SPSO Individual Decisions

C complained about the care and treatment provided to their adult child (A). A experienced a decline in mental health and was referred to their local community mental heath team by their GP. A was in contact with mental health services for a period of approximately three months before dying by suicide. C complained that the board had not reasonably listened to their concerns about A. C also complained about the board’s assessment and management of risk for A, A’s diagnosis and medications. The board completed a Significant Adverse Event Review (SAER) of the care and treatment provided in the six months prior to A’s death. The review concluded that, overall, appropriate care was provided by mental health services. The review identified some improvements and recognised that communication between A’s family and the consultant psychiatrist was poor. The review found that the issues identified did not contribute to A’s death. We took independent advice from a consultant psychiatrist. We found that the care and treatment provided to A was reasonable, including the assessment and management of risk for A, A’s diagnosis, the prescription of medications and the board’s handling of concerns from A’s family. We found some shortcomings in documentation. We found that the Board’s SAER was reasonable, as the standard of the review was good and the recommendations made by the review were appropriate, however, the review process took significantly longer than timescales stated in the guidance for SAERs, for which the board apologised. On balance, we did not uphold C’s complaint. Related reading View Decision Report 202408872 as a PDF (24.52 KB) Updated: May 20, 2026

C, a prisoner, complained that the partnership reduced and then stopped their prescription of co-codomol (a medication used to treat pain) for possible sciatica without consultation. The partnership did not did not identify any failings in C’s care. They said that reduction and discontinuation of the co-codomol prescription was a clinical decision. They acknowledged that C would have preferred to be included in this decision, but that this had not been possible in the specific circumstances. We took independent advice from a GP. We found that C’s prescription had been changed following the opinion of two different GPs. When the decision was made a letter was sent to C informing them of this. While we considered that there should ideally have been prior discussion with C, a letter was sent at the point the decision was made explaining the reasons for the change. In the circumstances, we did not consider this to be unreasonable. We found that the explanation for the reduction and cessation of C’s prescription appeared reasonable as there was no indication for C to be on regular co-codamol and this was not a medication that generally required a patient to be weaned off slowly. Therefore, we did not uphold C's complaint. Related reading View Decision Report 202408118 as a PDF (24.4 KB) Updated: February 18, 2026

C complained in relation to their late child (A) and the actions of the social work services. A suffered from significant and life-limiting health conditions. During the final months of A’s life, a number of healthcare and education professionals raised concerns about C’s approach to A’s medical needs and care. Social workers made contact with C and initiated a child protection investigation, which ultimately did not establish child protection issues. C complained that contact that they received from the partnership, both via the phone and in person, was harassing and unreasonable. C considered that the partnership failed to recognise that the reports of other agencies were inaccurate, and harassing in nature, and had displayed bias by ignoring C’s views in this regard. We took independent advice from an experienced social worker. We found that it was evident that healthcare professionals had been concerned about A and had notified social workers of these concerns. In making enquiries and initiating a child protection investigation, social work services had followed the process set out in the National Guidance for Child Protection and in doing so had acted appropriately. While we recognise the difficult circumstances involved, I did not uphold C’s complaint. Related reading View Decision Report 202401251 as a PDF (24.43 KB) Updated: April 30, 2025

C complained about the care and treatment provided to their adult child (A) by the partnership. A had received care from mental health services for several years prior to their death by suicide. C complained that the partnership failed to reasonably share information with A’s family and failed to involve them in A’s care. C also complained about the HSCP’s complaint handling. We took independent advice from a consultant psychiatrist. We found that the partnership had failed to evidence that there was any discussion with A about sharing information with their family or involving family in care and treatment, including risk assessment. We considered that not to have had this discussion, or to have had the discussion and failed to document it, was unreasonable. We upheld this aspect of C’s complaint. We found that there were delays in the partnership responding to C, and that they did not answer all points of the complaint. We upheld this complaint about complaint handlings.

C complained about the way that the partnership handled their complaint about the care and treatment provided to C’s late sibling. C said that the complaint process had been long and difficult to follow and it had been hard to obtain a clear and final complaint response from the partnership. C stated that they had to make their own enquiries to determine whether the complaint had been closed and they had been inappropriately referred to another internal complaint process. C also complained about staff conduct during complaint meetings, specifically citing instances of rude and defensive behaviour, as well as a failure to keep meeting notes. The partnership considered that they had reasonably handled C’s complaint in line with the correct complaint handling procedure (CHP). We found that it had been unclear which CHP had been followed (the council or NHS) and that there was a failure to comply with timescales. The partnership’s complaint handling did not consider the separate significant adverse event review undertaken by the partnership. Additionally, inaccurate information was provided about the stages of the CHP and the point at which C could escalate the complaint to the SPSO. Finally, we found that the partnership failed to apologise to C for the failings identified in their own complaint investigation. While we could not reach a decision on the behaviour of staff during meetings, we found that they failed to keep written records of complaint meetings. We upheld C’s complaint.

C and B complained about the support that they had received as foster carers from the partnership. C and B told us that they had been foster carers to two young people for a number of years. Following a significant incident in the fostering placement, social work services had taken the decision to remove both young people from their care. Following the end of the placement, C and B complained to the partnership about the adequacy of support and intervention offered to both them, and the young people, by social work services during the placement, the decision to remove both young people from their care and the lack of transition planning. In response to C and B's concerns the partnership concluded that a reasonable level of support had been offered to them during the placement. They said that the decision to end the placement had not been taken lightly, and staff had made a professional assessment in the young people’s best interests. They apologised for the delay in convening a disruption meeting, citing a number of mitigating factors, including operational constraints and government restrictions. We took independent advice from a social worker. We found that, in the weeks prior to the incident, the partnership failed to follow their Placement Support Practice Guidance, specifically a Placement Support meeting was not convened to explore how the placement could be supported and maintained. We found that following the incident, the partnership’s communication and support to the family was not robust or proportionate, and an appropriate debrief had not taken place, including an urgent risk assessment. We found that there was a lack of young people involvement in decisions about their future care planning. The partnership did not complete appropriate transitioning planning or risk assessment to assist the young people, and the foster carers, with the immediate impact of the end of placement, including seeking the young people’s views in respect of their onward

C was a carer for their parent (A). A carer's assessment self-referral form was submitted on C's behalf to the partnership's Carers Team. C was contacted by the Carers Team and advised that, in the circumstances, the requested assessment would be carried out by A's social worker. Within 24 hours the social worker had discussed and clarified the situation with the Carers Team. The Carers Team had also emailed C to advise that they had been under a mistaken impression the previous day and to request that C contact them to progress C's request. Relations between C and the Carers Team broke down during further email correspondence involving C, the Carers Team and the social worker the same day. Within this correspondence the Carers Team had made clear that they required further information from C to progress C's request and that they would end consideration of C's request if they had not received a response from C. The partnership responded to a complaint from C, and accepted that there had been short comings in the Carers Team's communication with C and stated that the social worker would contact C to discuss carer support further. Some time later, a further referral for carer support was submitted to the Carers Team. Relations between the Carers Team and C again broke down and C submitted a complaint about the Carers Team's actions and the partnership's failure to provide carer support. The partnership's response outlined their view of events regarding C's requests for carer support over a period. The partnership gave their view that C had not received carer support during this period because it had been unclear what supports C wished to access. The partnership accepted that there appeared to have been some confusion on the part of their staff as to who was ultimately responsible for moving forward with the matter and that this may have caused some delay. Given this, the partnership partially upheld C's specific complaint about this. The partnership noted that matters

C, an adult with autism, was receiving treatment from the Partnership as a new patient after moving into the area and was unhappy with their psychiatrist. C felt that the Partnership did not have appropriate staff who specialised in treating adults with autism. C complained that the psychiatrist questioned the diagnoses and treatment plan already in place, that the psychiatrist told them that the treatment plan was wrong, that they asked questions in an unstructured way and made unreasonable remarks about C’s personal life. Further, during an online consultation the psychiatrist allowed a second person to be present without having made C aware this would happen and ignored their request for an adjustment to have a doctor of the same gender as them. C also complained that the Partnership accused them of being misogynistic by asking for a same-gender doctor. The Partnership said that the psychiatrist did agree to provide the prescription C was seeking as C was very fixed on the recommendations made by their previous psychiatrist. The Partnership also said that C was derogatory towards the psychiatrist due to their gender and questioned their ability. We took independent advice from an adult consultant psychiatrist. We found that the evidence showed that the Partnership provided elements of good care and treatment to C. However, their response to C’s request for a same-gendered doctor was unreasonable, the consultation deviated significantly from recognised good medical practice and it was unreasonable to have an additional person present without C having been told or asked for consent beforehand. In addition, we found that there was no evidence that would support the Partnership’s position that C was derogatory towards the psychiatrist due to their gender, and there was no evidence to suggest C was significantly hostile. Therefore, the Partnership’s assertions about C’s manner were unreasonable. As such, we upheld C's complaints.

C complained about the care and treatment provided to their parent (A) who had dementia. C believed nursing staff had failed to provide A with a reasonable standard of care. They complained that A had been confined to bed inappropriately and that no assessment had been made of the impact this would have on A's mental health. C said that there were issues in arranging for suitable equipment to allow A to be transferred out of bed. C also complained about the communication of decisions about A’s care with them, A's next of kin and registered power of attorney. C said that after they complained, the Partnership told them that A was receiving end of life care but that this was not true and was a rationalisation of what had happened after A’s death. C also noted that the Partnership had been obliged to respond more than once to their complaint, after they had pointed out factual inaccuracies in their response. C suggested that this showed that there had not been a proper investigation into their complaint. The Partnership accepted that communication with C could have been better. They maintained, however, that A’s care had been of a reasonable standard and that staff had been clear that A was being provided with end of life care. They accepted that this should have been specifically set out in A’s care plan and noted improvements were being made to ensure this going forward. We took advice from a registered nurse with experience of medicine for the elderly. We found that A’s care and treatment had been reasonable. We did not uphold this aspect of the complaint. We found that there was failure to communicate with C appropriately. The communication with C fell below a reasonable standard, particularly as C was not informed that A was receiving end of life care. We upheld this aspect of the complaint. The Partnership acknowledged that staff could have done more to ensure A had the requisite specialist equipment. There could have been better communication between

C is an adult who requires support with various daily living tasks. C is in receipt of Self-Directed-Support (SDS) payments to enable them to employ personal assistants to help with these tasks. C complained that they were not permitted to employ their family member as a personal assistant. C told us that the partnership did not fully consider C's circumstances or explain the reasons for their decisions. The partnership said that family members of the supported person may be employed as a personal assistant where this is deemed appropriate, under exceptional circumstances. Ultimately the decision to permit such an agreement is at the discretion of the local authority. The partnership acknowledged the difficult circumstances faced by C, however, they considered that ultimately they did not agree with the request to employ a family member, particularly in light of the dynamics involved with someone being both an employee and a family member. In response to our enquiries, the partnership further explained that a social worker spoke with C and a family member to explain the reasons for their decision. They said that they considered C's circumstances, but also, that they considered the aims identified in C's support plan and it was their view that the employment of a family member would not be in keeping with C's assessed needs. We took independent professional advice from a social work adviser with particular experience in Adult Services. We found that decisions like these are discretionary decisions that the partnership is entitled to make. Each of the factors identified by C were considered by the partnership when making their decision. We found that the partnership made their decision in line with the regulations and reasonably explained their reasoning to C. As such, we did not uphold the complaint. However, our investigation highlighted a small error whereby the partnership referenced legislation rather than the related regulations. This did not impact the reasonab

C complained about the mental health care and treatment their late sibling (A) received at Gartnavel General Hospital. C complained that A was misdiagnosed and received inappropriate treatment. C complained that A was insufficiently supervised, as they were able to leave the hospital on a number of occasions. C also complained that A was discharged when they were still unwell. C believed there had been a focus on discharging A rather than ensuring their condition improved. We took independent advice from a consultant psychiatrist. We found that during each admission, A's care and treatment was reasonable and appropriate given their presenting symptoms. We found that the changes in A's diagnosis reflected a better understanding of their symptoms and presentation over time. We did not uphold this aspect of the complaint. With regard to the complaint about supervision, we found that the level of supervision was appropriate andthat there was no clinical justification for any enhanced observation. We did not uphold this aspect of the complaint. In relation to the complaint about A's discharge from hospital, we noted that difficult circumstances to do with A remaining in the ward was contributing to an escalation in their presentation. We found that the decisions to discharge A after the first and second admissions were reasonable. There was evidence of discharge planning with appropriate follow-ups being put in place. The decision to discharge after the third admission was more complicated, as A was discharged into police custody after their behaviour escalated. We found that under the circumstances this was reasonable, noting that follow-up arrangements were made with support agencies. We therefore did not uphold this complaint. Related reading View Decision Report 201901611 as a PDF (24.55 KB) Updated: July 20, 2022

C, a support and advice worker, complained on behalf of their clients (B) in relation to a child in B's care (A). It was decided at a Child Protection Case Conference (CPCC) that A be formally placed with B and as such, B were deemed as eligible for kinship care payments. As a result of this decision, a kinship care assessment was started but was not completed. It was also decided at the CPCC that a referral should be made to the Scottish Children's Reporter Administration (SCRA). While a full assessment was completed on A and one of their parents, this was not sent to SCRA. C complained that the partnership had unreasonably failed to carry out a kinship care assessment. We took independent advice from a social worker. We found that the kinship care assessment which had been started following the decision of the CPCC had not been completed within the timescales set out in the Guidance on the Looked After Children (Scotland) Regulations 2009. We also found that the decision taken by the partnership that a kinship care assessment was not required had not been communicated timeously to the other agencies involved in the CPCC or to B. Finally, we found that the level of record-keeping was unreasonable. C also complained that the partnership had unreasonably failed to make a referral to SCRA. We found that there was sufficient evidence to show that the referral should have been made at the time and that there was no evidence to support the partnership's decision that a referral was no longer required. We also found that the partnership's decision not to send the referral had not been communicated to the agencies involved in the CPCC or to B. Finally, C complained that the partnership had failed to provide reasonable social work/kinship care support. We found that the partnership had failed to demonstrate reasonable contact with B and had failed to provide sufficient evidence to support their decision to close the case. They also failed to adequately evidence t

C, an advocacy worker, complained about the partnership on behalf of their client (A). A has cerebral palsy (a condition marked by impaired muscle coordination, typically caused by damage to the brain before or at birth) and communication issues. For the last 18 years, A has lived in their home with support from the partnership. More recently, A’s self-directed support payments were reviewed. As a result of this, their budget was significantly reduced. C complained to us that, in making the decision, the partnership only took financial factors into account and that they had given little, or no, consideration to their statutory duties under Human Rights and Equality legislation. The potential impact of this decision was that A would be unable to remain in their home and would have had to consider moving to a care/nursing home. We obtained the partnership's records. The partnership also provided comments strongly objecting our consideration of the complaint. Their position was that the complaint was time barred (the time permitted to bring forward the issue has passed). However, we obtained legal advice that, if we were satisfied that there were special circumstances, that there would be a reasonable prospect of successfully defending a judicial review. We investigated the complaint as we considered that there were special circumstances and that the substantive issues of the complaint potentially raised public interest considerations. Complaint details were subsequently agreed with C. We also established at this time that the partnership had never implemented their decision and that A’s funding had never been reduced. A notification and enquiry letter was then sent to the partnership. They responded and confirmed that A’s funding had never been reduced and that it had actually been increased following a review. They asked us to consider what outcome could be achieved in the circumstances. They also noted that the partnership’s working practices had changed since 2018

C complained that treatment was provided without their express consent at a clinic. After the treatment was explained to C, C said that they refused to have the treatment, however instead, the clinician attempted to take a biopsy (tissue sample). C also complained that the partnership did not respond to their complaint appropriately by forcing them to accept further treatment and arranging an appointment without their consent. We took independent clinical advice. We could not find any reliable evidence that demonstrated a biopsy was attempted or taken without C's consent. We concluded that the partnership's response to the complaint was reasonable as they arranged meetings with C to discuss their concerns and took appropriate steps to investigate the complaint. We did not uphold C's complaints. Related reading View Decision Report 201906972 as a PDF (24.08 KB) Updated: August 18, 2021

C, a solicitor, complained on behalf of their client (A). A is elderly and has multiple disabilities. They live in their own flat and have care provided by the partnership. A number of support needs assessments were carried out over several years. The partnership proposed to reduce A's in-person care provision and put in place a telecare system. C complained about this and then complained to our office about a delay in receiving a response to that complaint. Our office made a discretionary decision to progress the complaint in light of significant complaint handling delays. We decided to consider the substantive matters, as well as the complaint handling process. We took independent advice from a social work adviser. We found that the assessments of A's needs were reasonable and evidence showed that A's views and those of their carers were taken into account. The partnership were entitled to review care arrangements and consider how they use their resources. The partnership also proposed a trial period, phasing in the changes, which we found to be reasonable. Therefore, we did not uphold this aspect of C's complaint. In relation to complaint handling, we found that there were significant delays in responding to C. We noted that the partnership's information about what they would and would not consider a complaint, was unhelpful. We upheld this aspect of C's complaint.

C is welfare guardian (a court appointed guardian who can make decisions on behalf of an adult with incapacity) for their adult sibling (A). A was assessed in hospital by the health and social care partnership as needing full-time residential adult care. C disagreed with this assessment and considered that A would be better cared for at home. C returned A to their home following their hospital discharge. C maintained that as A had been assessed as requiring full-time care, they were entitled to have this fully funded at home and that they were entitled to be offered the relevant self-directed support payment options for this care. Glasgow City Council refused to provide such funding, maintaining that they were only under a duty to fully fund the care assessed as needed. Adult protection procedures were considered but as C was now providing full-time care to A, alongside a council funded care package, no action was taken. C complained to the partnership about the assessment outcome and the failure to provide fully funded full-time home care for A. There were considerable delays in responding to the complaint for which the partnership later apologised, however they maintained their view that A was not entitled to full-time fully funded home care and their original assessment had been appropriate. C brought their complaint to this office and raised further concerns about the tone of partnership's communications and the investigation of their complaint. We found that A was entitled to assessment under the 1968 Social Work (Scotland) Act and funding to meet the needs assessed. However, the council were not obliged to provide funding to meet care costs where the care being provided did not meet that assessed need (in this case care at home rather than residential care). We concluded that the assessment of A's needs was appropriate and that the council were not obligated to offer self-directed support payments. Therefore, we did not uphold this complaint. Related

C, who is a solicitor, complained on behalf of their client (A). A lived alone and received 24-hour care from a private company in their adapted home. A's home care provider notified the partnership that they were withdrawing their services to A. When this happened A had to go into residential accommodation. B, who is A's parent, said that the residential accommodation was unsuitable. C complained about this and then complained to our office about a delay in receiving a response to that complaint. Our office made a discretionary decision to progress the complaint in light of significant complaint handling delays. We decided to consider the substantive matters, as well as the complaint handling process. We sought independent advice from a social work adviser. A had a support needs assessment (SNA) and an outcome based support plan (OBSP) carried out by the partnership. We found that the assessment should have considered all options under Self Directed Support (SDS) legislation, however option one, direct payments, had not been explored. We found that there were significant delays in responding to the complaint. The partnership's information about what they would and would not consider a complaint was unhelpful. We upheld both complaints.

C attended a clinic a number of times where it was found that they had non-specific urethritis (inflammation of the tube that carries urine from the bladder to outside the body). On one occasion C was diagnosed with chlamydia (a common sexually transmitted disease). C was prescribed antibiotics to treat these conditions. C raised concern that the partnership provided incorrect treatment. C told us that they were given multiple types of antibiotics and these had significant side effects. They were concerned that the antibiotics had impacted on their liver. The partnership said that C was prescribed the correct antibiotics for their diagnoses. They noted that liver damage is a rare side effect of the antibiotics prescribed and blood results from the time period in question showed normal liver results and suggested that there was not severe liver damage following the antibiotics. We took independent clinical advice from an adviser experienced in general practice, and an adviser experienced in hepatology and gastroenterology (a specialist in diagnosing and treatment disorders of the liver, stomach and intestines). We found that the treatments provided by the clinic were reasonable and that it was reasonable to treat C on the basis of the symptoms they presented with. We noted that the choice of antibiotics was reasonable, and that the partnership's position on liver damage (being a rare side effect) was reasonable. As such, we did not uphold the complaint. Related reading View Decision Report 201905949 as a PDF (24.44 KB) Updated: June 23, 2021

C complained about the care that they received from the partnership when they were visited by a health visitor following the birth of their baby. C declined the health visitor's offer to observe their latch while breastfeeding. C felt that the health visitor did not understand the importance of obtaining C's consent and that they had not respected their right to decline. In the partnership's response, they said that health visitors are required to identify any breastfeeding problems but that they apologised for how the health visitor had communicated with C. During our investigation, we took independent advice from a midwife. We found that it was appropriate that the health visitor offered to observe C while breastfeeding but that if a patient declines any offer of care, this should be respected. We found that the health visitor's communication with C had been unreasonable and we, therefore, upheld C's complaint. We found that the partnership had already taken appropriate steps to address the health visitor's communication with C, however, we found that their response had not clearly addressed C's right to refuse care and we made recommendations about that.

C held power of attorney (POA) powers for A and complained about the partnership's assessment of the financial contribution they required A to pay towards care at home costs. A received a direct payment from the partnership which helped to pay for a care at home service. A also paid for additional care with personal funds to increase the care received to 24/7. C complained that the financial assessment undertaken was not in accordance with the relevant charging policy and that the partnership failed to take account of the fact that A was paying for a significant amount of their care to ensure they had 24/7 care. The partnership confirmed that they were satisfied that the financial assessments were properly undertaken and the charges applied were in accordance with their charging policy. C felt that the additional costs A had, by purchasing additional care, should have been taken into account. The relevant guidance only requires the local authority to consider, using their powers to waive charges, if the supported person has difficulty in meeting the approved cost. We found that the partnership had applied the relevant charging appropriately and had explained the rationale for how the financial contribution charged complied with their charging policy. We, therefore, did not uphold the complaint. Related reading View Decision Report 201809520 as a PDF (24.31 KB) Updated: May 19, 2021

C submitted a complaint on behalf of their sibling (A). A was treated by the partnership over a period of approximately 18 months under two separate admissions to hospital. C complained about the treatment provided during that time through a number of complaint submissions. We took independent advice from an appropriately qualified adviser about the complaints. C complained that the partnership failed to provide reasonable treatment to A. We found that the medication prescribed for A was reasonable, adhered to relevant guidance and was reasonably monitored to ensure treatment benefits were balanced with possible side effects. Therefore, we did not uphold this complaint. C complained that the partnership failed to provide reasonable care to A. We found that while there was a failing in terms of A's contact with their child, overall the care provided to A by the partnership was reasonable. Therefore, we did not uphold this complaint. C complained that the partnership failed to use a reasonable level of restraint on A. We found that the use of physical restraint was appropriate and reasonable, was used in accordance with partnership's policies and in accordance with legislation. The adviser considered physical restraint was utilised for the minimum period of time necessary and there were no prolonged periods of restraint. As such, we did not uphold this complaint. C complained that the partnership unreasonably discharged A after their first admission. We found that the actions taken prior to A's first discharge were reasonable, with the discharge itself well planned and reasonable. They were of the view that risk were identified and the rationale given for discharge balanced the risks with the benefits to A. We considered that the actions taken to mitigate those risks were reasonable. As such, we did not uphold the complaint. C complained that the partnership unreasonably discharged A after their second admission. We found the partnership's rationale behi

C complained that the partnership had unreasonably failed to provide C with kinship care support in line with their obligations. C became the carer for their family member (A) when A's parent was no longer able to care for them. We took independent advice from a social work adviser. We found that the partnership had not published information about their application process for kinship care assistance in accordance with the relevant legislation and guidance and had failed to advise C how they or A could apply for a kinship care allowance. We upheld C's complaint that the partnership had unreasonably failed to provide C with kinship care support in line with their obligations. C also complained that the partnership had failed to provide A with transition support. Following independent social work advice, we found that a referral to an appropriate support scheme should have been made. We also upheld this aspect of C's complaint.

C complained about the care and treatment they received in hospital. We took independent advice from a consultant psychiatrist. We found that treatment was in line with recognised clinical practice. There were records of C’s medication being reviewed and altered on a number of occasions. There was also written evidence that a discharge plan was in place and discussed with C, although no specific discharge date had been set. We did not uphold C's complaint. Related reading View Decision Report 201905223 as a PDF (23.93 KB) Updated: November 18, 2020

C complained about a home visit to attend to their late spouse (A) concerning A’s PEG (a tube into the stomach to enable non-oral feeding) which was leaking. A family member of C had called the district nurses and was put in touch with an enteral feeding (a method of supplying nutrients directly into the gastrointestinal tract) nurse who agreed to visit the next day. The nurse advised C that the leak appeared to be due to constipation. C complained that the nursing care provided to A was unreasonable. The nurse also filed an Adult Support and Protection Referral (ASPR) with social work due to concerns about A’s safety. C complained that the ASPR was not appropriate. We took independent advice from a community health nurse. We noted that the partnership's pathways and referral process indicated that unscheduled care from the community enteral feeding team should be provided within four hours (or an alternative care plan identified). We found that an urgent response was required in this case as A was bedbound and dependent on the PEG for providing all nutritional needs, including administration of medications essential for managing long-term conditions. Any malfunction of A’s feeding and medication regimes would result in detriment to their wellbeing. The visit to A should have been classed as ‘unscheduled care' and A should therefore have been seen within a four-hour time period in terms of the process. In relation to the overall nursing care, we were critical that there was no detailed documentation of the assessment and examination during the visit, and no treatment plan recorded (other than advising the family to contact the GP to arrange an x-ray). However, we noted that the nurse followed up with the GP, which was good practice. We also noted that a subsequent hospital scope indicated that the nurse’s diagnosis of constipation appeared reasonable. In view of the lack of detailed records or care plan, and the failure to comply with the partnership’s own timeframe

C complained on behalf of their adult child (A), who has complex care needs and lives with C, about the care and treatment A received from the partnership. C said that the partnership failed to carry out a reasonable support needs assessment for A and that they failed to prepare an appropriate outcome-based support plan. We took independent advice from a social worker. We found that the action taken by the partnership in preparing the support needs assessment and outcome-based support plan was reasonable, and it was in line with relevant guidance and policies. We did not uphold the complaint. Related reading View Decision Report 201809055 as a PDF (23.97 KB) Updated: October 21, 2020