Not upheld, recommendations

Summary

Ms C complained on behalf of her late partner (Mr A) about his care and treatment at A&E at Ninewells Hospital. She said that Mr A was not assessed properly and she was unhappy that he was referred under the board's redirection policy to a primary care doctor (a doctor providing day-to-day medical care, such as a GP) rather than being seen and treated in A&E. Ms C said that the board had refused to treat Mr A.

During our investigation, we took independent medical advice from two emergency medicine consultants and from a consultant neurologist. The advice we received was that overall Mr A’s care and treatment was reasonable. The emergency medicine consultants said that it was reasonable and appropriate, after triage (the process of deciding which patient should be treated first based on how sick or seriously injured they are) and assessment by a senior doctor, to refer Mr A to primary care for further assessment. They were also satisfied that an adequate medical history was taken in the triage room and sufficient information gathered to decide that Mr A should be referred to a primary care doctor. We also received advice that the senior doctor who assessed Mr A had the skills and experience to assess the urgency of his case and that the clinical notes detailed the rationale for redirecting Mr A.

However, we were concerned that, given Mr A's symptoms, there was no measurement of his vital signs when he attended A&E. Although our advisers said that this did not compromise his care, they also said that measurement of these vital signs may in some cases reveal a condition meriting emergency care. Documentation of the vital signs would also add weight to the decision to redirect a patient from A&E after assessment by a senior doctor.

Recommendations

We recommended that the board:

• ensure that the relevant staff members in A&E are made aware of our adviser's comments in relation to the need to measure vital signs when deciding whether to redirect a patient from A&E and are given the opportunity to reflect on these for their future practice.

Summary

Mrs C complained about the care and treatment that her husband (Mr A) received from the practice. Mr A, who had a history of anxiety, had been suffering from episodes of breathlessness. Mr A was diagnosed with panic attacks and adjustments were made to his existing anxiety medication to treat this. He was later prescribed further medication following a phone consultation and when this proved ineffective, he was seen at home as his anxiety was preventing him from going outdoors. During this visit, no abnormal findings were made during a physical examination and a referral to the community mental health team was declined. Two days later, Mr A suffered a stroke. When he was admitted to hospital, he was also found to be suffering from a chest infection. Mr A did not recover from the stroke and passed away around three weeks later.

Mrs C complained that Mr A had not been properly examined by doctors from the practice as they had failed to diagnose his chest infection. After taking independent advice from one of our GP advisers, we found that the actions taken by the practice were reasonable. Mr A's symptoms suggested that he was suffering from anxiety/panic attacks and there was no evidence that he had a chest infection at either of the consultations with doctors from the practice. We did not uphold Mrs C's complaint but made a single recommendation as a result of record-keeping issues identified during our investigation.

Recommendations

We recommended that the practice:

• ensure the relevant GP reviews his medical record-keeping to ensure that both normal and negative findings are noted as part of normal practice.

Summary

Mr C, who is an advocate, complained on behalf of his client (Mrs A) about the care and treatment provided to Mrs A's late husband (Mr A) by his medical practice. Mr A had a history of chronic obstructive pulmonary disease (COPD, a disease of the lungs in which the airways become narrowed). Mr A called the practice and during the phone consultation reported having strained a muscle. The practice advised Mr A to take painkillers and prescribed him co-codamol (a painkiller formed of a mixture of paracetamol and codeine). They told him to contact them again if the condition got worse. Three days later Mr A attended the practice. The GP examined him and considered the possibility of a lung infection, however, decided it was more likely to be muscle strain and prescribed a stronger pain killer. Later that day Mr A was taken into hospital and died three days later from pneumonia (a serious lung infection).

Mr C complained that Mr A's condition was not assessed properly by the GP. Mrs A also raised specific concerns that at Mr A's COPD review the practice did not have a pulse oximeter (an instrument used to measure oxygen levels in the blood). Mrs A also raised concerns that Mr A was prescribed co-codamol and that this medication is not recommended for patients with COPD. When Mr C complained to the practice the GP who had examined Mr A responded to the complaint and Mrs A and Mr C said this was not impartial.

During our investigation we sought independent advice from one of our GP advisers. The adviser was satisfied that when Mr A attended the practice his symptoms were indicative of muscle strain and that the GP's actions were reasonable. The adviser was also satisfied that co-codamol is an appropriate painkiller to prescribe to patients with COPD as long as the prescriber is aware of the patient's COPD condition, as they were in this case.

The practice told us that they are a small practice of only one GP. As the complaint related to clinical matters, the complaint needed to be responded to by a doctor. We found this to be a reasonable position and for the reasons above did not uphold the complaints.

However, our adviser did say the practice should have had access to a pulse oximeter. The practice told us that they had already purchased one and we recommended that they ensure it is used appropriately.

Recommendations

We recommended that the practice:

• provide us with evidence of the steps taken to ensure the pulse oximeter is utilised as required.

Summary

Mr C complained about the medication he was prescribed at Dumfries and Galloway Royal Infirmary. He said the side effects were not explained to him properly and that his medication had caused him to suffer problems with his lungs.

As part of our investigation, we took independent medical advice from one of our advisers. He explained that not discussing the medication’s side effects would have been unreasonable and that such discussions should ideally be noted in the medical records. Our adviser was unable to determine the extent of any such discussions from Mr C’s medical records and, although he accepted it was possible that it may have caused Mr C’s subsequent health problems, he said it was a low probability. However, he said the actual decision to have prescribed the medication was not, of itself, unreasonable.

In light of the advice we received, we could not absolutely say Mr C’s medication caused his health problems or the decision to have prescribed it was unreasonable and so we did not uphold his complaint. We did, however, have reservations about the extent of the discussions about its possible side effects and the extent of the assessment that was done for Mr C and so we made three recommendations.

Recommendations

We recommended that the board:

• remind clinical staff of the importance of accurate note keeping;
• remind staff to carry out and follow up on appropriate physical examinations for lung disease (particularly where symptoms such as lung crackles have been identified); and
• remind clinical staff of this medication’s side effects and the need to explain them to patients, particularly in light of patients’ presenting symptoms.

Summary

Mr C was a student on a course that included an assessed placement. Towards the end of his course he complained about a number of issues regarding his experience on the course and in particular how his placement, and assessments which he had not passed, had been handled. Departmental staff held informal meetings to discuss Mr C's concerns with him and to resolve the issues to enable Mr C to complete his qualifications. Mr C then disputed some months later that one of the outcomes of these meetings required him to apologise to a member of staff about whom the college said he had made unfounded allegations, although arrangements were made that he could complete his qualification free of charge once the apology was made. Mr C then complained to the college about the issues he had raised previously, and also complained that he was required to apologise before progressing with the final element of his course. The college determined that the outcomes of the informal meetings required him to give an apology.

Mr C complained to us that the college had not adequately investigated the issues he had raised. We reviewed all the correspondence and responses given by the college, the college's complaints handling procedure, and the evidence considered in their investigation of his complaint. Our investigation found that, although the college had made every attempt to thoroughly explore matters at stage two of their complaints handling procedure, there was no record of the early stages of the college's handling of Mr C's concerns and the outcomes of initial meetings were not communicated clearly to Mr C. Whilst we did not uphold Mr C’s complaint, we made a number of recommendations.

Recommendations

We recommended that the college:

• apologise for not clearly confirming the outcome of the meeting to Mr C;
• consider how best to ensure that all staff are aware of good practice in dealing with frontline complaints, including an appropriate level of record-keeping and communication; and
• re-consider whether an apology from Mr C is now appropriate before allowing him to complete his qualification.

Summary

Mr C complained to us that the Scottish Prison Service (SPS) failed to properly maintain the weights and cardiovascular equipment in two fitness rooms within a residential hall, a weights room and cardiovascular room. We did not find evidence to support this and did not uphold this aspect of Mr C's complaint. The SPS had also, however, decided to remove what had been the weights room, and although this decision was discretionary, we were concerned that there was a lack of clarity around the future use of the room.

Mr C also complained that the SPS failed to provide prisoners with adequate access to the prison's main gym. We found that there was different access to the main gym, but that the prison has the authority to offer this, as the prison rules allow for different provisions to be in place for prisoners located in different parts of the prison. Again, we did not uphold the complaint.

Mr C also complained about the SPS's handling of his complaint. We found that, although some information was not recorded as required by the complaints process, they had responded in reasonable terms. On balance, we did not uphold this complaint.

Recommendations

We recommended that SPS:

• finalise the plans for the former weights room as soon as possible and confirm this to us.

Summary

Mr C's child went missing while using the school bus service. Mr C complained that his child was put at risk because the driver did not know which children were travelling on the bus that day and did not check when asked by Mr C's wife (Mrs C) to make sure that her child was not on the bus. Mr C complained to the council that the bus driver had not followed procedures. The council had investigated his complaint, and although they made recommendations to improve their school bus service, they found that the driver had followed the procedures in place at the time of the incident. Mr C said that he was not confident in his child using the bus service to and from school because he did not believe that the council had investigated the matter properly. He complained also that the council's recommendations had not been implemented, and he did not believe, therefore, that adequate controls had been put in place to ensure that a similar situation did not occur.

Our investigation found no evidence that the council's investigation into Mr C's complaint had not been conducted in accordance with the council's complaints procedure, so we did not uphold Mr C's complaint. However, the council had told Mr C that as part of their investigation, they would interview him and this did not happen. The council told us that there had been sufficient information in a statement made by Mrs C at the time of the incident to uphold Mr C's complaint without further interview. The council had failed to make this clear to him and we made recommendations for an apology to be given to Mr C about this.

We understood Mr C's concern that there should not be a recurrence of what had clearly been a serious and distressing incident involving his child. Our investigation found that the council had not given Mr C and his wife sufficient advice about the changes being made, or provided him with clear and consistent advice about the progress and timescale of the implementation of the recommendations. However, we did not uphold the complaint because there was evidence of the changes which had been recommended in the council's findings having been implemented, and no further problems had been reported to the council.

Recommendations

We recommended that the council:

• formally apologise to Mr C and his wife for the failure in the decision letter issued to them to be more empathetic, and the failure to explain to them before, or in the decision letter the reason why it was not considered necessary to interview Mr C's family; and
• formally apologise to Mr C and his wife for not giving fuller advice, at the time of the decision, about implementation of the recommendations.

Summary

Miss C complained that tear duct surgery carried out on her young daughter caused a deterioration in her daughter's vision. She raised concerns that no vision problems were detected at the preoperative assessment, however, problems were subsequently identified post-surgery and her daughter now needed glasses. The board maintained that the vision problems were not caused by the surgical procedure.

We took independent advice from one of our medical advisers. He noted that the test carried out at the preoperative assessment was a standard test for very young children. He explained that it was common for children who could only initially manage this level of testing to be able to undergo more advanced testing when they returned a little older and more able to cooperate. This was the case with Miss C's daughter and the more rigorous testing carried out at the postoperative assessment identified a modest need for glasses. The adviser said the vision problems were likely to have been caused by the underlying problem of the blocked tear duct. He did not consider there to be any evidence to suggest that they were attributable to the surgery itself.

We accepted the advice we received and we did not uphold the complaint. However, our adviser raised some concerns about the number of doctors involved in Miss C's daughter's care. He considered that there should have been one doctor overseeing the care and he felt this lack of continuity might have contributed to confusion surrounding the complaint. He also noted that, while Miss C's daughter's vision was checked postoperatively, this does not appear to have happened automatically. He advised that it would be good practice to routinely carry out vision checks following this type of surgery. We, therefore, made some recommendations.

Recommendations

We recommended that the board:

• consider mechanisms for introducing a level of continuity of consultant care into the care pathway for tear duct surgery; and
• consider the need for vision to be routinely assessed postoperatively in children following tear duct surgery.

Summary

Mrs C's mother (Mrs A) had a distended abdomen and her GP arranged tests for her. Mrs A made an appointment, as requested, to discuss the test results with the GP, and Mrs C said that at the consultation her mother was shocked to be told that she had ovarian and bowel cancer and was given details of the sort of treatment that was available. Mrs C complained to us that the medical practice should have warned her mother she was to be given bad news, so she could take a family member with her.

We took independent medical advice from an adviser who is a GP, who said that it was not for reception staff to interpret test results. We also considered Mrs A's GP's explanation to be reasonable, in that he said Mrs A knew what the tests were for and that it would have been for her to decide if she wanted to bring someone with her to her consultation. We did not uphold this part of the complaint.

Mrs C also complained about the consultation itself. Subsequently, it turned out that her mother did not have cancer, and Mrs C said the GP had jumped to the conclusion that her mother had bowel and ovarian cancer, based on inadequate information.

We considered the GP had been thorough in trying to establish whether Mrs A had cancer. However, our adviser considered that, strictly speaking, the GP could be considered to have acted prematurely in arranging blood tests and in arranging a scan at the same time as the blood tests, as clinical guidance suggested a different approach. We also found the GP had used a test which was not indicated in the diagnosis of bowel cancer. There was no evidence that he had told Mrs A she had cancer, other than indicating that some of the test results raised the possibility of ovarian cancer and should be investigated further. On balance, we considered that the GP had acted reasonably and we did not uphold this part of the complaint. However, we did recommend that the GP review the relevant NHS guidance as a learning opportunity, to help guide his approach in any future cases.

Finally, Mrs C complained about a later meeting she and her mother had with the GP. We concluded that that meeting had been conducted reasonably and also did not uphold that part of the complaint.

Recommendations

We recommended that the practice:

• ensure the GP reflects on relevant guidelines as a learning opportunity.

Summary

Mr C appealed against the university's decision not to offer him a place. He said that he had met the conditions of his offer, but the university had used optional courses to determine his final mark for entry. He complained that this was not stipulated in his offer and when he phoned the admissions office to ask, he was given wrong information and staff there treated him badly and did not respond to the issues he raised. The university decided he had not established grounds for an appeal and considered his complaints about the unfair treatment he felt he had received. He said he had been harassed by members of staff in the admissions office who had put the phone down on his call. The university investigated and did not uphold his complaints. Our investigation examined the university's consideration of his appeal and their investigation into his complaint, along with their procedures for handling admissions appeals and complaints. We found that Mr C's dissatisfaction was based on his belief that the university had made a wrong academic decision and concluded that the university had provided detailed explanations of their position and acted in line with their procedures, so we did not uphold his complaint.

Recommendations

We recommended that the university:

• consider how to re-word the terms of the conditions set to make clear what is expected when more than one course in a subject is taken.