Not upheld, no recommendations

Summary

Mrs C's late mother (Mrs A) was diagnosed with cancer in 2011. Mrs C complained that when blood test results were found to be abnormal, a GP from her mother's medical practice (GP 1) failed to tell Mrs A about these when he was the on-call doctor. Mrs C was unhappy that her mother did not find out the results until nine days later when she attended the local community hospital's accident and emergency department (A&E) and GP 1 (who was the on-call GP in the hospital at the time) accessed the results.

The background to this is that another GP at the practice (GP 2) had arranged for Mrs A to attend the surgery in late December 2010 to have non-urgent blood samples taken. These were sent to the laboratory the following day where they were immediately identified as abnormal. At the time, the laboratory's procedures set out that they must communicate abnormal test results to medical staff quickly, and make a computer entry showing when the call took place and to whom. The procedure also included an out-of-hours number for laboratory staff to call if it concerned an out-of-hours GP.

In their response to Mrs C's complaint, the board apologised for a failure in the timely reporting of the abnormal blood results. However, the board advised us that it was unclear to them whether the laboratory had failed to follow procedure. When we investigated, we found that it was difficult for us to be certain whether the laboratory had telephoned and told the practice the results. There was an entry on the computer system suggesting that a call had been made to GP 2. However, the surgery had closed an hour before the laboratory had apparently made the call. In addition, GP 2 saw his last patient in the surgery at 12:45 and was not the on-call doctor that particular day. There was also no entry in Mrs A's medical records to indicate that the surgery had received a call from the laboratory. There was, therefore, no conclusive evidence that confirmed that the practice were aware of the test results.

The medical records showed that GP 1 accessed the results in early January 2011 when Mrs C's mother attended A&E. We did not uphold the complaint, as we considered that GP1 had taken appropriate action to have Mrs A further assessed at that time, and there was no evidence to support that he was aware of the blood test results before he accessed them in January 2011.

Summary

Mr and Mrs C underwent in vitro fertilisation (IVF) treatment (fertility treatment) in 2010 and had a child. They understood that they were not entitled to further treatment from the health board and had been saving for private treatment. They made an appointment for a private consultation. However, Mrs C said she received a telephone call from the board in April 2011 saying she was entitled to a further cycle of treatment. On that basis, Mr and Mrs C cancelled their private treatment, and made appointments at the board's assisted conception unit. Around three months later, Mrs C contacted the board to confirm the dates of her appointment with the assisted conception unit and was told that there had been an error, and she was in fact no longer entitled to further NHS treatment.

The board conducted an investigation including tracing their call logs, but could find no record of the call to Mrs C in April 2011. There was also no record of appointments having been made for her with the assisted conception unit in 2011. The board considered Mr and Mrs C's case again, but reached the decision that they would not deviate from their normal policy on IVF to offer a second cycle of treatment. We considered the board's investigation and obtained further information. We found that there was no independent evidence to support Mrs C's position about the telephone call, although we did not disbelieve her position. We also found the board's position of following their policy to be reasonable. Although we did find that there was a delay in Mr and Mrs C obtaining IVF treatment as a result of their experiences, on balance we did not uphold the complaint.

Summary

Ms C complained about the treatment her mother (Mrs A) received from a GP at her medical practice. Mrs A had attended an appointment with the GP in relation to rectal pain and bleeding. The GP performed an examination, diagnosed piles, prescribed a treatment, and advised Mrs A to return within seven to ten days if her symptoms did not improve. Mrs A returned some five weeks later, by which time her symptoms had worsened and she had blood in her stools. Another GP referred Mrs A to hospital for tests, and she was given a clinic appointment for just over two months later. In the meantime, Mrs A attended the practice on two further occasions, when she was seen again by the first GP. On one of these occasions, the GP physically examined Mrs A again.

Mrs A was diagnosed with colorectal (bowel) cancer after the hospital appointment. She underwent chemotherapy and radiotherapy. Due to other medical conditions, it was considered that surgery was not a suitable option and Mrs A died just under a year and a half after being diagnosed. Ms C said that if the GP had properly recognised her mother's symptoms at the start, she might have had a better life expectancy and an improved quality of life. Ms C was also concerned that, given the subsequent cancer diagnosis, the GP had said that there was 'nothing untoward' on the occasions that she examined Mrs A.

Having taken independent advice from one of our medical advisers, we found that the GP's care of Mrs A had been appropriate. We found that it was reasonable for the GP to prescribe medication for piles at the first appointment, and to advise Mrs A to attend seven to ten days later if her symptoms had not improved. We accepted that the referral was appropriate, and that there was no requirement for the GP to try to speed that up after Mrs A's later appointments. We noted that, as a hospital appointment had already been made and was due shortly, this would have had no practical impact upon Mrs A's prognosis and treatment time. We also found that the GP's statement that there had been 'nothing untoward' was made in the context of the physical examinations. It was reasonable that further tests at the hospital were needed in order to discover a cancer diagnosis.

We did draw to the practice's attention that it might have given Ms C some reassurance if they had told her that they had carried out a Significant Event Analysis (a detailed investigation into what happened) as a direct result of her complaint, and had put in place the learning outcomes that it identified.

Summary

Mr C complained about the board's actions in relation to his elderly father (Mr A). He said that his father had been admitted to hospital late in the evening. After being examined and declared fit, he was sent home in the early hours of the morning by car, with a relative. Mr C said the relative was not entirely happy with this but, nevertheless, complied. When Mr A reached home, a neighbour had to be recruited to help him get into the house. Mr C said that his father should not have been discharged, particularly because he was elderly, disabled and had memory problems.

We investigated the complaint taking all the relevant information, including all the complaints correspondence, the relevant clinical records and the board's discharge policy, into account. We also obtained independent advice from one of our advisers, who is a nurse.

In responding to the complaint, the board had confirmed that Mr A was considered fit for discharge and was keen to go home. There was, therefore, in their view, no clinical reason to keep him in hospital. They pointed out that the Scottish Ambulance Service did not provide out-of-hours transport and, as there was a relative available and willing to take Mr A home, they had asked him to do so. They said that if this had not been the case, they would have had to consider whether a taxi was appropriate.

Our nursing adviser reviewed the files and confirmed that the information in them indicated that Mr A was fit to go home. She also confirmed that Mr A was not in fact admitted to hospital, and so the board's discharge policy would not apply in his case. She said that in all the circumstances, it was not unreasonable for Mr A to return home with a relative, given that an emergency department was not an ideal place for an elderly and frail person.

Taking all the information into account, we did not uphold the complaint as we found that, while not ideal, in all the circumstances it was not unreasonable for the board to discharge Mr A home.

Summary

Mr C had a hernia operation, but was admitted to hospital a week later with severe pain in his testicles. It was discovered that the blood supply to one of his testicles had been cut off and it had to be removed. The surgeon said that the obstruction in the blood supply had been caused by a combination of the hernia operation and a vasectomy that Mr C had previously had. Mr C complained to us about the standard of the hernia repair surgery.

We found that the hernia operation Mr C had was the standard procedure. Our medical adviser said that the operation note was a well-completed document that complied with good surgical practice. We also found that it was appropriate that the operation was carried out by a suitably experienced junior doctor under the direct supervision of a surgeon. Damage to the blood supply to a testicle is a recognised, but rare, complication of hernia surgery. If a testicle does not have any blood supply, it has to be removed. However, our adviser said that there was no evidence that Mr C's earlier vasectomy had been a factor in the complication he suffered and we told the board this.

Mr C also complained that the board failed to adequately communicate with him before and after his surgery. We found that the consent forms for the operations had been completed appropriately. The surgeons also recorded that they met Mr C before and after the operations to discuss the procedures. Mr C disputed this and his version of events clearly conflicted with the surgeons. However, there was no clear and objective evidence to support his complaint about this matter.

Summary

Mr C was a PhD student at the university. Following submission of his thesis, he was accused of academic misconduct (plagiarism - passing off someone else's work as one's own) and his case was considered at a hearing by the university board of adjudication. Mr C was found guilty and the board decided that his studies should be terminated, with no right to complete his doctoral programme. Mr C appealed against the decision, but his appeal was not upheld.

Mr C raised a number of complaints about the procedure that the university followed when considering his case and about the validity of the sanction applied. He also complained that he was required to submit an electronic version of his thesis prior to his viva (oral examination) potentially making it vulnerable to copyright infringements.

We were satisfied that the university were able to demonstrate that they had followed the procedures set out in their academic misconduct policy and that the correct staff were involved at each stage. We were also satisfied that exceptional personal circumstances, disclosed by Mr C in his appeal, were adequately taken into account. Although we found that the sanction applied in Mr C's case was worded incorrectly, its intention was clearly stated and Mr C was not disadvantaged by the error.

With regard to the requirement to submit an electronic version of his thesis, we found that Mr C was asked to do this but when he declined, the university noted his position and proceeded with their review of his case. Although electronic copies are not normally required at this stage, we found the reasons for the university's request to be legitimate and their subsequent action to be reasonable.

Summary

Ms C, who is a solicitor, complained on behalf of her client (Mr A) who was working towards a degree of Doctor of Clinical Psychology. This was a three year course, the third year of which was assessed by practical placements and academic work, including a thesis. Ms C said that over the course of Mr A's thesis the university had failed to provide him with an adequate level of supervision in terms of their own policies and procedures.

We found no evidence that explained the exact level of supervision a student should receive. This was because the level varies from project to project and trainee to trainee. There was also no evidence that Mr A had raised any concerns about the level of supervision while he was working on his thesis, and it was clear that Mr A and his supervisor disagreed about the level of supervision that was provided. There was insufficient evidence that the level of supervision was below an adequate level in terms of the university's policies and procedures, and we did not uphold the complaint.

Summary

Mr C complained to Scottish Water about the length of time they were taking to complete pipe replacement works along a stretch of road. The works affected his commute and he felt that they were taking longer than necessary as Scottish Water's contractors were not working during evenings and weekends. During his correspondence with Scottish Water, Mr C asked why work was not being carried out at these times, and was told that the local authority had placed restrictions on the hours that could be worked. However, when Mr C contacted the local authority, they told him that they had not done this.

Mr C complained that Scottish Water deliberately misled him in their letter, as there were in fact no restrictions on the hours that could be worked. Our investigation found that several departments in the local authority were involved in the pipe-replacement works. In their capacity as roads authority, the local authority had placed no restrictions on working hours for the project. Mr C's enquiries had been addressed to the roads service and they had confirmed this to him. However, in their environmental health capacity, the local authority had applied their standard working hours restrictions, which prevented work after 18:00 Monday to Friday and 13:00 on Saturdays, with no work permitted on Sundays or public holidays. We were satisfied that working hours restrictions were in fact in place and that Scottish Water did not deliberately mislead Mr C in their correspondence with him.

Summary

Mr C, who is a prisoner, complained that he had not received the appropriate wage payment after transferring from one prison to another. Mr C said that the first prison did not pay him for the final week that he worked prior to his transfer. He also said the first prison told him that the second prison would pay him a repeat wage as his first wage payment there.

We made enquiries with the Scottish Prison Service about Mr C's complaint. Having considered what they said, and having looked at Mr C's prisoner account, we were satisfied that Mr C had received the appropriate wage payments and we did not uphold his complaint.

Summary

Mr C complained that one of the three specific magazine titles he regularly received was removed from his possession. When he complained to the prison about this, he was advised that they were reviewing their policy on sexually explicit publications. In complaining to this office, Mr C stated that the publication he used to receive should not have been excluded.

When we investigated, the prison told us that following their review they decided to allow all publications that are freely available within reputable newsagents. They provided me with a list of titles which are available for prisoners to purchase direct from their regular supplier. This included two of the magazines Mr C received. The prison also confirmed that the list was not exhaustive and that Mr C could submit a request for the third title, which would be permitted as long as reputable newsagents were willing to stock it. As the prison rules give the governor discretion to decide what items to allow, we considered this reasonable and did not uphold the complaint.