Not upheld, no recommendations

  • Case ref:
    201501647
  • Date:
    May 2016
  • Body:
    Greater Glasgow and Clyde NHS Board
  • Sector:
    Health
  • Outcome:
    Not upheld, no recommendations
  • Subject:
    clinical treatment / diagnosis

Summary

Miss C suffered from stomach pain and was given medication by her GP practice for an acid-related stomach disorder or an ulcer. She attended the out-of-hours clinic a few days later and was given antibiotics for a urinary tract infection. Miss C continued to suffer symptoms and she was referred for an appointment with a gastroenterologist (a doctor specialising in the treatment of conditions affecting the liver, intestine and pancreas). However, the appointment was delayed and when she was seen about three months later she had few symptoms. The board said Miss C told the gastroenterologist she had stopped taking her stomach medication before the appointment, but Miss C said the gastroenterologist told her during the appointment to stop taking her stomach medication.

The gastroenterologist told Miss C that, if her symptoms returned, her GP could call his secretary to arrange an endoscopy (where a tube-like instrument is put into the body to look inside). Miss C's symptoms returned over the next week and she asked her GP to do this, but her GP had not yet received the clinic letter with these instructions. Miss C then arranged a private endoscopy overseas, which showed she had probably had a stomach ulcer which had now healed.

Miss C complained that the out-of-hours doctor did not diagnose or treat her stomach ulcer, and the gastroenterologist did not arrange an endoscopy. She also raised concerns about the delay in the clinic letter.

After taking independent advice from a GP and a gastroenterologist, we did not uphold Miss C's complaints. We found that the out-of-hours treatment was reasonable, and it was appropriate for them to refer Miss C back to her own GP for management of ongoing symptoms. We also found the gastroenterology care was reasonable, as there was no clinical need for an endoscopy. While there appeared to have been a misunderstanding about the medication, there was no evidence that this was due to a failing by the gastroenterologist. Although the two-week delay in sending the clinic letter was not ideal, we found this was reasonable in the context of Miss C's clinical condition.

  • Case ref:
    201500673
  • Date:
    May 2016
  • Body:
    Greater Glasgow and Clyde NHS Board
  • Sector:
    Health
  • Outcome:
    Not upheld, no recommendations
  • Subject:
    admission / discharge / transfer procedures

Summary

Miss C's mother (Mrs A) was admitted to hospital at Mearnskirk House, following her discharge from the Prince and Princess of Wales Hospice where she received five weeks' care with advanced cancer. Miss C's sister (Mrs D) took their mother home from the hospital and Mrs A was officially discharged from the hospital into Mrs D's care three days later, following a meeting earlier that day at the hospital with medical staff and the family to discuss Mrs A's care.

Miss C complained about the board's decision to discharge her mother from the hospital and the way this decision was made. She listed a number of concerns, including that her mother was discharged without any input from her GP, with no care package in place and with no referral to a district or palliative care team.

We obtained independent medical advice on Miss C's complaint from a consultant physician in elderly care medicine. The adviser said this was an unusual case in that Mrs A had been taken home by Mrs D for a week's trial prior to her formal discharge. The board did not have time to plan Mrs A's discharge in the normal way. Mrs A and Mrs D were adamant that Mrs A should go home and the adviser said it would, therefore, be difficult to be critical of the board if their normal discharge procedure was not followed when they were trying to accommodate Mrs A and Mrs D's wishes. Therefore, we did not conclude that the board unreasonably discharged Mrs A from the hospital.

  • Case ref:
    201405055
  • Date:
    May 2016
  • Body:
    Greater Glasgow and Clyde NHS Board - Acute Services Division
  • Sector:
    Health
  • Outcome:
    Not upheld, no recommendations
  • Subject:
    clinical treatment / diagnosis

Summary

Mr A had mental health problems. His mother (Mrs C) complained to us about the care and treatment Mr A received when he attended the Western Infirmary on three occasions after taking overdoses. We took independent advice from a medical adviser, who is a consultant in emergency medicine, and from a psychiatric adviser. We found that the medical care and treatment provided to Mr A when he attended the hospital, along with the care he had received there for his mental health problems, had been reasonable. We did not uphold this aspect of Mrs C's complaint.

Mrs C also complained that staff in the hospital had not treated Mr A with respect and that a member of staff had shouted at him. The notes in the medical records about this specific incident were detailed. However, as always with written records, the exact content of the conversation was impossible to determine and there were differing views of the conversation. There was no clear and objective evidence that a member of staff had shouted at Mr A or that staff had failed to treat him with respect. In the absence of such evidence, we did not uphold this aspect of the complaint.

Finally, Mrs C complained that the follow-up arrangements each time Mr A was discharged from the hospital were unreasonable. We found that Mr A had been physically fit on each occasion that he was discharged, and that the discharge plans in relation to his psychiatric care were reasonable and appropriate. We did not uphold this aspect of Mrs C's complaint.

  • Case ref:
    201502620
  • Date:
    May 2016
  • Body:
    Forth Valley NHS Board
  • Sector:
    Health
  • Outcome:
    Not upheld, no recommendations
  • Subject:
    clinical treatment / diagnosis

Summary

Mrs C complained about her mother (Mrs A)'s discharge from Forth Valley Royal Hospital. Mrs A was 82 years old at the time and was admitted with chest pains, later diagnosed as a heart attack. Further to treatment, plans were made to discharge Mrs A but her family were concerned that she remained in poor health. Mrs C said they had alerted staff to Mrs A's breathing difficulties, shivering, leg swelling, lack of appetite and general weakness but were assured that she was fit to go home. Following discharge, Mrs A was readmitted in the early hours of the following morning. She was diagnosed with sepsis and did not recover. She passed away five days later.

Mrs C considered that the signs of sepsis were present prior to Mrs A's discharge and were not detected by staff. The board advised that the results of pre-discharge tests were not consistent with a diagnosis of sepsis. We took independent advice from a consultant in general and geriatric medicine. They noted that Mrs A's symptoms, observations and blood test results were considered prior to discharge and were relatively normal. In particular, they noted that her blood test results were sufficiently normal to allow discharge to proceed. They did not consider that there was any evidence Mrs A was suffering from sepsis at the time and, overall, they considered it reasonable for her to have been discharged. They noted that she was re-admitted a short time later and subsequently died but were not of the view that this could have been reasonably predicted at the time of discharge or that it was due to poor medical care during Mrs A's admission. We did not uphold Mrs C's complaint.

  • Case ref:
    201405422
  • Date:
    May 2016
  • Body:
    A Medial Practice in the Forth Valley NHS Board area
  • Sector:
    Health
  • Outcome:
    Not upheld, no recommendations
  • Subject:
    clinical treatment / diagnosis

Summary

Mrs C brought a complaint to us on behalf of her late husband (Mr C), in relation to the care and treatment he received over a five week period shortly before his death. She was concerned that the medical practice had not acted with enough urgency when she felt Mr C's condition was deteriorating. He had three consultations with a GP over a four week period. At the final consultation the GP had concerns about his breathing and referred him for an x-ray, which took place the next day. The results of the x-ray indicated that Mr C had pleural effusion (a build-up of excess fluid around the lungs). The results arrived in the practice the following day, and the GP referred Mr C back to hospital when he viewed the results on his return to work the day after. Mr C was treated in hospital, and was discharged home, to await further treatment. He died before this further treatment could take place.

We sought independent advice from a GP adviser. The adviser reviewed all three consultations, and was satisfied that the GP had taken appropriate action, on the basis of the symptoms which Mr C presented with. They noted that there was no indication of pleural effusion until the third consultation.

The adviser also reviewed the practice's response to the x-ray results, and noted that the results did not indicate a need for urgent action. They considered the practice's response to the x-ray results to have been reasonable.

We noted concerns that Mrs C had raised which were beyond the scope of this investigation, in relation to conversations which could not be corroborated. We noted the adviser's comments in relation to the GP's actions, and we did not uphold Mrs C's complaint.

  • Case ref:
    201504017
  • Date:
    May 2016
  • Body:
    University of the West of Scotland
  • Sector:
    Universities
  • Outcome:
    Not upheld, no recommendations
  • Subject:
    communication staff attitude dignity and confidentiality

Summary

Mrs C complained that the university did not tell her sooner that the course she applied for was full. She also complained that the university did not deal with her application in line with their process, and about their handling of her complaint.

We found that the university told Mrs C that the course was full as soon as they knew this to be the case, which was the day after the school exam results were issued; it was only then that it became clear to the university that the course had no places available. We also found that the university followed the correct procedure in considering Mrs C's application, and when investigating and responding to her complaint. We did not uphold Mrs C's complaints.

  • Case ref:
    201503586
  • Date:
    May 2016
  • Body:
    University of the West of Scotland
  • Sector:
    Universities
  • Outcome:
    Not upheld, no recommendations
  • Subject:
    policy/administration

Summary

Mr C complained that his university withdrew him from his course because he failed to attend classes, and about their handling of his appeal.

We found that Mr C was warned about his lack of attendance at classes, and when he was further warned that his case was being considered by a university panel, he failed to engage properly with the process. The university followed the process for dealing with Mr C's lack of attendance and considered the evidence available to them at the time and, on that basis, decided to withdraw him from the course. We also found that the university followed the process for dealing with Mr C's appeal. We did not uphold Mr C's complaints.

  • Case ref:
    201500986
  • Date:
    May 2016
  • Body:
    University of the West of Scotland
  • Sector:
    Universities
  • Outcome:
    Not upheld, no recommendations
  • Subject:
    communication staff attitude dignity and confidentiality

Summary

Ms C complained that she had made the university aware of issues she was experiencing at home during her third year of studies in relation to childcare and illness, but they had not informed her of the mitigation process. She also complained that communication she had had with the university had not been responded to. She identified four specific emails to two members of staff which were not responded to.

We found that, in the context of seeking an extension for an assignment and explaining why she had been unable to attend academic support sessions, she had informed staff on these particular occasions that she (or her child) had been unwell or had issues with childcare. It did not appear that Ms C was seeking advice or support on these issues and their impact on her studies; rather they were an explanation for the extension request or the reason for not attending meetings. Therefore, we did not consider that it was unreasonable that staff had not mentioned the mitigation process to her directly in response to these emails. The university also provided us with a copy of the student programme handbook for the course which provided details of how and when to apply for mitigation. We considered that it was Ms C's responsibility to familiarise herself with the information the university had provided. Therefore, we did not uphold her complaint.

In relation to Ms C's second complaint about emails not being responded to, unfortunately, because of the length of time which had passed since these emails had been sent, both the university and Ms C were unable to provide us with sufficient evidence to allow us to establish whether the emails were received and responded to or, if they were not, whether this was unreasonable. Therefore, there were no grounds for us to uphold Ms C's complaint.

  • Case ref:
    201504475
  • Date:
    May 2016
  • Body:
    University of Edinburgh
  • Sector:
    Universities
  • Outcome:
    Not upheld, no recommendations
  • Subject:
    policy/administration

Summary

Mr C complained that a school at the university failed to accept his evidence of special circumstances in relation to his exams, and about the university's handling of his appeal.

We found the school did consider Mr C's evidence; they decided that it was not evidence of the impact of Mr C's claimed special circumstances on his academic performance. The school did this by assessing Mr C's previous academic record and we accepted that, in this case, it was allowed for in university policy and it was a matter of academic judgement. We cannot investigate matters of academic judgement and, therefore, we could not comment on that issue. However, we were satisfied that it was reasonable in the specific circumstances for the school and the university to consider this as a matter of academic judgement, and that the school did consider Mr C's evidence. We were also satisfied that Mr C's appeal was handled in line with the relevant procedure. We did not uphold Mr C's complaints.

  • Case ref:
    201502220
  • Date:
    May 2016
  • Body:
    Fife College
  • Sector:
    Colleges
  • Outcome:
    Not upheld, no recommendations
  • Subject:
    policy/administration

Summary

Miss C complained that the college failed to allow her to complete an award, and about their handling of her complaint. We looked at Miss C's account of what happened, at the college's comments and file on the complaints, as well as copies of correspondence and college records.

The college's view was that Miss C left a lot of coursework until the last minute, and they said it would be unreasonable to expect them help Miss C with this given that she had been on the course, that was supposed to last a year, for 18 months. Miss C's view was that, according to her college assessor, she was told that her progress was satisfactory, and there would be no problem completing the course. Miss C said her assessor promised that she would be able to finish her work. There was no conclusive written evidence to prove either version of events, or that the college unreasonably failed to allow Miss C to complete the award.

We found that the college complied with their complaints procedure, and they took steps to review evidence from their records as well as taking statements from staff. There was no evidence that Miss C's complaint was handled inadequately. We did not uphold Miss C's complaints.