Not upheld, recommendations

Summary

Mr C complained to us about the care and treatment he had received from an opticians practice he attended with a problem in his left eye. He was examined by two optometrists at the practice. When he then phoned the practice again about the matter, they referred him to hospital, where a retinal detachment was diagnosed and surgery performed. Retinal detachment occurs when the thin lining at the back of the eye called the retina begins to pull away from the blood vessels that supply it with oxygen and nutrients. Without prompt treatment, it will lead to blindness in the affected eye. Mr C said that the sight loss he suffered in his left eye would not have been as severe had the optometrists referred him to hospital earlier.

We took independent optometry advice. We were unable to say for certain whether the retinal detachment was present on the two occasions Mr C attended the opticians. However, we found that the initial examination carried out when he attended the opticians was reasonable and appropriate according to the relevant guidelines. This would have offered a reasonable chance to detect whether retinal detachment was present at that time. When Mr C attended the opticians on the second occasion, his pupils were not dilated and the full set of relevant tests was not carried out. However, we found that this was reasonable as there was no evidence of increasing symptoms.

We did not uphold Mr C's complaint, as there was no clear evidence that he should have been referred to hospital earlier. However, there was no evidence that he was given an information leaflet about retinal detachment in line with both local and national guidance and we made a recommendation to the opticians in relation to this.

Recommendations

We recommended that the opticians:

• take steps to ensure that in appropriate cases, patients are provided with a retinal detachment warning leaflet.

Summary

Mrs C underwent cataract surgery to her right eye at the Golden Jubilee National Hospital and had no concerns. However, she then complained about the care and treatment she received following subsequent cataract surgery to her left eye because she was experiencing pain and double vision. Mrs C was concerned that she was not informed prior to the operation that a different doctor would be performing the second surgery, that her left eye was not properly anaesthetised, and about the lack of treatment after she raised her concerns, post-surgery.

We took independent medical advice and found that it was reasonable for a different doctor to have performed the second surgery. However, we found that it should have been properly explained to Mrs C when she consented to the surgery that it could be a different doctor. In addition, we found that the consent form did not clearly state all of the known risks and complications of her surgery, which would have been accepted good practice. There was documentation indicating that some form of conversation took place with Mrs C about the risks of post-operative inflammation and the possibility that further surgery might be needed. However, we were critical that it was not clearly completed and recommended the board take further action to address these two issues relating to the consent process.

However, we did not uphold Mrs C's complaint on the basis that there was no definitive evidence to support that there was a problem with the anaesthetic or the operation itself. There was a small amount of plaque left behind but we considered it was reasonable not to remove it due to there being an increased risk of complications if removed.

We considered that it was reasonable for Mrs C to be discharged to the care of her optician after the operation. We noted that the optician referred Mrs C to a different hospital when she experienced pain and inflammation in her left eye, and that the care plan was to carry out further surgery. We considered it was appropriate for the board to advise Mrs C to continue with this suggested care plan. Whilst we did not uphold Mrs C's complaint, we were critical that there was no evidence to clearly show that the operative findings had been explained to Mrs C or her optician and that as a result of these findings she may develop inflammation and require further surgery. We therefore made recommendations to address these communication problems.

Recommendations

We recommended that the board:

• share the findings of this investigation in relation to the consent process with staff concerned;
• consider amending their consent form to include a separate section for listing all the relevant risks and complications discussed with the patient;
• draw to the attention of the doctor who carried out the second surgery the importance of sharing the operative findings and potential for further surgery with both Mrs C and the optician who managed her post-operative care; and
• apologise to Mrs C for the failings identified in this investigation.

Summary

An arrangement was in place whereby Mr C received his meals in his prison cell. This was as a result of the anxiety Mr C experienced in attending the prison dining hall due to post-traumatic stress disorder (PTSD). However, the board advised the Scottish Prison Service (SPS) that Mr C could return to the dining hall to have his meals. Mr C complained about the board's decision that he was fit to do so.

We took independent medical advice from a consultant forensic psychiatrist who noted that the in-cell dining arrangement did not appear to have been a significant feature of Mr C's historic clinical assessments. They also noted that there was no indication that PTSD was felt to have been a major ongoing issue for Mr C. They considered that Mr C was appropriately reviewed by clinicians before deciding that he was fit to attend the dining hall and that this decision was reasonable. We did not uphold the complaint.

However, the adviser considered that the psychiatrist who reviewed Mr C's fitness to attend the dining hall should have provided clearer and more definitive advice to the SPS. As they were still in training, they should have discussed the situation with their supervising consultant if they were unclear on what to advise. There was no evidence that this happened. We noted that the psychiatrist had indicated they would leave it for the SPS to make the final decision, rather than focusing on providing clear and specific advice upon which they could base their decision. We considered that the board's role in such decision-making could benefit from being clarified through the provision of guidance to mental health staff and we made recommendations accordingly.

Recommendations

We recommended that the board:

• take steps to ensure that any non-consultant-grade psychiatric staff providing input to the SPS are appropriately supervised;
• remind prison mental health staff to ensure that they provide clear and specific advice and/or recommendations to the SPS when they receive a reasonable request for clinical input into a decision; and
• consider introducing written guidance for prison mental health staff on dealing with requests from the SPS for clinical input into decisions relating to the management of prisoners, taking account of the psychiatric adviser's comments.

Summary

Mr C complained to us on behalf of his daughter (Mrs A). Mrs A experienced complications following hysterectomy surgery at Glasgow Royal Infirmary, including an injury to her bladder. Her right ovary and fallopian tube were also removed. Mrs A subsequently developed a vesico-vaginal fistula (an abnormal tract between the bladder and vagina). Mr C complained that the hysterectomy surgery had not been performed appropriately.

We took independent advice on the complaint from a consultant gynaecologist. We found that the hysterectomy surgery provided to Mrs A had been reasonable. The adviser said that whilst the development of a vesico-vaginal fistula was likely to be due to the hysterectomy surgery, there was nothing that suggested the surgery had not be performed to a reasonable standard. Additionally, the adviser considered it reasonable that Mrs A's right ovary and fallopian tube were removed as it had been deemed necessary during the surgery. However, in our investigation we identified some areas of the consent process which did not meet national guidelines. We made a recommendation to the board on this basis.

We also determined that in response to Mr C's complaint, the board had failed to respond to all the issues raised. We therefore recommended that the board take steps to address this.

Recommendations

We recommended that the board:

• apologise to Mrs A for the failure to notify her of all the risks involved in hysterectomy surgery;
• apologise to Mr C for the failure to adequately respond to his complaint;
• feed back the findings of this investigation to the relevant staff and ensure that they review their process for taking consent for hysterectomy surgery to ensure it is in line with national guidance; and
• take steps to ensure that complaint responses address all issues raised by complainants.

Summary

Ms C complained about the treatment she received after fracturing her ankle and that she had attended unnecessary out-patient appointments.

Ms C underwent surgery on her ankle at Western Infirmary. As she continued to suffer constant pain in the ankle and restricted mobility, she was referred to orthopaedic appointments at Glasgow Royal Infirmary and she received different opinions on treatment options. Ms C was dissatisfied with the explanations she was given about her ankle and the treatment options.

We took independent advice from a consultant trauma and orthopaedic surgeon. They noted that the orthopaedic care and treatment received by Ms C had been appropriate and was within the range of standard medical practice. Although Ms C had seen several doctors, their opinions fell within the range of accepted treatments. Therefore we did not uphold this aspect of Ms C's complaint.

We accepted that it must have been both inconvenient and frustrating for Ms C to have attended unnecessary out-patient appointments. The board had apologised to Ms C for this and acknowledged that on one occasion the correct patient hospital appointments process was not followed by staff and that they had taken action to address this. While we considered the board's action to have been reasonable, we made a recommendation relating to this.

Recommendations

We recommended that the board:

• provide evidence of the action taken on staff feedback and training with regard to issuing patients with hospital appointments.

Summary

A firm of solicitors (company C) complained that their client (Mr A) did not receive a reasonable standard of care and treatment from the board for his mental health while in prison. Their concerns included that the board failed to provide Mr A with one-to-one appointments with a psychiatrist when this had been provided for him in a previous prison. They were also concerned that the board incorrectly suggested that Mr A failed to attend appointments, when his disengagement was as a direct consequence of him being unable to participate properly. Mr A died during our investigation of the complaint and his mother (Ms B) gave us her consent to continue the investigation.

We obtained independent medical advice from a consultant psychiatrist. The evidence showed that Mr A attended joint assessment appointments with a psychiatrist and a mental health nurse on two occasions. At the first appointment, Mr A voiced his concerns about joint assessment. However, after explanation from the psychiatrist, he appeared to accept this approach and the board then arranged a further joint assessment. The adviser said that when Mr A expressed further concern at the second assessment, it was not reasonable for the board to have attempted to continue joint assessment that day. The evidence also showed that for the period under consideration in this complaint, Mr A only failed to attend one appointment (for a self-referral clinic) and that the board's statement about his attendance was, therefore, incorrect.

Whilst noting that it was not reasonable for the board to attempt to continue with the second joint assessment after Mr A had expressed further concern, the adviser said that overall, Mr A received a reasonable standard of care and treatment from the board for his mental health. We therefore did not uphold company C's complaint. However, we made recommendations to address aspects of the board's complaints handling.

Recommendations

We recommended that the board:

• feed back our decision on this complaint to the health and complaints staff involved;
• ensure that, in future, complaints are forwarded to the complaints team in a timely fashion and are acknowledged in accordance with the board's complaints procedure; and
• apologise to company C and Ms B for the failings identified.

Summary

Mr C raised a complaint with the council on behalf of his mother (Mrs A) regarding home care. As the complaint was regarding social work, it was progressed through the statutory social work complaints procedure and a complaints review committee (CRC) was held. Mr C complained about various aspects of the council's handling of his complaint.

We found that while there had been a delay in the CRC being held, it was not unreasonable. We concluded that there was no evidence of bias. We were satisfied that the council had handled the request for the CRC to be recorded in a reasonable way. We were satisfied with the council's explanation regarding the effect of the power of attorney on the complaint and that the CRC had accepted Mr C was the power of attorney. Mr C had decided not to continue with the CRC and therefore they were not given the opportunity to consider the complaint itself at the meeting. We therefore did not uphold Mr C's complaint.

We did have concerns that the council had subsequently written to Mr C stating that they would not reschedule the CRC and referred him to the SPSO as this meant that the complaint that had been raised was not actually considered at CRC stage, which is a complainant's right under the statutory social work complaints procedure. We also had concerns that the council continued to correspond with Mr C following the referral to the SPSO after the CRC and treated his correspondence as a new complaint. We therefore made recommendations to address this.

Recommendations

We recommended that the council:

• offer Mr C a final option to have this complaint considered by a CRC on the basis of the written submissions he and the council had previously made to the CRC; and
• remind staff that complaints about complaints handling should not normally be treated as a new complaint and that if appropriate, complainants should be referred to the SPSO.

Summary

Mrs C complained on behalf of her sister (Ms A). Ms A attended at A&E at Queen Elizabeth University Hospital as she had slumped to the side and had facial weakness. She was discharged with a diagnosis of 'non-organic causes'. Four days later Ms A re-attended the hospital following referral by her GP and at this point was diagnosed with having had a stroke. Mrs C complained that no scan had been carried out on Ms A's first presentation at A&E and that had it been, the stroke may have been diagnosed earlier. Mrs C also complained that staff had relayed to the family that Ms A's symptoms were possibly due to drug or alcohol consumption.

During our investigation we obtained independent medical advice. We found that appropriate tests and assessments had been carried out on Ms A during her first presentation at A&E and that her medical history had been reasonably taken into account. We found that a scan was not clinically indicated at this point and that the likely diagnosis of non-organic causes was reasonable. Overall we found the care and treatment was reasonable. We were, though, critical that staff had relayed to the family that Ms A's symptoms were possibly due to drug or alcohol consumption, however we noted that the board had previously apologised for this. We did not uphold this complaint, but we made a recommendation.

Recommendations

We recommended that the board:

• draw to the attention of A&E staff the importance of not discussing possible causes of symptoms with family whilst investigations within the department are ongoing.

Summary

Mrs C complained on behalf of her daughter (Miss A) about the college's failure to support Miss A's educational needs, specifically how the college and their staff dealt with Miss A during one academic year in relation to her attendance. Mrs C also complained about inaccurate information provided by the college to the Student Awards Agency for Scotland (SAAS) and about the handling of and response to her complaint.

We did not find evidence that the college unreasonably failed to support Miss A's educational needs or that their handling of and response to Mrs C's complaint was inadequate. We did not uphold these aspects of Mrs C's complaint.

In terms of the information provided to SAAS, this did appear to be at odds with Miss A's student record. However, this resulted in a benefit to Miss A in terms of a reduced invoice from SAAS. We did not regard this as unreasonable and, therefore, we did not uphold this aspect of Mrs C's complaint.

We did have concerns about the lack of a college procedure for the withdrawal of students on medical grounds and about staff making and keeping records of interviews carried out during the investigation of complaints. We made recommendations to address these concerns.

Recommendations

We recommended that the college:

• introduce a procedure for the withdrawal of students on medical grounds; and
• ensure that staff investigating complaints make and keep records of interviews as part of the complaint file.

Summary

Mr C complained that the council unreasonably invoiced him for the cost of work associated with two emergency statutory notices carried out four years previously. These had been issued to make safe masonry on a building where Mr C owns a flat. Mr C was concerned that the council could only provide evidence of the amount they paid the contractor for the work, rather than an itemised bill. He was also concerned about the length of time it took the council to invoice him for the share of the costs.

The council said that invoices from the contractor could not be retrieved as the company was no longer trading. They said that the invoices were submitted by the contractor electronically through the council's internal payment system, therefore there was no paper copy on record other than printouts confirming the payments the council had made to the contractor. The council said that there was no evidence to suggest that the work carried out had not been satisfactory, and so they felt the invoices were accurate and recoverable from the owners.

We were critical that the council was unable to provide records to show that the site had been inspected to verify completion of the work before payment was authorised to the contractor. However, there was no evidence to suggest that the work carried out had not been satisfactory. We were satisfied that the council had implemented guidance on the emergency statutory notice process. We also found that the council had delayed issuing the invoices due to an investigation into their former property conservation section and that the council was entitled to pursue the outstanding costs after four years. We therefore did not uphold Mr C's complaint. However, we recommended that the council apologise to Mr C for the failings in their record-keeping.

Recommendations

We recommended that the council:

• apologise to Mr C for the failings in their record-keeping.