Not upheld, recommendations

Summary

Miss C underwent cataract surgery at Falkirk Community Hospital and, during this operation, she suffered a leak of the fluid in her eye and her eye was stitched following surgery. A few years later, Miss C suffered a detached retina and underwent surgery for this. Following the surgery, Miss C's vision deteriorated significantly, and she subsequently had to have further surgery. Miss C was concerned that the stitching of her eye following her first surgery may have contributed to the detached retina, and she said that staff had commented at the time that they did not have the correct equipment on hand (but went ahead anyway). Miss C was also concerned that she had high pressure in her eye following the second surgery, and required to be readmitted a couple of days later. She felt that she should have been kept in hospital for longer for observation and queried whether this had impacted on the poor outcome of the surgery.

In response to Miss C's complaint, the board explained that the first surgery was complicated by zonule dehiscence (the breaking of the structures that hold the lens in place, which can cause fluid within the eye to come forward). The board said that this may have contributed to Miss C's subsequent detached retina, but that it was unlikely since the detached retina occurred a long time after the surgery.

We took independent advice from a consultant ophthalmologist (a doctor who deals with diseases and injuries to the eye). We found that Miss C suffered a recognised complication during her first surgery, which was appropriately managed, and that the decision to stitch her eye was reasonable. We also found no evidence that staff did not have the correct equipment for stitching the eye and, therefore, we did not uphold Miss C's complaint. However, we noted that there was no record of any discussion with Miss C to explain the complication that had occurred. Therefore, we made a recommendation to the board regarding this.

In relation to Miss C's second surgery, we found that the decision to discharge Miss C for follow-up in a few days was reasonable. Although Miss C had high pressure in her eye, this was not so high as to require continued admission and observation. We found that Miss C's poor vision was affected by the known risks of surgery rather than an outcome of her aftercare. Therefore, we did not uphold this complaint. However, we noted that when Miss C returned to hospital a few days later, staff did not measure her eye pressure and did not record why this was not done. We made a recommendation to the board regarding this.

Recommendations

What we said should change to put things right in future:

• Where a complication has occurred in surgery, staff should inform the patient of this and clearly record this discussion.
• Where staff do not follow the standard practice, the reasons for this should be recorded.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

Summary

Ms C complained to us about the care and treatment her later father (Mr A) received from the cardiology department at Victoria Hospital. Mr A had been referred to the hospital by his GP because he was feeling some discomfort in his chest after exertion and increasing fatigue. When he attended the hospital, Mr A had a scan. This showed significant impairment of the pumping function in his heart.

A letter from the hospital to Mr A's GP also referred to a significant recent increase in the frequency of his chest pain and a corresponding reduction in the amount of effort required to bring on these pains, along with recent chest pain at night. These are characteristic features of unstable angina (a coronary condition which can be predictive of an impending heart attack.) The hospital changed Mr A's medication and made an appointment for him to see a consultant cardiologist the following week. However, Mr A continued to have chest pain and died six days later.

Ms C complained that the cardiology department should have admitted Mr A to hospital given the findings at the initial appointment. We took independent advice from a consultant cardiologist. We found that it had been reasonable not to admit Mr A to hospital and we did not uphold the complaint. However, we found that the cardiology department should have given Mr A and his GP more information about his condition and its management. We made recommendations to the board in relation to this.

Ms C also complained that a doctor discussed the decision not to resuscitate Mr A whilst he was in a very critical condition. We recognised that this would have been distressing for the family, but given the seriousness of Mr A's condition, it had been reasonable to discuss the issue of resuscitation. We did not uphold this aspect of Ms C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms C for failing to provide Mr A with adequate information about his diagnosis and guidance as to what to do if he deteriorated whilst awaiting review. The apology should meet the standards set out in the SPSO guidelines on apology available at https://www.spso.org.uk/leaflets-and-guidance.

What we said should change to put things right in future:

• Patients given a diagnosis of unstable angina or severe but stable angina should be clearly informed of the diagnosis and should have clear guidance about what to do if their condition deteriorates whilst awaiting review. This information should also be shared with their GP.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

Summary

Mr C was required to withdraw from his course and, despite him no longer being a student at the university, the faculty appeals committee took the decision to mark Mr C's thesis. Although Mr C was initially told that it would be possible for his thesis to be curated in the university library, the unviersity later told him that this would not be appropriate. They explained that the library collection is the official repository for university research produced as a result of the successful award of a research degree, and that if Mr C's thesis was housed there it would wrongly imply that he had achieved such an award. Mr C complained to us about the university's refusal to curate his thesis in the univerisy library, which he said was contrary to university regulations.

We were critical of the university for suggesting that it might be possible for his thesis to be curated in the library. However, we considered this to have been a genuine mistake and we noted that an apology had been given. We found that there was no regulation supporting Mr C's position that his thesis should have been curated in the library. We found that the unviersity's explanation of why the thesis could not be curated was reasonable and we did not uphold this complaint.

However, we considered that by agreeing to mark the thesis the university may have raised Mr C's expectations that it would be curated in the library. We also acknowledged that there was a delay in Mr C finding out the result of his thesis, noting that it had not helped his situation to have been waiting several months to find out whether he had passed or failed. Although we did not uphold the complaint, we recommended that the university apologise for the shortcomings identified.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for the delays in communicating with him about his thesis. The apology should meet the standards set out in the SPSO guidelines on apology available at https://www.spso.org.uk/leaflets-and-guidance.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

Summary

Mr C raised concerns about the council's handling of a Section 75 Agreement contained in a planning approval for a residential agreement. A Section 75 Agreement of the Town and Country Planning (Scotland) Act 1997 enables land owners to enter into a legal agreement with the planning authority to restrict or regulate the development or use of land. In this case, the Section 75 Agreement related to a replacement football pitch. Mr C complained that the council had failed to take enforcement action in respect of the planning approval in relation to the condition of the replacement football pitch.

We took independent planning advice. The advice we received was that the council had failed to give adequate consideration to the policy provisions of the National Planning Policy Guideline 11: Sports, Physical Recreation and Open Space (NPPG 11), which was in place at the time of the application. The relevant guidance is now the Scottish Planning Policy 2014. We found that the council, as planning authority, had no capacity to take enforcement action in this case, as what had been built met the terms of the Section 75 Agreement. However, we found that the council had unreasonably failed to make provision through the Section 75 Agreement that a specification for the replacement pitch be agreed in writing before construction began to ensure that the replacement pitch met the full terms of the NPPG 11. As such, the replacement pitch was not suitable in terms of accessibility, amenity and community benefit. While we identified shortcomings in the handling of the planning application in relation to the report of handling, consultation and the adequacy of the Section 75 Agreement, given that the council had no capacity to take enforcement action we did not uphold Mr C's complaint about enforcement action.

Mr C also raised concerns about the handling of his complaint. We found that the council's handling of his complaint was reasonable, and we did not uphold the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for failing to give full regard to the terms of the NPPG11, which has led to the construction of a football pitch which is not of a serviceable standard. The apology should comply with the SPSO guidelines on making an apology, available at https://www.spso.org.uk/leaflets-and-guidance.

What we said should change to put things right in future:

• Current practice should ensure that planning applications take explicit account of the requirements of the Scottish Planning Policy in terms of replacement playing fields and sports pitches.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

Summary

Mr C complained about an assessment that concluded that his mother (Mrs A) did not require hospital based complex clinical care (HBCCC). After admission to hospital, Mrs A was assessed and it was decided that she would require HBCCC and was therefore transferred to the appropriate facility. Mrs A was re-assessed at this facility, and it was found that she had become ineligible for HBCCC. Mr C disagreed with the decision that Mrs A was now ineligible and brought his complaint to us.

We took independent advice from a consultant in geriatrics. We found that the level of care Mrs A required could be provided in a care home setting and that the decision that she did not need HBCCC was reasonable. We did not uphold this complaint. However, we found that there was a delay in organising a re-assessment after the decision was appealed by Mr C and we made a recommendation in connection to this.

Recommendations

What we said should change to put things right in future:

• HBCCC reassessments should, wherever possible, be carried out within two weeks, in line with the relevant policy.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

Summary

Mrs C complained on behalf of her daughter (Miss A) about a lack of support from the college around the time when Miss A decided to leave her course. In particular, she complained about a meeting between Miss A and her lecturer before Miss A decided to leave the course. Mrs C also complained about the college's response to her complaint.

The information available did not establish exactly what was said between Miss A and her lecturer during the meeting in question. Based on the evidence available to us, we did not uphold this aspect of Mrs C's complaint.

We found the college had reasonably responded to Mrs C's complaint and so we did not uphold this aspect of her complaint. However, we found that the college's complaints procedure was not fully compliant with the Model Complaints Handling Procedure, so we recommended that they address this.

Recommendations

In relation to complaints handling, we recommended:

• The college's complaints handling procedure should be reviewed to ensure it is compliant with the Model Complaints Handling Procedure.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

Summary

Mrs C complained on behalf of her daughter (Miss A) about a lack of support from the college around the time when Miss A decided to leave her course. In particular, she complained about a meeting between Miss A and her lecturer before Miss A decided to leave the course. Mrs C also complained about the college's response to her complaint.

The information available did not establish exactly what was said between Miss A and her lecturer during the meeting in question. Based on the evidence available to us, we did not uphold this aspect of Mrs C's complaint.

We found the college had reasonably responded to Mrs C's complaint and so we did not uphold this aspect of her complaint. However, we found that the college's complaints procedure was not fully compliant with the Model Complaints Handling Procedure, so we recommended that they address this.

Recommendations

In relation to complaints handling, we recommended:

• The college's complaints handling procedure should be reviewed to ensure it is compliant with the Model Complaints Handling Procedure.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

Summary

Ms C complained on behalf of herself and other residents in the apartment complex where she lives. The council had decided that Ms C, and other owners of the property, were liable for emergency and statutory repairs to a drainage system. Over the course of a number of months several emergency and statutory notices were served in relation to this. Ms C complained to the council about the various actions related to the serving of the notices. The council were of the view that they had acted appropriately and had reached decisions reasonably. Ms C remained unhappy and brought her complaints to us.

Ms C complained about the process by which the council reached decisions on whether repairs were emergency repairs and which property owners were liable for the costs of the works. We considered the administrative aspects of these matters and concluded that the council had acted reasonably in this regard. We did not uphold these aspects of Ms C's complaint.

Ms C also complained about the administration of the notices and other correspondence to the property owners. We found that there were no significant failings in the council's actions related to this. We did note that there was a delay at one point in the council issuing an emergency repair notice to property owners, that owners had received invoices at one point which the council believed had been cancelled before they had been sent out, and that the council had incorrectly stated that a letter and report were hand delivered to each liable property. However, given the overall context and the volume of correspondence that the council had to deal with regarding these notices, we did not consider that these failings were significant enough to warrant upholding the complaint. As such, we did not uphold these aspects of Ms C's complaint, but we did make some recommendations.

Recommendations

What we asked the organisation to do in this case:

• Apologise to residents via the Proprietor's Committee that an emergency repair notice was not issued within a reasonable timescale, and that their statement that a letter and report were hand delivered to each liable property was incorrect. The apology should meet the standards set out in the SPSO guidelines on apology available at https://www.spso.org.uk/leaflets-and-guidance.

What we said should change to put things right in future:

• Investigate how invoices that were believed to have been cancelled were received by owners, and take steps to avoid a similar situation recurring.
• Investigate whether an emergency repair notice could have been issued earlier and, if so, take steps to avoid a similar situation recurring.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

Summary

Mr C complained that staff at Ninewells Hospital failed to consider a diagnosis of brugada syndrome when he was being investigated for fainting episodes. Brugada syndrome is a condition associated with blackouts, serious arrhythmias (where the heart can beat too slow, too fast or irregularly) and sudden death. The syndrome is characterised by a particular electrocardiogram (ECG - a test to check the heart's rhythm) abnormality, either spontaneously or after a drug test.

During investigation of his fainting episodes, Mr C was advised not to work or drive. Mr C experienced a further fainting episode when a cannula was being inserted into his vein prior to an ajmaline challenge (a drug test to identify the characteristic ECG pattern changes associated with brugada syndrome) being carried out. The ajmaline challenge did not go ahead and Mr C was dissatisfied that it was not rescheduled prior to being discharged from the cardiology service. Mr C moved and said that he was diagnosed with brugada syndrome following an ajmaline challenge at a different hospital.

We took independent advice from a consultant cardiologist. We found that there was evidence to demonstrate that hospital staff had considered the possibility of brugada syndrome. We considered that from the various tests carried out there was no evidence to support a diagnosis of brugada syndrome. We found that it was reasonable for staff to diagnose Mr C with vasovagal syncope (the temporary loss of consciousness due to a neurologically induced drop in blood pressure) and not to have rescheduled the ajmaline challenge. We did not uphold the complaint. However, we were critical of the time it took the board to investigate Mr C's fainting episodes. We also found that there was no evidence to clearly show that Mr C's diagnosis and the reasons for not rescheduling the ajmaline challenge had been fully explained to him. We made three recommendations to address these shortcomings.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for not ensuring that he was fully informed about his diagnosis. Also apologise for the time taken to investigate his fainting episodes. The apology should meet the standards set out in the SPSO guidelines on apology available at https://www.spso.org.uk/leaflets-and-guidance.

What we said should change to put things right in future:

• Staff should ensure that, in similar cases, patients are fully informed about their diagnosis, including any decisions made in relation to further investigations, and clearly document when this has been done.
• Staff should ensure that investigations are carried out in a timely manner, particularly when patients are unable to work or drive.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

Summary

Mr C complained about the care and treatment that the board provided to his late mother (Mrs A) at Wishaw General Hospital.

Mrs A became ill and she was taken to the hospital by ambulance. Staff examined her and considered that she had pneumonia (a lung infection) and acute kidney injury. Mrs A also had symptoms of life-threatening sepsis (a blood infection). Given Mrs A's condition, staff made a Do Not Attempt Cardiopulmonary Resuscitation decision (DNACPR decision - a decision taken that means a healthcare professional is not required to resuscitate the patient if their heart or breathing stops). Mrs A's condition continued to deteriorate, and she died early the next morning. Mr C raised specific concerns about the DNACPR decision, and the medication provided to Mrs A.

We took independent advice from a consultant in acute medicine. We found that, given the medical condition that Mrs A was in, it was reasonable for a DNACPR decision to be made. There was evidence of discussion with a senior consultant and with the family. We also found that the medication prescribed to Mrs A as reflected in the medical records was reasonable. We did not uphold Mr C's complaint.

Whilst we did not uphold the complaint, we found that the board were unable to provide a completed DNACPR form from their records. Therefore, we made a recommendation to address this.

Recommendations

What we said should change to put things right in future:

• DNACPR forms should be completed and filed appropriately.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.