Not upheld, no recommendations

Summary

Mrs C complained about the care and treatment provided to her late grandson (Mr A) during an admission to Royal Cornhill Hospital. Mr A had a history of mild learning disability, drug and alcohol misuse and self-harm. He had a previous admission a couple of months earlier following attempted hanging and also attempted to hang himself while an in-patient when his discharge was planned. Mr A was discharged with support in the community but was readmitted following a further attempted hanging several weeks later. Mr A remained on the ward for two weeks and was then discharged again. Mr A completed suicide by hanging that evening. Mrs C complained that staff had not adequately assessed Mr A and that the discharge decision was unreasonable.

Following Mr A's death the board conducted an adverse event review. The board did not consider Mr A suffered from a major mental illness and although he was at risk of harming himself, staff did not consider an ongoing hospital admission would be in his best interests.

After taking independent psychiatric advice, we did not uphold Mrs C's complaints. We found that staff had appropriately assessed Mr A and reasonably concluded he did not have a major mental illness and would not benefit from ongoing hospitalisation. The adviser also explained that hospitalisation does not necessarily prevent attempts to self-harm (and noted that one of Mr A's previous attempts at suicide occurred in the in-patient setting). In view of Mr A's participation in the discharge planning and his previous pattern of behaviour, the adviser considered there was no indication that Mr A planned to harm himself that evening and it was reasonable for staff to predict that, although Mr A may attempt self-harm in future, he would likely warn someone before doing so. Overall, we considered that Mr A's suicide was an event that could not have been predicted by staff at the time of discharge.

Summary

Mrs C complained that her husband (Mr C) did not receive a reasonable standard of care from the practice. Mr C suffered from a number of health conditions, including asthma, and passed away from sudden cardiac arrest whilst he was a patient at the practice. Mrs C felt that the practice did not investigate Mr C's condition urgently enough, and said that there had been a sequence of failed attempts to diagnose and treat Mr C.

We took independent advice from a GP adviser. The adviser noted that the practice had investigated Mr C's condition within a reasonable timeframe and with the appropriate level of urgency. The adviser said that appropriate investigative tests had been arranged and concluded that the care Mr C received was reasonable. We accepted the adviser's comments and we did not uphold Mrs C's complaint.

Summary

Mr C, who works for an advice and support agency, complained about the care and treatment of his clients' late daughter (Miss A). Miss A attended the practice on a number of occasions from May 2014 with symptoms including a persistent cough, sore joints, fatigue and weight loss. A number of possible diagnoses were considered and investigated but Miss A's symptoms persisted. In October 2014 following an out-of-hours attendance, Miss A was admitted to hospital and diagnosed with endocarditis (a rare and potentially fatal infection of the inner lining of the heart). Miss A passed away in hospital a few weeks later. Her parents raised concern that a window of opportunity had been missed to diagnose Miss A. They felt that there was a delay in the practice arranging appropriate investigations and referrals.

The practice met with Miss A's parents and carried out a significant event analysis. The practice considered the care provided was reasonable, although they identified some learning points for improvement including improving continuity of care and having a lower threshold for investigatory blood tests in young people with persistent symptoms.

After taking independent medical advice we did not uphold Mr C's complaint. We found the practice had arranged appropriate investigations in view of Miss A's symptoms, including seeking advice from Miss A's former specialist to check for any connection between her symptoms and another ongoing condition and making referrals to hospital specialists. The adviser explained that Miss A's symptoms varied over this time and appeared more in keeping with a respiratory problem (which the GPs appropriately investigated). The adviser considered symptoms indicating a possible problem with the heart were first documented at the out-of-hours admission in October 2014, so it was not a failing that the practice did not investigate this possibility earlier.

Summary

Mr C complained about the way in which his pain relief medication was handled by the prison health centre and that the doctor refused to see him in private.

Mr C had been prescribed pain relief for pain in his leg. This was later stopped and an alternative medication prescribed. However, due to concerns that Mr C was failing to take the medication in the way it was prescribed, this medication was also stopped and further alternatives, including anti-depressants, were suggested.

We took independent advice from a GP adviser. We found that, when reviewing Mr C's medication, the health centre had acted in line with Scottish national guidelines on the management of chronic pain and on prescribing. We considered the health centre's actions to be reasonable given the assessments carried out for Mr C.

The board told us that there were no records of Mr C asking to see health centre staff in private. We considered that in a secure environment, it would not be unreasonable for Mr C to be accompanied at health centre appointments. We saw evidence of only one occasion on which Mr C had been accompanied and that this was reasonable. We therefore did not uphold Mr C's complaints.

Summary

Mr C complained that a GP practice did not properly maintain the medical records of his wife (Mrs A) and as a consequence, when she was admitted to hospital she was given medication which led to serious side effects. He further complained that a member of staff spoke to him inappropriately and told him that by stopping his wife's medication he could cause Mrs A's death.

We took independent general practice advice and noted that while Mrs A's medical records showed that a conversation with Mr C had taken place where he said that he was stopping her medication due to his belief that it caused side effects, they did not record a change to her medication. This was because Mrs A had the capacity to make decisions about her treatment and any changes could only be made after discussion with her. Whilst the records noted a terse conversation with Mr C about his wife's medication, there was no evidence that he had been spoken to inappropriately. It was clear that the repercussions of Mrs A stopping taking her medication had been clearly explained to Mr C. We did not uphold the complaint.

Summary

Mr C complained about the length of time his wife (Mrs A) spent in Dumfries and Galloway Royal Infirmary. He also complained that before giving medication to Mrs A, staff had not asked him which medication Mrs A was taking prior to her admission.

Mr C also said that the medication prescribed to Mrs A had a detrimental effect on her, physically and mentally, and that the tests she underwent after her admission were unnecessary.

We took independent advice from a consultant geriatrician. The adviser noted that because Mrs A was able to tell staff about her medication, there was no requirement for staff to discuss it further with Mr C. The adviser also found that the admission and the tests subsequently undertaken were appropriate and reasonable. We therefore did not uphold Mr C's complaints.

Summary

Mr C complained that he was not prescribed medication to treat high blood pressure and that during a home visit a GP did not diagnose a deep vein thrombosis (DVT) in his leg.

Mr C had a knee replacement operation in December 2014 and requested a home visit in January 2015 as he was suffering from pain and swelling in his leg. A GP attended and examined Mr C's leg but did not find any obvious signs of DVT. A week later, Mr C had a post-operative check on his leg and the DVT was discovered and he was admitted to hospital for treatment.

Our investigation included taking independent advice from a medical adviser who was of the view that the examination carried out by the GP was appropriate and that there were no recorded signs that would have suggested DVT. The adviser stated that DVTs can develop over time and that the signs are difficult to identify in the early stages. We did not uphold this aspect of the complaint.

Following his treatment for the DVT Mr C was referred to the anti-coagulation clinic to monitor his blood, and he was prescribed Warfarin (an anti-coagulation medication) to reduce the risk of further clots for six months. During this time Mr C stopped taking the medication to treat his high blood pressure. When he was advised by the clinic to stop taking the Warfarin, Mr C requested a prescription for his blood pressure medication from the GP which he stated was not provided for seven days. The records showed that the prescription was issued on the day it was requested and we did not uphold this aspect of the complaint.

Summary

Miss C appealed to the university that she had failed her final exams due to ongoing personal circumstances. The university did not accept her appeal and Miss C complained to us.

We found that Miss C had reported personal circumstances twice in previous years of study; however, she did not continue to report them to the university as her studies progressed. It was only when she found out that she had failed her final exams that she raised the issue of personal circumstances.

Miss C did not provide the university with evidence of how her personal circumstances affected her at the time of her final exams. As the university acted in line with their procedures, we did not uphold Miss C's complaint.

Summary

Ms C complained to the college about the assessment of her work and asked to be moved class. The college investigated the assessment of her work, including having it re-assessed by different assessors, and determined that the initial assessment had been reasonable. The college entered into discussion with Ms C about moving class and her being re-assessed on some aspects of her work. Ms C was dissatisfied with the actions the college had taken and complained to us.

We decided that we could not consider her complaint about the assessment of her work, as it related to academic judgement. By law we cannot investigate matters of academic judgement and, therefore, we could not comment on that issue.

We did not uphold Ms C's complaint about agreements she said that she had made with the college about re-assessments. We could not see any evidence that any agreements, such as those Ms C referred to, had been made.

Summary

Mr C complained to us that Business Stream had not followed the correct procedure for taking meter readings. He said that since opening his business in May 2010, his water bills had greatly increased although his water consumption had not. He complained about this to Business Stream in August 2014 and was told that he should check for a leak. A leak was found and was fixed in October 2014.

Business Stream applied a leak allowance to Mr C's account for the six month period immediately before the leak was fixed. Mr C felt that this was insufficient and that Business Stream had not followed their procedure for taking meter readings. He believed the leak allowance should have been backdated to the opening of his business.

Business Stream's procedure requires them to take two meter readings per year. Mr C said that he was not alerted to the possibility of a leak because of Business Stream's failure to do this. However, we found that Business Stream had taken readings over the time in question, apart from a period between August 2013 and September 2014 (and they had attempted to do so in March 2014 but the premises were closed). It was towards the end of this timeframe that Mr C raised his concerns and was advised to check for a leak.

Business Stream said that Mr C had a responsibility to regularly check his water bills and to check for possible leaks and have them repaired. Once the leak was found and repaired, a six-month leak allowance was successfully applied for and paid into Mr C's account, in accordance with policy.

We found no evidence that Business Stream had failed to follow the correct procedures and therefore did not uphold the complaint.