Not upheld, recommendations

Summary

Mr C complained to his prison that officers appeared to know confidential information relating to his health. Mr C was not satisfied with the prison's response and so he complained to us.

We looked at the prison's records on Mr C's complaint, and we found that it had been difficult for them to establish the facts of the incident that led to the complaint. A prison manager interviewed officers involved, and their recollections were unable to confirm where the information about Mr C had originated. Although it was not possible to determine exactly what happened, we were satisfied that the overall approach taken by the prison and their response to Mr C's complaint was adequate in the circumstances and, therefore, we did not uphold his complaint.

Although we did not uphold the complaint, we felt it would be helpful if the prison shared with Mr C the investigation of his complaint and the conclusions reached, by giving him a copy of the prison manager's report. We also made a recommendation to address a concern raised by another prison manager during the prison's consideration of Mr C's complaint, given the importance of preserving the confidentiality of personal health-related information.

Recommendations

We recommended that Scottish Prison Service:

• consider giving Mr C a copy of the prison manager's investigation report; and
• discuss the concern about staff overhearing confidential health information with relevant prison and NHS staff to determine what steps could be taken to preserve the confidentiality of such information.

Summary

Mr C complained to us about the council's social work service's decision to create a child protection plan in relation to his partner's child's welfare. Mr C was dissatisfied with how the case conference was conducted. We initially engaged with the council to establish the reason why Mr C had not been offered a right to request a social work complaints review committee, but the council said that their handling of the complaint was in line with their complaints procedure.

Mr C complained that he had been told he could not submit a report to the case conference, but we found nothing to suggest that Mr C had been given such advice, or that he had a right to submit a report. Although we did not uphold this complaint, we were concerned that the council had agreed to Mr C's request to amend the minute to record that he had not submitted a report, but the minute of the case conference included a reference to him doing so. We recommended to the council that they should consider whether the minute needed to be amended to correct this reference, and to apologise to Mr C if it was found there had been a failure to make the correction earlier.

We found Mr C's complaint that he had not been allowed to speak freely at the case conference was not backed by the evidence in the minute of the number of times he had spoken and did not uphold this complaint. Further, we found no evidence to justify Mr C's complaint about the council's failure to provide him with a satisfactory response when he said that there had been incorrect compilation and reporting of information about him in the minute of the case conference, and did not uphold it.

With regard to the council not dealing with his complaint under the final stages of the social work complaints procedure (a complaints review committee), we considered the council's interpretation of Mr C's complaint was too narrow and did not fully reflect that someone complaining about the withholding or withdrawal of a service might, in the course of making that complaint, complain about staff. However, as the decision whether or not to hold a complaints review committee was a matter for the council to take, and we had seen no evidence of maladministration in the handling of Mr C's other complaints, we did not uphold this complaint.

Recommendations

We recommended that the council:

• consider an amendment or addendum to the minute of the meeting of the initial child protection case conference, if it is necessary to correct the reference to Mr C's views also being provided in a written report; and
• apologise for the failure to correct the minute of the initial child protection case conference if an amendment or addendum to the minute is made.

Summary

Ms C, whose first language is not English, complained that she did not receive appropriate treatment for an injury to her left knee at the Royal Infirmary of Edinburgh after she suffered a fall.

We took independent advice from one of our medical advisers, who found that there was a lack of evidence of a physical examination of Ms C's knee at one of the out-patient clinic appointments she attended and there was an initial failure to diagnose that Ms C had sustained an anterior cruciate ligament injury to her knee. However, our adviser considered the delay in diagnosis was not unreasonable and did not adversely affect the eventual outcome and that, overall, the management and treatment of Ms C's knee injury was appropriate and in keeping with accepted medical practice. Furthermore, there was no evidence that an interpreter not being present at Ms C's clinic appointments adversely affected the treatment she received. We accepted this advice and we did not uphold Ms C's complaint.

However, when Ms C complained to the board about her treatment, she had asked the board for the reply to her complaint to be translated into her first language and also for a meeting to discuss her complaint with an interpreter being present, which the board declined to do. While there was no requirement on the board to meet with Ms C to discuss her complaint, we were of the view that declining Ms C's requests was not in keeping with the principles of the board's interpretation and translation guidelines, so we made some recommendations about this.

Recommendations

We recommended that the board:

• apologise to Ms C for the failures in the way they dealt with her complaint;
• draw to the attention of the relevant clinical staff our adviser's comments regarding the lack of evidence of a physical examination of Ms C's knee at her clinic appointment;
• draw their interpretation and translation guidelines to the attention of the clinical staff Ms C saw; and
• ensure that their interpretation and translation guidelines are taken into account by staff when they are dealing with a complaint from a patient whose first language is not English.

Summary

Mrs C complained that she was not offered reasonable treatment by the board for urinary retention problems she developed following hip surgery, when she was referred to them from another health board. She also said there were unreasonable delays in her accessing treatment from the board.

We obtained independent medical advice on this case from two of our advisers: a consultant urologist and an urologically trained nurse.

Our urologist adviser said it was common practice for a consultant to accept patients either by referral by phone or letter and then, based on the clinical need, to arrange further assessment/investigations prior to seeing a patient, as happened in Mrs C's case. However, our adviser considered that if Mrs C could have been seen earlier to explain the reasons for arranging investigations and home assessments and to provide reassurance prior to her out-patient consultation, further distress could have been potentially prevented.

Our nursing adviser explained that the actions of the nursing staff were exactly what she would have expected and said Mrs C's treatment was in line with the guidelines in this area.

Both our advisers found that the timescale for Mrs C's treatment was satisfactory and acceptable and could find no evidence to suggest that there was an unreasonable lack of urgency about her situation which resulted in her being left with long term health problems. However, although we didn't uphold Mrs C's complaints about her treatment, we considered that their communication with her about her treatment could have been much better and that their failing in this area resulted in increased distress and anxiety for Mrs C so we made two recommendations.

Recommendations

We recommended that the board:

• feed back the advisers' comments on communication with Mrs C to the clinical and nursing staff involved; and
• provide Mrs C with a written apology for failing to communicate clearly with her about her proposed treatment.

Summary

Mrs C complained about the care and treatment she received for endometrial cancer (cancer in the lining of the womb) between April 2011 and March 2012 at Raigmore Hospital. Specifically, she was concerned that she was not given enough information about the cancer and her treatment options. She also raised concerns about the treatment she received in 2011 and about delays in surgery going ahead after evidence of cancer was identified in 2012. Mrs C also complained about inaccuracies in the board's response to her complaint.

We found the record-keeping by the staff involved in Mrs C's care and treatment was of an appropriate standard and reflected reasonable attempts to help her understand the diagnosis and treatment plan. We considered that this was done within a reasonable timescale after she presented with abnormal symptoms in 2011. The board also ensured Mrs C had the opportunity to discuss her concerns about her care with relevant specialists.

We took independent advice on her case from one of our medical advisers who found that the treatment given in 2011 was appropriate and in line with national guidance. Our adviser said that there were certain factors that had to be properly considered before decisions could be made regarding Mrs C's care, because of the risk to her life. Whilst we noted a slight delay in a second opinion being sought after it was indicated in 2012 that there was residual evidence of the cancer, this did not impact on Mrs C's outcome as the cancer was in the early stages and had not spread. We also found that it was not clear whether the results of an abnormal scan were highlighted to the gynaecology team through the multi-disciplinary team process. Although the subsequent delay did not have any impact on Mrs C's prognosis, it is important that radiology staff acknowledge that the referring team may not have the experience to interpret any identified abnormalities and action these appropriate. Whilst we made a recommendation to address this, we concluded that there were justified reasons why the management of her care took time to consider and did not uphold the complaint.

We did not identify any significant inaccuracies in the board's written response to the complaint.

Recommendations

We recommended that the board:

• review the current arrangements for multi-disciplinary team meetings to ensure that there are processes in place for abnormal scan or x-ray results to be flagged and actioned as appropriate.

Summary

Mrs C complained about the standard of treatment she received during her pregnancy and labour given that she had developed antibodies which can cause anaemia in babies during pregnancy. In particular, Mrs C was concerned about the way the pregnancy was managed, and the lack of urgency shown by staff in the antenatal ward and the delay in the delivery of her baby at the Southern General Hospital. As a result, she said that she and her baby had to remain in hospital during which time her baby had to have blood taken regularly. Mrs C said that the treatment she received was unacceptable and she remained extremely distressed about her experiences.

We took independent medical advice from three advisers, who are specialists in obstetrics and gynaecology, paediatric haematology and midwifery. We found that the antenatal care was reasonable and that Mrs C was monitored and managed appropriately in light of the complication. We also found that while there was a delay between admitting Mrs C to hospital to an antenatal ward, and then admitting her to a labour ward to induce labour, this was reasonable given Mrs C's and her baby's clinical condition at the time. Overall, we found that the standard of in-patient care and treatment was reasonable but made a recommendation in light of one of the adviser's concerns about staffing levels.

Recommendations

We recommended that the board:

• review how frequently patients' transfer to the labour ward at the hospital during induction of labour have been delayed to ensure they are satisfied the unit has sufficient capacity for its workload.

Summary

Mr C complained about some dental work he had done. He was unhappy because he did not think he had been given sufficient information about the procedure. He had a replacement bridge fitted (a device to replace a missing tooth), and was unhappy with the colour and size of the crown. Mr C was also concerned that, when the dentist tried to remove the crown, he was unable to do so.

We took independent dental advice on this complaint. The adviser noted that it was not clear exactly what information Mr C had been given in relation to his proposed treatment, because there was not enough detail in his notes. However, he said that from the evidence available, it was reasonable for the dentist to have suggested that a new bridge was necessary. He also said that, while the replacement bridge had not been an appropriate fit, the dentist had taken appropriate action in offering to replace it. He also noted that crowns can be difficult to remove, and that the dentist had acted with appropriate caution in choosing to drill the crown off, rather than try and remove it by force.

On the basis of the advice we received, we were satisfied that, while Mr C's dental treatment was not as straightforward as Mr C would have liked, the dentist's actions were reasonable, and he acted in Mr C's best interests.

Recommendations

We recommended that the dentist:

• review current record-keeping standards and take steps to ensure these are applied in practice.

Summary

Mrs C complained that the board failed to appropriately manage her late husband (Mr C)'s adverse reactions to chemotherapy. In 2010, Mr C developed a troublesome itch and his chemotherapy was stopped half way through. In 2013 he had a severe reaction to one of his chemotherapy drugs. He later developed thrombocytopenia (a reduced platelet count), which ultimately led to his death.

We took independent advice from one of our medical advisers, who considered that there was nothing else the board could reasonably have done to treat Mr C's itch. We were advised that the cessation of chemotherapy was ultimately the only approach likely to resolve the problem. As Mr C's leukaemia had responded well to treatment, it was considered that the board's decision to stop this when they did was reasonable. We were also advised that the drug Mr C reacted to in 2013 was administered with appropriate caution and reasonable steps were taken to address the reaction when it occurred. The adviser considered that Mr C's development of thrombocytopenia could not have reasonably been predicted or avoided, noting that appropriate, but unfortunately unsuccessful, efforts were made to treat this. We concluded that Mr C's adverse reactions to chemotherapy were appropriately managed and we did not uphold the complaints.

However, we identified that the board's haematology day unit provided a poor service when Mrs C contacted them one Friday to express concern about some of the symptoms Mr C was displaying. There were no medical staff or blood analysing service available on the unit that day so they merely referred Mr C to his GP, without proper instruction. The adviser considered that this was a basic level of care that the board should have been in a position to provide. We, therefore, made some recommendations.

Recommendations

We recommended that the board:

• apologise to Mrs C for the identified failings in the care provided by the haematology day unit; and
• urgently review the identified failings, with a view to improving the service offered by the haematology day unit, and report back to us with their findings.

Summary

Mr C complained about the care and treatment his late wife (Mrs C) received at University Hospital Ayr. Mr C was concerned that mistakes had been made when his wife had attended A&E. In particular, he told us about his concerns in relation to the insertion of chest drains, the removal of oxygen and the loss of four pints (units) of blood. Mr C was also concerned about the standard of communication with him and his family and that, as a result of information given directly to his wife, she lost any fight for life.

During our investigation, we took independent advice from a consultant in respiratory medicine. The complaint was investigated and showed that the treatment given to Mrs C was reasonable and appropriate. While she had in total three chest drains inserted these were necessary according to the circumstances and as part of her symptoms. We found no evidence in Mrs C's medical records that she had lost four units of blood nor was there evidence that oxygen was removed. The advice we received was that the medical records demonstrated that Mrs C was closely monitored even a few hours before she passed away and that she was given the maximum treatment necessary. There was no evidence of service failure on the part of the board and we did not uphold the complaint that the treatment given to her was unreasonable.

The board accepted that there had been some failings in communication and while they met with Mr C and his son as a result of these failings we were concerned that there was no written record of the meeting. The board also explained that a medical decision was taken not to resuscitate Mrs C and this was discussed with her. While the advice we received was that it would be good practice to document that this would be discussed with the family when they were available, our adviser also said that Mrs C's critical condition and poor prognosis, including that she was too unwell to be considered transfer to the intensive care unit or for resuscitation, was communicated to Mr C and his family reasonably well.

Recommendations

We recommended that the board:

• remind relevant staff that it is good administrative practice to keep a record of any meeting held with a complainant as part of the complaints process.

Summary

Mr C's home was being repossessed and he applied to the council for housing. The council initially concluded that Mr C was not homeless or threatened with homelessness and decided it was reasonable for him to continue living in his home. Mr C complained about the way his housing assessment was handled and the council acknowledged that the service he received could have been better. The council took steps to address the issues prior to Mr C bringing his complaint to us and we were satisfied there was no evidence to suggest that Mr C's housing application has been affected. In addition, Mr C was made an offer of housing, which he accepted, shortly after referring his complaint to us. We concluded that the council’s handling of Mr C’s application for housing was reasonable and we did not uphold the complaint.

We also looked at the council’s handling of Mr C’s complaint. We were satisfied that his complaints were investigated appropriately by the council and they provided clear responses. The council acknowledged there were issues and took appropriate steps to address them. For example, when Mr C’s housing application was closed down, the council acknowledged that more information should have been gathered and because of that, they agreed to review the decision. However, the council did not inform Mr C of his right to refer his complaint to us and they should have done that. Nonetheless, the information available confirmed that Mr C brought his complaint to us in the same month he received the council's final response. Therefore, even though he was not referred to us by the council, the failure to do so did not adversely affect his right to come to our office. We were satisfied that, on balance, the council’s overall handling of Mr C’s complaint was reasonable.

Recommendations

We recommended that the council:

• apologise to Mr C for failing to advise him of his right to refer his complaint to us.