Not upheld, recommendations

Summary

Ms C complained that the association had failed, over a period of three years, to investigate fully and resolve her complaint about a continuing strong smell of sewage in her home. When Ms C brought the complaint to us, she said that the association had eventually used a camera to inspect the drainage pipework, and had found a burst pipe in the bathroom which had been fixed, and had later replaced a section of piping in the kitchen, which was also found to be cracked. However, Ms C maintained that there was still a smell, and she was unhappy that the association would not agree to her request for her garden to be dug up to investigate further.

Our investigation found that there was evidence that the association had done what they could to resolve the matter, and that their actions and decisions about carrying out work had been reasonable. There was, however, evidence that they had not followed up on a request they made to Scottish Water to inspect the communal public drainage system, to check for any further blockages, and so we made a recommendation about this.

Recommendations

We recommended that the association:

• follow up with Scottish Water the action they have taken in relation to their email request, and let Ms C know the outcome.

Summary

Ms C said she had suffered back pain since about 2006 but had only managed to get her GP (with whom she had been since 2008) to send her for a bone scan in 2013. She said she could not be specific about dates as she could not remember them exactly but about three years ago she had collapsed in the street, and had difficulty walking. She said she was in considerable pain and asked to have her back x-rayed, but the GP refused. When Ms C was later referred for a bone scan she was very upset to be told that she had four fractures in her back.

We took independent advice from one of our medical advisers, who considered Ms C's medical records, and said that the GPs in the practice had made reasonable assessments of her back pain when she went to the surgery. Although we did not uphold her complaint about delay in referring her for a scan, our adviser also said that it was possible for a GP to order a lumbar spine x-ray if a worrying cause of back pain is suspected, and that the GP had misinterpreted the findings of the bone scan, so we made recommendations.

Recommendations

We recommended that the practice:

• ensure that all GPs note that it is possible for a GP to order a lumbar spine x-ray if a worrying cause of back pain is suspected;
• update Ms C's records to accurately reflect that she has four osteoporotic fractures in her spine and take the opportunity to re-evaluate her pain management given this information; and
• apologise to Ms C for the misinformation concerning whether or not she has four fractures and that a GP cannot refer a patient directly for a spinal x-ray.

Summary

Mrs C, who is an advice worker, complained on behalf of Mr and Mrs B about the care and treatment of their late son (Mr A). Mr A had an aggressive form of leukaemia (cancer of the white blood cells), and received a transplant of stem cells (cells made in the bone marrow, which can produce other cells). However, after the transplant it became apparent that the donor had developed an immunity to a virus called cytomegalovirus (CMV, a member of the herpes virus family) after he was accepted as a donor. This was evident in a blood test that the board received shortly before the transplant, but the change was not identified until after the transplant. Mr and Mrs B were concerned that this should have been identified, and that they were left not knowing what would have happened if it had been identified and acted on earlier.

Mr A became unwell after the transplant, and showed signs of very low levels of CMV in his blood, which was treated with medication. However, he had problems with his lungs, and his condition deteriorated further. Mr and Mrs B expressed concerns that this was worsened by the presence of CMV. His condition continued to deteriorate, despite a reduction in his level of CMV, and six weeks after his transplant, he died.

The board accepted that an error was made in not identifying the change in the donor's CMV status. However, there was no policy or procedure in place at the time to ensure this unusual event was identified. They also said that although this was discussed with the family at the time, the focus on his treatment meant that the discussions about CMV were not as detailed as they could have been.

As part of our investigation, we took independent advice from a specialist medical adviser, who said that the care and treatment given to Mr A was reasonable. She said that this was a most unusual problem. We noted that as there was no procedure in place at the time for checking for changes in blood tests, there was no failure of procedure, and also that as this was such a rare occurrence it was not surprising that this was not catered for. Our adviser also said that there was an urgent need for Mr A to have a transplant, and that the donor was still the most appropriate match, despite the change in his CMV status, as the risks associated with CMV were much less than those of not having a transplant at all. She said that Mr A's CMV level was reducing before his death, and that she was of the view his death was due to complications resulting from his transplant, and not the CMV. She noted that there was a lack of information in the records of discussions with the family in relation to their son's CMV status and the change in donor's status.

We did not uphold Mrs C's complaints, as we found that the board had followed their procedures in so far as they covered such a situation. We noted that they had now introduced procedures to ensure checks are made in future. We did consider whether Mr A in fact gave informed consent to the procedure as he did not know about the donor's status, but accepted our adviser’s view that it was very difficult to provide fully informed consent given all the variables involved. We also acknowledged that the reason that Mr A was not told about the change in status was because the team did not know about it, not because they did not tell him. Based on the advice we received, it appears that Mr A died of other complications, and the change in the donor's CMV donor status did not appear to have caused his death.

Recommendations

We recommended that the board:

• review the consent form and consider including reference to CMV risks and update the list of immunosuppressants used in the procedure; and
• remind staff of the need to ensure that appropriate records are kept of all discussions in relation to the giving of test results, particularly those where consent is required, and of subsequent meetings with family members.

Summary

Mr C complained that the Scottish Prison Service (SPS) refused to accept responsibility for items that went missing when he sent them to the prison laundry. Prisoners are given bags, in which their items are sealed and sent to the laundry to be washed and dried. Mr C said that there were items missing when a bag was returned to him, and submitted a claim for lost property to the SPS. The SPS investigated, but recorded that the laundry had no knowledge of the missing items. They said that they could not accept responsibility for missing items, as there was no evidence to show that the bag had been returned open.

It is not for us to decide if the SPS should have awarded Mr C money for the lost items. However, we can check that the SPS have considered all of the relevant information and followed the correct process before reaching their decision. We checked the sheet that was completed when Mr C sent the bag to the laundry. It showed that a number of bags were sent and that the same number of bags were returned. There was nothing on the sheet to indicate that any of the bags were open when they were returned. There was, therefore, nothing to support Mr C's claim and no evidence that the SPS were responsible for the missing items.

Although we considered that the SPS should have clarified with Mr C the specific date that his laundry went missing, we were satisfied that they had considered this sheet along with others when they investigated the matter. We were also satisfied that the prison had taken a discretionary decision that they were entitled to take and that in the circumstances we could not question it. That said, during our investigation we identified that, for security reasons and to try to cut costs, the prison were not acting in line with their laundry exchange process. Decisions in relation to security and managing resources are for the SPS to take, but the process should have been line with the actual practice in the prison. We, therefore, made a recommendation to the SPS about this.

Recommendations

We recommended that the SPS:

• review the laundry exchange process in the prison to ensure that it reflects current practice.

Summary

Mr C complained that the council had not appropriately handled a planning application for an extension to an existing quarry. In particular, he complained that the public and neighbours to the site had not been suitably consulted and notified of the application, that the consent was at odds with an existing planning consent for the site, that the applicant had not provided all the information required and that he was not able to make representations in person to the planning committee.

Our investigation found that the quarry has existing planning consent for mineral extraction and subsequent land fill. The application to which these complaints related was for an extension to the mineral extraction to one side of the area that already had consent for such extraction. We also took independent advice from one of our planning advisers, who said that the application had been appropriately notified through the local press, and that neither an environmental impact assessment nor pre-application consultation was necessary. The adviser also noted that there were shortfalls in the site plan provided, but that this was probably because the council already had plans from a previous application. He said that the council had were not required to make all documents on an application publicly available, and the application had been dealt with appropriately in relation to the plans and information that were considered. We did not, therefore, uphold this complaint, but we made a recommendation to the council to ensure they have all the plans required for future planning applications.

The planning application was determined under delegated powers, and this meant that the council's planning committee were not required to consider the application. The process was conducted according to council policy, and we did not uphold Mr C's complaint that he should have been able to make representation to the committee.

Recommendations

We recommended that the council:

• ensure that plans submitted with a planning application are sufficient to satisfy the terms of Part 3 Regulation 9 section 3 (a) and 3 (b) of the Town and Country Planning (Development and Management Procedure) (Scotland) Regulations 2008.

Summary

Mrs C complained that the council had not followed their procedures when dealing with concerns about her son at school. Mrs C was concerned about incidents of alleged bullying, as well as the school's communication with her.

We looked at the relevant procedures and the school's records about Mrs C's son. We found that the council had taken reasonable steps to deal with failings they had identified previously. We also found that, while some aspects could have been dealt with better, where procedures were in place they were followed, and the actions of school staff were reasonable in the circumstances. Although we did not uphold Mrs C's complaint, we did make two recommendations to reinforce good practice.

Recommendations

We recommended that the council:

• apologise to Mrs C for the failings identified as a result of their investigation into her complaint; and
• consider sending parents of bullies and victims a copy of the council's bullying booklet as part of the follow-up to recorded bullying incidents.

Summary

Mr C complained on behalf of his daughter (Ms A) about the care and treatment she received when twice admitted to hospital. Mr C questioned whether Ms A was properly assessed on both admissions and why, although he said she had suicidal thoughts, she was discharged on the second occasion with a large amount of drugs, before taking an overdose. He believed that this would not have happened if things had been handled differently, and that they should have dealt with her medical problems holistically.

The complaint was investigated and all the relevant information, including the complaints correspondence and the relevant medical records, was given careful consideration. We also obtained independent psychiatric advice from one of our medical advisers. As part of the investigation, the adviser reviewed Ms C's records with specific reference to the assessments made on her admissions and the circumstances of her discharge. He was satisfied with these and had no criticism to make about them. While Mr C believed his daughter had psychiatric problems which meant she should have stayed in hospital, our investigation found that on both admissions, she was a voluntary patient. She had been admitted primarily in relation to her excessive drinking and her admissions were based on an agreement that if she was found to possess or use alcohol she would be discharged. As Ms C had broken that agreement, she was discharged, and the records showed that reasonable outside support arrangements had been put in place for her. We did not uphold the complaint but as our adviser said that, though they would not have changed the outcome, there were some things that could have been done better, including the use of ICD10 (a classification of mental and behavioural disorders - clinical descriptions and diagnostic guidelines) we made some related recommendations.

Recommendations

We recommended that the board:

• consider using ICD 10 diagnoses;
• give attention to the dates on which letters are compiled and dispatched to satisfy themselves that they are issued in a timely manner;
• identify the responsibilities of agencies involved, and further, identify the lead; and
• review the procedure for passing information to carers and satisfy themselves that it is fit for purpose.

Summary

Mr C, who is a prisoner, complained that his confidentiality was unreasonably breached, as he was given medication in the sight of other people. In their response to our enquiries, the board said that healthcare staff try as far as possible to issue medication in pharmacy bags. However, they said that prison officers are present when medication is given out, as they are needed to escort the prisoners to and from the dispensing hatch. They said that this is a security matter and that the prison officers are necessary as security for nursing and healthcare assistants whilst they dispense medication. The board said that there are other prisoners in the same area who are waiting for their names to be called and their movements are controlled by the prison officers. Our investigation found that there are clearly some practical issues about ensuring confidentiality in a prison setting. Staff in the prison health centre have to ensure that the correct medication is prescribed at the right time to a large number of prisoners whilst maintaining confidentiality. At the same time, prison officers have to ensure that security is maintained. In the circumstances, we considered that the board's response was reasonable.

Mr C also complained that his request for a review of his glasses was unreasonably refused. We found that the board had in fact arranged for him to see an optician but there was a delay, because the optician left without prior notice. The board then arranged for Mr C to see an optician from another prison. We found that this was reasonable.

Finally, Mr C complained that the board failed to provide chiropody treatment. There is no longer a chiropodist service in the prison. When Mr C asked to see a chiropodist, he was told that he could obtain nail clippers from officers to cut his nails. The board told us that when he complained about this, they asked a nurse to assess his feet. The nurse then ordered a pumice stone for Mr C, as he had hard skin on his feet. Again, we found that this was reasonable.

That said, we found that in their response to Mr C's complaint the board said that the first stage of the complaints process is to raise the matter directly with the healthcare team, who will do their best to resolve it. They also said that the second stage is to complete a feedback form, which the local healthcare team will respond to within seven days. The board said that only then should prisoners complete a complaint form. Although the board dealt with Mr C's letter as a complaint, they said that they would appreciate it if he would follow this process in the future. We have previously raised concerns that NHS boards are using their feedback system as an additional stage in the complaints process. There is no requirement to complete a feedback form, or to raise the issue with staff for that matter, before submitting a complaint to NHS boards. The Scottish Government have written to NHS boards to highlight our concerns about this, and in view of this, we made a recommendation.

Recommendations

We recommended that the board:

• ensure that the local process in place for the management of prison health care complaints is in line with the good practice outlined in the Scottish Government Guidance 'Can I help you?'

Summary

Miss C complained that after her mother's death, a doctor influenced the family's decision not to have a post-mortem carried out, and misrepresented the family's views to the procurator fiscal (PF). In responding to the complaint, the board advised Miss C that the doctor should have immediately reported the death of Miss C's mother to the PF rather than discuss whether or not a hospital post-mortem should be carried out at this stage or a significant event review into events leading up to Miss C's death.

We found evidence indicating that the doctor had appropriately explained to the family what a hospital post-mortem would involve and that this appeared to be in order to help them decide whether or not they wanted one carried out, rather than trying to influence their decision either way. Although the doctor did not follow the correct procedure in reporting the death to the PF, we did not consider there was evidence that he was intentionally misleading the family because he had clearly documented in the medical records and disclosed his concerns about some aspects of the care to them. We noted that a different doctor informed the PF of the death but the PF did not consider that a fiscal post-mortem was required.

We were unable to clearly establish what the doctor said to the family immediately after Miss C's mother died, as there was no independent evidence of this. However, we noted that a record made by the doctor at the time documented that the family were not keen on a post-mortem being carried out and that the PF was told about this in an email. Although we did not uphold Miss C's complaints, we made recommendations to ensure that matters are more clearly understood and explained in future.

Recommendations

We recommended that the board:

• ensure that relevant staff are aware of the situations in which reporting death to the PF is necessary; and
• ensure that relevant staff clearly explain to families the process regarding post-mortems.

Summary

Mrs C complained about an out-of-hours hospital consultation with a trainee doctor, which she attended with her four-year-old daughter, Miss A. The appointment was made after Mrs C called NHS 24 to report that Miss A had been unwell for several days and that her condition was worsening. She complained that the doctor did not examine her daughter, and inaccurately concluded that Miss A was suffering from a viral infection. She also complained that he was patronising and condescending. She said she left the examination room and went to the accident and emergency department at another hospital, where Miss A was quickly diagnosed with scarlet fever.

In responding to the complaint, the board explained that the doctor was at the beginning of his second year as a general practice registrar and that a fully qualified GP trainer had been on the premises to supervise him. They said it was unfortunate that Mrs C had chosen to leave the premises before the supervisor could intervene. However, they acknowledged that the incident had thrown up a number of training issues that they needed to address with the doctor before he could complete his training and demonstrate his competence as a qualified GP. In particular, they said this would cover the recognition of scarlet fever.

In bringing her complaint to us, Mrs C acknowledged that the board had identified training gaps and had undertaken to address these. However, she also felt that the incident had highlighted gaps in the supervision of trainee doctors. She noted that she had been in the examination room for up to ten minutes and considered this too long for a trainee to be left unsupervised.

We discussed the case with one of our independent clinical advisers and he had no concerns about the doctor having been left unsupervised for this period of time. He said this was perfectly reasonable for a doctor at this stage of training. We, therefore, did not uphold the complaint. However, we did make recommendations as our adviser had concerns about the adequacy of the proposed action to address the identified training gaps. He noted that the board said the issues needed to be addressed before the doctor could complete his four year training programme, but he considered that they should be addressed much sooner than this. He highlighted that hospital out-of-hours clinics, with the requirement to work with sick children, were one of the more challenging aspects of general practice. Our recommendations on the case, therefore, reflect our adviser's concerns.

Recommendations

We recommended that the board:

• put an action plan in place to ensure that the issues arising from this incident are addressed within three months;
• make arrangements for the doctor's next two sessions to be directly supervised by a GP trainer to ensure that he is competent in this setting; and
• make the doctor's educational supervisors aware of this incident, which should be included in his training record.