and we will publish our analysis with the responses in the new year. All the responses will also be considered carefully in the run up to the implementation and we would like to thank all of those who took the time to contribute. We remain keen to listen as much as possible over the next few months and, while the formal consultation is now closed, are very happy to discuss the new role with anyone who has an interest.
Recruitment is underway for the welfare fund review team, which will be based in our Edinburgh offices. We are working closely with the Scottish Government and our two SWF sounding boards (made up of local authority and third sector representatives respectively) to ensure that we are on track to deliver the review service from 1 April. As well as developing the new guidance and process, we are expanding our website to include the new role. The site will host an online review function, and our new communications materials which we are preparing for user input in the new year. We will provide regular updates to stakeholders on our progress on the fund over the coming months.
If you have any questions meanwhile, please contact Paul Smith, SWF project lead, at paul.smith@spso.org.uk or 0131 240 2969.
SPSO Draft Strategic Plan Consultation
We have received a number of responses to our Plan, which lays out the key challenges and opportunities we foresee over the next four years and how we are preparing for them. The full consultation can be found on our website, and is open until 18 December.
Our Complaints Standards Authority update is below.
Read my overview and summary of this month's investigation reports in PDF (196KB) or via the links below.
'advice from a cardiologist was not sought when Mrs A was admitted to the emergency department. It was also not sought at a time when, according to my adviser, signs were very suggestive that she had had a heart attack.'
Clinical treatment; diagnosis
Lanarkshire NHS Board (201405155)
View a summary of this case and download the full report on the SPSO website
'the psychiatric nurse adviser was very critical of the nursing care Mrs A received, and concluded that it was disorganised, unsystematic and unreasonable.'
Nursing care; clinical treatment; record-keeping; complaints handling
Highland NHS Board (201404874)
View a summary of this case and download the full report on the SPSO website
'I found that there were failings at almost every contact Mr C had with health care professionals in relation to the second cycle of chemotheraphy and that the system in place to ensure he was treated safely was inadequate.'
Clinical treatment; diagnosis
Fife NHS Board (201406099)
View a summary of this case and download the full report on the SPSO website
'Mrs A's care lacked any knowledge of dementia, and I am concerned that her needs and preferences were not taken into account.'
Nursing care; record-keeping; communication; complaints handling
Borders NHS Board (201404767)
View a summary of this case and download the full report on the SPSO website
All media enquiries to SPSO Communications on 0131 240 2974 or by email
Complaints Standards Authority
NHS
Our work to develop a revised NHS model complaints handling procedure (CHP) continues to make progress. We have worked closely with the Scottish Government and NHS stakeholders to form a project steering group which provides overall programme governance for the project. Three distinct sub groups are leading on the development of: the revised model CHP and associated information; an agreed and consistent approach to recording and reporting of performance; and a training and awareness programme. The next meeting of the steering group will be held in January where each sub group will report on the progress made to date.
The current plan is for the NHS model CHP to be published during 2016 with implementation by NHS Boards from April 2017.
Social Work complaints
The Scottish Government’s consultation on social work complaints closed on 14 December. The draft order proposes to revise procedures for complaints about social work in line with the SPSO model CHP and seeks views on amending the SPSO’s role to allow it to investigate complaints about professional judgement elements of social work decisions. Subject to the outcome of the consultation, including the Scottish Government’s response, we will aim to work with relevant stakeholders to develop the model CHP together with preparing for any new functions transferred to this office.
Local Government
The local authority complaints handlers network last met in October 2015 in Glasgow and considered local authority performance against the SPSO performance indicators for 2014/15 and reporting and learning from complaints. Local authority performance was analysed and presented by the Improvement Service and demonstrated a continuation of positive performance from the previous year. The next meeting of the network will be in January.
Further Education
The further education complaints advisory group met in December. Topics discussed included the work of the short life working group to develop standardised complaints categories for the sector, and planning for the next further education complaints handlers benchmarking workshop, which is likely to be held in April.
Housing
The next meeting of the housing complaints handlers network is scheduled for January. The network will consider complaints handling performance over the first half of the year, together with learning from complaints and good practice in complaints handling. There will also be the opportunity for complaints handlers to share knowledge and expertise through the complaints surgery.
Further information on the role of the network, including details of how you may join, can be obtained from anne.fitzsimons@tollcross-ha.org.uk.
For all previous updates, and for more information about CHPs, visit our dedicated website www.valuingcomplaints.org.uk.
Season's Greetings from SPSO
Instead of sending cards, this year we have made a donation to
Alzheimer Scotland.
Jim Martin, Ombudsman | 16 December 2015
