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February 2017

Today we are laying 73 reports before the Scottish Parliament, including one full investigation report about the NHS. In this overview, we highlight:


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, 170KB)
 

New Ombudsman

Rosemary Agnew, the current Scottish Information Commissioner, will take up the post of Scottish Public Services Ombudsman on 1 May 2017.  She was nominated by a cross-party panel of the Parliament following an open recruitment process, and her appointment was unanimously approved by MSPs. The current Ombudsman's eight-year term ends on 30 April 2017.
 
You can read more about the appointment process on the Parliament’s website.
 

Key points from the full investigation report

Clinical treatment and diagnosis, complaints handling
Today’s full investigation report (201507615) is about the care of a 68-year-old woman (Mrs A) who died in hospital.  We found that there were missed opportunities to identify the severity of the deterioration in her condition and that she should have been referred earlier to the intensive care unit.  We also criticised the board for their failings in relation to Mrs A being given a penicillin antibiotic when she had a known allergy to penicillin, and for not taking appropriate steps when this error was reported to them. 
 
We accepted that while what had occurred in Mrs A's case was a human error, drug administration policies had not been followed by staff.  The correct completion of the allergy section of Mrs A's prescription chart and the use of a red allergy identification wrist band should have prevented this, and the failure to do so represented serious failings in care.    
 
While the board acknowledged that Mrs A was unreasonably prescribed and given the penicillin antibiotic, we considered their own investigation had not fully acknowledged the seriousness of what had happened.  Our report contains 11 recommendations, several of which aim to support the board in ensuring that these errors are not repeated.
 
To enable learning and improvement, we publish reports of investigations on our website. You can search these by authority, date, subject etc by visiting our website.
 

Informed consent: learning from complaints

Our Learning and Improvement Unit will shortly publish our first thematic report, on the subject of informed consent.  It draws on more than 20 SPSO decisions involving consent issues and places our findings within a wider legal and policy context, as well as linking into human factors literature.  The report contains a self-assessment consent checklist which we urge healthcare professionals, policy-makers and regulators to make use of.  We will discuss the report at an event hosted by the Parliament’s Health and Sport Committee in early March.
 
Our aim is not only to highlight the recurring issues around consent that we see, but also to explore the context and reasons for this. There is a great deal of work underway in Scotland to strengthen consent processes and increase people’s involvement in their health decisions.  We think it is timely to add our own perspective, so that the real-life experiences of patients and their families can be taken into account in developing changes to policy and practice.

SPSO Improvement Conference

Making the most of complaints: Using learning to improve public services
15 March 2017, Central Hall, Edinburgh

We are pleased that there continues to be strong demand for our improvement conference.  It is designed for complaints handlers and those involved in quality, improvement and governance in public services. It is relevant to all sectors, including local authorities, health service providers, registered social landlords, the prison service, higher and further education and water authorities.
 
The key themes are:
 
1.   Using complaints to drive improvements
Using complaints data and other sources of management information to identify themes and trends
 
2.   Impactful outcomes
Assessing the potential impact of improvements and measuring actual success
 
3.   Improving complaints handling
Using QA and self-reflection
Using a complaints investigation as a ‘critical friend’
 
Read further information about the event and download a booking form. 
 


Complaints Standards Authority (CSA)

Social work complaints procedure

The social work model complaints handling procedure (CHP) was published in December 2016.  Both the CHP and the accompanying Guide to Implementation, which details what organisations will need to know as they prepare to adapt and adopt the CHP ready for implementation in April 2017, are available on the Valuing Complaints website.
 
Read about the social work model CHP.

SPSO's extended role in deciding social work complaints 

We have appointed two independent professional advisers to help with our upcoming extended role in social work complaints, where we will be able to consider the professional judgement of social workers where complaints are made to organisations after 1 April 2017.  Importantly, councils will continue to hold Complaints Review Committees (CRCs) for some time after 1 April 2017.  This is because complaints made to them up to and including 31 March 2017 must be considered in line with the existing process which ultimately culminates in a CRC.  As such, our short-term focus will be for the professional advisers to hold SPSO staff awareness sessions outlining key aspects of social work and related issues, in addition to contributing to our existing internal knowledge bank.
 
We are continuing with our stakeholder engagement and we recently published articles in SSSC News (the Scottish social service sector’s online magazine) and About Advocacy (the Scottish Independent Advocacy Alliance’s magazine).  We also presented to the Scottish Government’s Older People’s Development Group and Social Work Scotland’s Complaints sub-group.  We are keen to continue this engagement work in the coming months and are happy to provide support to organisations as they prepare to implement the new CHP in April.  We can be contacted directly at CSA@spso.org.uk.

Complaints handling networks

Local Government
The local government complaints handlers network will next meet in March. There will be an opportunity at that time to consider the early findings of the short life benchmarking workgroup which had its first meeting in January 2017.  The purpose of this group is to consider how the network’s approach to benchmarking for improvement may be further developed to deliver added value.  The benchmarking  workgroup will prepare proposals for the network to consider the annual performance of councils through an agreed process. This will include consideration of the specific data to be submitted to the network/Improvement Service, the date by which the data should be submitted and in what format.

Further Education Complaints Handling Advisory Group
The Complaints Handling Advisory Group met in February 2017. Having previously agreed on and introduced standardised complaints categories, the sector is now exploring the potential to standardise the category of complainant. Plans for the Advisory Group’s annual complaints event to be held in May 2017 are progressing well.  As in previous years, the event will include an update on the sector’s performance in handling complaints.  It will also look at areas of good practice, and learning from complaints.  Further details will be provided by the College Development Network in due course. 

NHS model CHP - supporting implementation
We are working closely with NHS Education for Scotland and other partner organisations to support a programme of ‘Feedback and Complaints and Duty of Candour’ training and awareness events, including participation at four regional roadshows during March 2017. Specifically, we will deliver a workshop based on the requirements of the new NHS and social work model CHPs.  This will be an interactive session and will involve working in groups for further discussion around the key requirements of the new procedures, including: 
  • the definition of a complaint
  • recognising feedback, comments and concerns
  • details of the two-stage process
  • good governance arrangements.
We continue to provide a bespoke support service to specific NHS organisations, and will represent SPSO at the forthcoming Patient Advice and Support Service regional events to be held in Dundee and Glasgow, where we will present on the revised NHS CHP which will be introduced on 1 April 2017.

For all previous updates, and for more information about the networks and the CSA, visit our dedicated website or email csa@spso.org.uk.

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Scottish Welfare Fund

Communications and engagement

This month we explored how we can expand our communications activity in the coming months. This includes potentially increasing the volume of casework information we publish and investigating setting up a Twitter account to expand our social media interaction.
 

Statistics and reporting 

We have responded to 605 enquiries and made 316 decisions (149 on Crisis Grants and 167 on Community Care Grants) since the scheme began on 1 April 2016 to the end of January 2017. January was our busiest month to date, with 55 cases being determined, representing a 12% increase on our previous busiest month.


Casework outcomes 

This month, we determined a number of crisis grants where applicants had already received three awards within the previous 12 months. In line with the guidance, it was therefore necessary for us to consider whether the circumstances surrounding applicants’ current applications were exceptional to allow a further award to be made. In several of these cases, we observed that councils did not clearly explain the rationale for their decision in their decision letters. 
 
In one such case, an applicant applied for a crisis grant as she did not receive her full bursary payment due to a previous overpayment. She therefore did not have money to provide for herself and child until she received her next bursary payment. The council determined that the circumstances surrounding her current application were not exceptional and did not award a crisis grant. On reviewing the case, we noted that the applicant’s previous awards were all due to issues outwith her control and none concerned issues with her bursary. Additionally, we found that she had contacted social work for support as her situation had become very severe and she was concerned for her and her daughter’s wellbeing. We considered the risk to her daughter and that there were potential implications for her college course and future bursary payments as she was unable to attend classes due to having no money. Overall we considered that the circumstances surrounding her application were exceptional and upheld the review request. We also highlighted how the council could improve their decision letters as we considered that they provided minimal, non-specific information and enclosed a generic information sheet which included outdated information.

Compliance and follow-up 

In line with SPSO practice, my office will follow up with the organisations to ensure that they implement the actions to which they have agreed.
 

Jim Martin, Ombudsman | 15 February 2017

The compendium of reports can be found on our website: www.spso.org.uk/our-findings.
For further information please contact: SPSO, 4 Melville Street, Edinburgh, EH3 7NS
Emma Gray Tel: 0131 240 2974 Email: emma.gray@spso.gsi.gov.uk

The Scottish Public Services Ombudsman

The Scottish Public Services Ombudsman (SPSO) provides a ‘one-stop-shop’ for individuals making complaints about organisations providing public services in Scotland. Our service is independent, impartial and free.

We are the final stage for handling complaints about councils, housing associations, the NHS, prisons, the Scottish Government and its agencies and departments, the Scottish Parliamentary Corporate Body, water providers, colleges and universities and most Scottish public authorities.

We normally consider complaints only after they have been through the complaints procedure of the organisation concerned. Members of the public can then bring a complaint to us by visiting our office, calling or writing to us, or filling out our online complaint form.

We aim not only to provide justice for the individual, but also to share the learning from our work in order to improve the delivery of public services in Scotland. Our Complaints Standards Authority promotes good complaints handling in bodies under our jurisdiction.
 


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