Not upheld, no recommendations

Summary

C complained on behalf of their client (A) who was admitted to the Royal Alexandra Hospital after fainting at home. A CT scan showed that A had suffered a fractured bone in their neck. A was initially fitted with a collar but C complained that this did not fit well and caused A severe pain and discomfort, to the extent that A's neck injury became worse. Due to A's ongoing pain, a further CT scan was carried out which confirmed that the fracture had displaced (not lined up) slightly. A was referred to the spinal unit at another hospital and was fitted with an alternative form of brace. C complained that A should have been referred to the spinal unit from the outset.

We took independent advice from an orthopaedic consultant (a doctor specialising in the treatment of diseases and injuries of the musculoskeletal system). We considered that the initial investigations and treatment were reasonable. We found evidence that the fitting of the collar was checked by staff. We also considered that the subsequent change to an alternative brace was reasonable, and there was no indication for an earlier referral to the spinal unit. However, we were critical of a delay in reporting the second CT scan. This was an urgent scan which should have been reported within days, but it was not reported for three weeks. This delay did not cause A harm, but it did prolong their pain and discomfort. The treatment of A's injury was otherwise of a good standard and, on balance, we did not uphold this complaint.

Summary

C underwent surgery at Victoria Hospital to repair a fracture in their left wrist. Following the surgery, infections developed and this led to several further procedures being required to clean the wound and address damage caused by the infections. C complained that the board failed to provide them with appropriate care and treatment. Their concerns included that the board did not detect and effectively treat the infections, and that blood tests were not carried out to check for infection after C was discharged from hospital.

We took independent advice from a consultant orthopaedic surgeon (a specialist in the treatment of diseases and injuries of the musculoskeletal system). We found that recognised complications (including infection) were discussed with C as part of the consent process and that there did not appear to have been undue delay in identifying C's first infection. We also found that blood tests to check for infection were carried out with reasonable frequency. However, the board should have ensured that blood test results were monitored and acted on timeously. Though we noted that there was a delay in responding to a blood test result, which suggested infection was present, this could not itself be said to have negatively affected the overall outcome for C.

We concluded that the overall care and treatment provided to C was reasonable. It was noted that the board had acknowledged the blood test result failing and taken appropriate remedial action. As such, we did not uphold the complaint.

Summary

Ms C complained about the care and treatment her mother (Mrs A) had received in Dumfries and Galloway Royal Infirmary and Castle Douglas Hospital. She was transferred to these hospitals after having surgery on her brain, which left her with quadriplegia (paralysis of all four limbs).

We took independent advice from a consultant geriatrician (a doctor who specialises in medicine of the elderly) and a nursing adviser. In relation to Ms C's complaint about the care provided to Mrs A, we did not uphold the complaint, as we found that:

staff had assessed Mrs A in detail after her transfer and there was no evidence of a negative or palliative approach to her care;

a detailed physiotherapy assessment was carried out promptly the day after her transfer and this was followed by regular sessions with physiotherapists;

Mrs A's care in relation to alerting staff and consuming meals had been reasonable;

it was reasonable that Mrs A did not receive counselling, as there was no clear indication for this in the observations of staff, or requests from Mrs A or her family; and

the level of care provided to Mrs A in relation to massage, physiotherapy and bodily movement was reasonable.

Ms C also complained that the board did not provide reasonable treatment to Mrs A following her admission. We found that there was evidence of a comprehensive assessment of Mrs A's needs and specific attempts to provide care and rehabilitation for her in both hospitals. The prescription of medication, based on the assessments carried out, was reasonable even if it did cause some sedation as a side-effect. We did not uphold this aspect of the complaint.

Finally, Ms C complained that the board unreasonably instructed staff not to talk to her. We found that it had been reasonable for staff to propose a contact time for Ms C every day. This meant that rather than deal with a number of calls from Ms C, staff could give a focussed update. We did not uphold this complaint.

Summary

C complained about the treatment the board provided to their spouse (A). After falling unwell, C had contacted NHS 24 on A's behalf as they were concerned that A's symptoms may have been due to a cardiac (heart and its blood vessels) issue. A then spoke to a medical professional from NHS 24 who signposted them towards Borders Emergency Care Service (BECS), an out-of-hours service, which they attended.

When A attended BECS, they were examined by a trainee advance nurse practitioner (ANP). After examining A and taking a history from them, the trainee ANP's view was that A's symptoms were due to a muscular strain rather than being cardiac in nature. A was discharged on this basis but died four days later as a result of coronary artery atheroma (fatty deposits that build up on the walls of arteries around the heart). C complained that A's death was preventable and that they were not examined appropriately when they attended BECS.

We took independent advice from a nurse. We found that the examination of A, and the trainee ANP's decision-making, were reasonable given the information provided to them. In addition to this, it was appropriate for a trainee ANP to examine A and reach conclusions on their treatment. We concluded that A received appropriate treatment when they attended BECS. Therefore, we did not uphold this complaint.

Summary

C complained on behalf of their parent (A) about the care they received by the practice. A had been unwell and required a home visit from the practice. C believed that A had not been adequately examined during this visit, which had placed A's life at risk. C said that within days of the home visit, another GP had reviewed A, which resulted in A's admission to hospital. During this admission a significant amount of fluid was removed from A's legs and A was found to have a damaged heart valve. C felt that the practice had failed to honestly admit their failings or to offer a sincere apology.

We took independent advice from a GP. We found that A had been reviewed thoroughly and appropriately. There was no evidence that clear symptoms of heart failure had been overlooked. There was also no evidence that A had an acute condition at the time of the home visit, and the symptoms reported and recorded were consistent with A's pre-existing medical conditions.

We found that the care provided to A was of a reasonable standard and did not uphold the complaint

Summary

C complained about the care and treatment the board provided to their late spouse (A) at University Hospital Crosshouse (UHC). A suffered a heart attack and was taken by ambulance to a hospital in another health board area. Following treatment, A was transferred to UHC, but then suffered what was thought to be a stroke event and died a week later.

C complained about several aspects of A's care, including that staff did not tell them what was happening with A and failed to advise them that A was in a coma. C also said that A's health had improved at the other hospital and they understood that A was being moved to UHC to recuperate before being sent home, but A died shortly after their arrival at UHC.

We took independent advice on the case from two advisers - a consultant cardiologist (a doctor that specialises in diseases and abnormalities of the heart) and from a nurse. We found that the medical records showed staff gave C regular updates about A's condition and tried to be realistic about the likely outcome, while being supportive of C. We considered that there was evidence that staff kept C reasonably updated about A's condition during the admission. However, we welcomed the board's apology that the communication did not meet C's needs; this showed a sensitivity to the responsibility for ongoing learning and improvement to ensure communication is tailored to the needs of individuals and their families. We found that there was a lack of clarity from the other hospital about A's prognosis and future treatment plan at the time of their transfer to UHC, which may have contributed to C's confusion and distress at this time. We included some feedback to the board about this. However, we noted that this did not influence A's care at UHC, following the sudden stroke that they suffered soon after transfer, which was ultimately fatal. We considered that, overall, A's care and treatment at UHC was reasonable and we did not uphold the complaint.

Summary

C, a solicitor, complained on behalf of their client (A) about the actions of Scottish Natural Heritage (SNH) relating to the proposed denotification of a Site of Special Scientific Interest (SSSI) of which A was one of the landowners of the site. C's complaints related to a number of issues including SNH's contact with the media and their communication with A.

We found that SNH had discretion in relation to any additional contact with the media they considered appropriate and provided a reasonable explanation in relation to their actions. SNH informally notified landowners of their impending action and formally notified A in writing once formal notification commenced as per their procedure. There was a delay in written notification arriving with A but this was outwith SNH's control. Having considered the information available, we determined SNH's actions to be reasonable and in line with policy and procedure. As such, we did not uphold the complaints.

Summary

C complained about two incidents involving their child (A) and another child at school. C said that child protection procedures should have been followed.

We did not consider that C's complaint was a child protection matter and therefore child protection procedures did not require to be followed. We did not uphold this aspect of the complaint. However, we considered that the school could have managed the incidents better, particularly in relation to their communication with A so that they felt supported and respected.

C also complained that there was an unreasonable delay in the school advising them of the first incident. We considered that C was told within a reasonable period of time. We did not uphold this aspect of the complaint.

C also complained about a refusal to allow them to take an audio recording of a meeting with the head teacher of the school. Whilst we appreciated why C wanted to record the meeting, we did not uphold this complaint on the basis that the head teacher was entitled to refuse this. We considered that the offer to bring someone to support C to the meeting and the opportunity to comment on a minute of the meeting afterwards to be reasonable.

Summary

Mrs C complained on behalf her daughter (Ms A) that Ms A had been unreasonably removed from the council's homeless waiting list for settled accommodation.

After Ms A had been placed on the waiting list, she accepted a private let outwith the council area but did not inform the council of her change in circumstances. Ms A and her family were later sent a provisional offer for settled accommodation, which Ms A accepted, however the council noted in the course of their pre-allocation checks that Ms A had taken up a private let and no longer met the homeless criteria. As a result, the council withdrew the offer and removed Ms A from the homeless waiting list.

We found that Ms A had signed an agreement to inform the council of any changes in circumstances, including a change of address, and she had not told the council that she had moved to a private let outwith the council area. Additionally, we found that in taking up the private let, she no longer met the criteria to be provided settled accommodation by the council and it was reasonable that the council removed her from the waiting list. As a result, we did not uphold this complaint.

Summary

Mr C complained that the partnership failed to take account of relevant evidence when reviewing priorities for the provision of healthcare premises in North Ayrshire. He also complained that the partnership rejected his complaint.

We found that, in a report on local health care premises, the partnership referred to various data sources and included sets of data about economic, population and health factors, as well as information about state of premises and whether they were fit for purpose. We concluded that it was for the partnership, not us or Mr C, to interpret and assess the data in order to propose a ranked list of premises developments. Mr C disagreed with their interpretation and assessment, and he had an opinion on what evidence was most relevant; however, this was not evidence of an administrative failing by the partnership.

We also found that the partnership investigated and responded to Mr C's complaint appropriately. We did not uphold Mr C's complaints.