Not upheld, recommendations

Summary

Mr and Mrs C complained about the council's handling of an application for two wind turbines which were proposed to be built some distance from their rural farmhouse. The application was submitted in 2011 following two previous applications, one of which had been withdrawn and one of which had been refused. Mr and Mrs C were particularly concerned about the adequacy of acoustic reports submitted by the applicant's agents and had sent the council several letters about this, making representations about their concerns. They complained to us that the council did not reasonably respond to their enquiries about noise and other issues. They were also unhappy with a report about the application submitted to the council's committee, because they felt that the methods the council had used to assess the impact of noise from the proposed development on their property had not been reasonable.

Our investigation did not uphold either complaint. However, we noted that when Mr and Mrs C complained of not getting a response to points raised in their representations, a senior planning officer told them that it was not possible for the council to correspond because of the volume of objections received from third parties and because responding to third parties might be construed as prejudicial to the council's later consideration of an application. Mr and Mrs C had not been told this when their representations were acknowledged, so we made a recommendation to the council about this. In respect of the second complaint, we found that the council's report was full and balanced and the consideration of whether Mr and Mrs C's property would be affected by noise was in line with central government advice.

Recommendations

We recommended that the council:

• review whether the content of their standard letter of acknowledgement of receipt of representations should include an explanation as to why officers are unable to enter into discussions with third parties on the details of those representations.

Summary

Mr C complained that he was unreasonably told that he had lung cancer, when in fact he had tuberculosis (a bacterial infection mainly affecting the lungs). Mr C explained that he was admitted to hospital for investigation of possible lung cancer. After a CT scan (a special scan using a computer to produce an image of the body) he was told that he had lung cancer and part of his lung would need to be removed. Mr C said the procedure was carried out, but when he received his patient discharge letter it showed his diagnosis as pulmonary tuberculosis.

Mr C's own account and the information in his medical records showed that at the time he was admitted to hospital he was aware that it was a possibility rather than a certainty that he had lung cancer. Having read Mr C's medical records, our independent medical adviser said that in later discussions Mr C was told of the likelihood rather than the certainty that the abnormality represented a lung cancer. The adviser said that, given that in his opinion the likelihood of Mr C having lung cancer at that point was at least 80 to 90 percent, it was not unreasonable to say that he might have lung cancer.

Our investigation did find a number of examples of the board failing to record information in Mr C's medical records, or entering incorrect information, so although we did not uphold the complaint, we made a recommendation about this.

Recommendations

We recommended that the board:

• feed back our findings on the board's record-keeping to the staff involved.

Summary

Mr C's wife (Mrs C) became unwell and visited her GP who arranged for tests, which showed she had kidney stones. Mrs A continued to suffer abdominal pain but a CT scan (a special scan using a computer to produce an image of the body) and various other gastrointestinal investigations (investigations of the stomach and intestine) did not show any significant abnormality. Mrs C's GP referred her to a hospital accident and emergency unit (A&E) surgical team for further assessment. An urgent out-patient CT scan was requested and she was discharged the same day.

Nine days later, Mrs C went to A&E again because she continued to suffer severe pain, and was reviewed by the medical and surgical teams. Further tests were carried out and although she could have been admitted at this time, Mrs C preferred to go home and prepare herself for being admitted in two days' time. However, as Mrs C could no longer tolerate the pain, she returned to A&E the next day and was admitted to hospital. A CT scan and biopsies (tissue samples) confirmed that Mrs C had cancer of the pancreas that had spread to her liver, and she died a few weeks later.

Mr C complained that the consultant did not examine his wife and that she was only prescribed painkillers and advised to take laxatives. We took independent advice from one of our medical advisers, who said that Mrs C was appropriately assessed and examined by the junior A&E doctor and that although laxatives had been recommended, there was evidence that the staff were also considering other causes of the pain. We also noted that relevant tests were organised, including x-rays and blood tests and Mrs A was appropriately given morphine for pain relief.

However, we upheld Mr C's complaint, as we identified that it would have been reasonable and appropriate for the consultant, as the senior A&E doctor in attendance, to have examined Mrs C to confirm the junior doctor's assessment and findings. In doing so, we noted our adviser's view that such an examination was unlikely to have resulted in an earlier diagnosis of cancer. We also considered that the consultant should have pro-actively consulted with the surgical team, rather than having done so at Mrs C's request. Finally, we were critical that the consultant did not document his consultation with Mrs C. The General Medical Council provides guidance, which says that it is good medical practice to make such a record.

Recommendations

We recommended that the board:

• inform the consultant of our findings in relation to matters related to Mrs C's examination and the documenting of his consultation.

When it was originally published on 27 March 2013, this case was wrongly categorised as ‘not upheld’. The correct category is ‘upheld’ and it was amended on 8 May 2013.

Summary

Mr C's wife (Mrs C) was admitted to hospital for an operation to repair a hernia (a condition where an internal part of the body pushes through a weakness in the muscle or surrounding tissue wall).

After her operation Mrs C complained of pain. The surgeon examined her and found evidence of swelling. A CT scan (a special scan using a computer to produce an image of the body) was requested and the results suggested that Mrs C's bowel had been pierced. Mrs C was operated on and had the section of pierced bowel removed. She suffered pain and discomfort from this procedure and it took her eight weeks to recover from it. Mr C told us that he considered that the staff at the hospital had failed to provide appropriate treatment during the operation. He felt that this resulted in Mrs C's bowel being pierced.

We did not uphold Mr C's complaint. After taking independent advice from our medical adviser, we concluded that a pierced bowel was a recognised complication of this type of surgery. We found that Mrs C's treatment during the operation was reasonable, although we were critical of the board's consent policy. We felt that common and serious risks of surgery should be clearly explained to all patients and that these discussions should be recorded on the patients consent form or clinical records. This did not happen in Mrs C's case.

Recommendations

We recommended that the board:

• considers reviewing their consent policy to ensure that all common and serious risks are fully explained to patients when obtaining consent and that these are clearly recorded on the consent form or clinical records.

Summary

Mr A had a history of contact with psychiatric services since he was a teenager and had received a range of diagnoses. Mr A's mother (Mrs C) complained that a staff member in the hospital's rehabilitation unit verbally abused him and restrained him inappropriately and, when Mrs C reported this to a senior person, it was ignored.

We did not uphold Mrs C's complaint. We looked at her account of what happened and compared it with the hospital's records, and found that there was a discrepancy in the dates of when the alleged verbal abuse and restraint took place. Because of this, it was not clear whether the board investigated the incident Mrs C referred to in her complaint. We asked our mental health adviser to review all the recorded incidents throughout Mr A's admission. We were satisfied there was only one recorded episode of physical restraint being used, which took place on a different date from the alleged incident Mrs C referred to.

We found nothing in the clinical records to suggest that the amount of force used in the recorded incident was excessive. However, we accepted what our adviser said about a lack of documented detail of the restraining techniques used. We were, however, generally satisfied that Mrs C's concerns were taken seriously and investigated promptly. The investigation which was carried out appears to have been as thorough as it could have been with the evidence available. The lack of detail in the records reflects the guidance available to staff about restraint techniques and the recording of incidents of aggression from patients. We noted that, had the incident been recorded in further detail, it might have been possible for us to comment more constructively on the appropriateness of the restraint techniques used.

Recommendations

We recommended that the board:

• considers creating a specific restraint policy, detailing the techniques that can be used and the information that should be recorded in the clinical records.

Summary

Mr C lives in a rural location accessed from a trunk road currently maintained by contractors instructed by Transport Scotland. In 2002/03 the trunk road and improved access works were upgraded by contractors appointed by the predecessor trunk road authority.

In the summer of 2011 Mr C experienced problems of standing water, deterioration of his private drive, the functioning of his septic tank and an underground cable for his satellite dish. He thought these were linked to the earlier road drainage works. Dissatisfied with Transport Scotland’s response to his complaints Mr C complained to us that the previous trunk road authority failed to make adequate provision for water draining from the trunk road, that Transport Scotland denied liability for damage caused as a result of their failures and delayed in responding to Mr C’s problems.

Our investigation did not find evidence to uphold any of these complaints. Changes in trunk road contractor and the misplacing or disposal of relevant drawings meant that it was not possible to establish what was designed. Transport Scotland had not accepted liability, as they were entitled to do. On a 'without prejudice' basis, Transport Scotland had instructed works in the summer of 2012 to try to resolve the problems, but Mr C disputed the effectiveness of those works. In the light of that dispute, therefore, we made one recommendation.

Recommendations

We recommended that Transport Scotland:

• monitor the effectiveness of the measures undertaken in July 2012 and, should these prove not to be effective in draining water from the trunk road, the need for further works be considered.

Summary

Mr C, who is a prisoner, purchased footwear over a year ago through the prison's local process for purchasing mail order goods. Mr C was not allowed the footwear when it was delivered to the prison as staff identified it as a pair of boots, and not training shoes as described by Mr C on the order form. Mr C complained that the order form had been approved by the prison. In addition, he said that there were difficulties returning the footwear as the prison had destroyed the packaging.

In response to the complaint, the prison advised Mr C that the footwear was not on the approved list of items that prisoners were allowed to have in use and whilst the order form specified training shoes, they were more like a boot and came over the ankle. The prison explained that reception staff did not always have the time to check every order number against the description in the catalogue before the article arrives at the prison and is examined by staff before issue. The prison also highlighted that the footwear was a security risk as there was potential for weapons to be easily concealed within it.

Our investigation found that the governor of the prison has responsibility for the security and good order of the prison. Under section 47(2)(a) of the Prison and Young Offenders Institutions (Scotland) Rules 2011, for security purposes the governor has the discretion to refuse a prisoner any items of property. We also considered that the prison acted in line with their policy on articles that were allowed in use. Although we acknowledged Mr C's dissatisfaction about the packaging being destroyed by the prison when the footwear arrived, the mail order company have a flexible returns policy and there was no evidence that Mr C had attempted to return the footwear. The Scottish Prison Service have limited resources and we considered it would be disproportionate for staff to be able to give complete approval for items ordered until such time that they can be fully checked on arrival at the prison. We concluded that the prison acted reasonably but asked that they consider including additional information on their articles in use list to on the types of footwear that are not permitted with the prison.

Recommendations

We recommended that the prison:

• review their articles in use list with a view to including information on the types of footwear that are not allowed in use within the prison.

Summary

Mr C’s late wife (Mrs C) was diagnosed with a thickened area of the womb due to complex hyperplasia (the result of the formation of extra cells) and was referred to a waiting list for a hysteroscopy, dilatation and curettage (a D&C - treatment to correct this). Mrs C had the operation as a day procedure. Mr C said that following the procedure and on discharge home that day, Mrs C became increasingly unwell. Two days after the procedure, he phoned the local medical practice GP for a home visit, and the GP arranged for Mrs C to go to hospital. Mrs C was taken to the intensive care unit where she died four days later. A post mortem was carried out and the death certificate stated the cause of death as septic shock (severe infection), intrauterine sepsis (a viral infection in the womb), acute renal (kidney) failure and cardiomegally (enlarged heart).

Neither the board nor the Procurator Fiscal’s post-mortem could establish the reason for Mrs C’s death. Mr C and his family complained to the board about this. The board investigated the case, held an internal review and met with Mr C, his family and an independent caseworker. Mr C believed that the board had a responsibility for his wife’s death and had failed to provide an explanation for it. He also said the board failed to communicate with him and Mrs C and that there was a failure to act on nursing staff's concerns about Mrs C's discharge.

Our independent medical adviser considered all aspects of Mr C’s complaints. Having taken account of his advice alongside the evidence provided by Mr C and the board, we concluded that there was no proof of the cause of Mrs C’s infection. In the absence of such evidence, we found that the board had not in fact failed to provide Mr C with a reason for the cause of infection. We also carefully considered all aspects of the communication between the board, Mr C and Mrs C. There was no evidence to support the complaint of failure to communicate, or that the risks of the operation were not explained to Mrs C, and that Mr C had not been advised of the warning signs to observe on Mrs C’s discharge. There was also no evidence that nursing staff had raised concerns about Mrs C before she was discharged. Although we did not uphold Mr C's complaints, we did make recommendations to address issues that had emerged during our investigation.

Recommendations

We recommended that the board:

• ensure that medical staff (and patients) legibly complete every section of a consent form at the time consent is obtained;
• ensure all staff complete a record or document outlining the information leaflets they provided to patients; and
• provide the Ombudsman with an update on their review of the written information provided.

Summary

Miss C complained that before her misconduct hearing, the university failed to give her a formal statement detailing the allegations of misconduct made against her. She also complained that they failed to allow her the opportunity to challenge the evidence before they rejected her appeal.

We found that, although they did not give her a written statement of the allegations, these were fully discussed with her at an earlier meeting with a senior member of staff. In terms of the appeal, the university's policies give the student the opportunity to present any new evidence they may consider relevant to their appeal, prior to its consideration. The policy does not, however, allow the student to challenge evidence at this stage. As the university did provide details of the allegations of misconduct prior to the hearing, and as Miss C was not entitled to challenge the evidence at the appeal stage, we did not uphold her complaints. We did, however, make a recommendation based on Miss C's experience.

Recommendations

We recommended that the university:

• consider amending the academic misconduct policy to include a requirement to confirm in writing the type of academic misconduct alleged to have occurred, prior to a hearing.
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Summary

Mr C made a complaint on behalf of his partner (Ms C) who was admitted to hospital with a suspected stroke. Two days after being admitted, Ms C collapsed in the bathroom, where she was discovered by ward staff. She was moved to an acute ward and was under observation for five days until she was discharged from hospital. It was thought that Ms C, who had epilepsy, might have suffered a seizure.

Four months later, Ms C met with a doctor at the hospital as she was concerned about what had happened. She had concerns that she had been given the wrong medication and that the collapse had not been reported as an accident nor been subject to an accident investigation. She was also unhappy about the actions of the medical team following her collapse, including the taking of a blood sample from her groin. Ms C provided a list of questions for the doctor to respond to, and he did so by letter.

Ms C remained dissatisfied and wrote again with some additional queries. This letter, however, was sent directly to the doctor and was not received by the board's complaints team. Ms C then sent her original set of questions to the complaints team, who responded. Ms C then complained to us that the board had not answered her additional questions.

During our investigation we found that the second letter had been addressed to the doctor and said that Ms C would be making a formal complaint. The doctor had, therefore, placed it in Ms C's medical file, and explained to her how to access the complaints procedure. We found this to be reasonable. However, this meant that the complaints team had not in fact seen Ms C's additional queries which is why they did not respond to them. We found that the board's responses to the complaints Ms C made to them were reasonable, and noted that the complaints team had in fact phoned her to try to establish what she was still concerned about. Although we did not uphold the complaint, we made a recommendation to allow Ms C another opportunity to raise any further matters with the board.

Recommendations

We recommended that the board:

• contact Ms C to arrange either a meeting or further correspondence to address any outstanding concerns.