Not upheld, recommendations

Summary

Mr C complained to us about the university's handling of his academic appeal. In particular, he complained that his appeal was initially considered informally by his college within the university, that the formal appeal sub-committee did not consider all aspects of his appeal and that a conflict of interest was overlooked.

We found that it was not clear why a draft of Mr C's appeal was considered informally by his college, and we found that communication with Mr C about this was not clear. We made recommendations to the university to remedy this issue. However, we did not find evidence that this consideration had a detrimental impact on the consideration of Mr C's formal appeal, as he was able to submit his formal appeal within the deadline set in the regulations. We did not uphold this aspect of the complaint.

The formal appeal sub-committee saw the evidence submitted by Mr C, as well as evidence the university administration gathered from academic staff. A member of the sub-committee suggested that Mr C's college should draw examiners' attention to programme-specific regulations, and we made a recommendation to address this point. However, the sub-committee concluded that Mr C did not meet the grounds for appeal. While we appreciated that Mr C disagreed with their decision, the sub-committee were entitled to reach their own view on the evidence available to them as part of the formal appeal process. The evidence showed that Mr C's formal appeal was handled in line with the regulations. We did not uphold this part of the complaint.

In relation to a conflict of interest, Mr C did not raise this issue in his formal appeal and, based on the information we saw, there was no evidence of a conflict of interest. As such, we did not uphold this aspect of Mr C's complaint.

Recommendations

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

• The university should recommend to the college that they draw the attention of examiners to any programme-specific regulations that apply.
• It should be clarified under what circumstances a draft of a student's appeal would be considered informally at a college committee before the student submits their formal appeal electronically to academic services. Communication with students about this should be clear.

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 about her transvaginal tape (TVT) surgery not being performed appropriately at St John's Hospital, as she suffered heavy post-operative bleeding. Mrs C also complained that her post-operative bleeding was not treated appropriately at the Royal Infirmary of Edinburgh. In particular, Mrs C complained that she was given painful vaginal packing (an emergency treatment for excessive bleeding of the vagina) before she was referred for surgery to stop the bleeding.

During our investigation we took independent advice from a consultant gynaecologist. We found that Mrs C had suffered a rare but well-recognised complication of surgery, which did not evidence that the TVT surgery was carried out improperly. The adviser considered that Mrs C was given appropriate treatment for her post-operative bleeding as it was reasonable to try conservative management to try to stop the bleeding before referring Mrs C for surgery. We did not uphold the complaint. However, the adviser considered that the consent form should have documented the risks of TVT surgery so we made a recommendation in light of our findings.

Recommendations

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

• The risks of surgery discussed with a patient should be documented, in order to reduce the likelihood of a miscommunication or misunderstanding.

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 a complaint on behalf of Ms A about the medical and nursing care and treatment she received during an admission to Hairmyres Hospital.

We took independent advice from a consultant in acute medicine and a nursing adviser. The advice we received from the consultant in acute medicine was that the medical care and treatment provided to Ms A was appropriate and reasonable. We did not uphold the complaint.

In relation to the nursing care given to Ms A, the advice we received from the nursing adviser was that while there were some record-keeping issues, overall the nursing care provided was systematically planned. Ms A's condition was monitored and assessments were effectively carried out and documented. Whilst we did not uphold Mr C's complaints about nursing care, we did make recommendations about record-keeping and the information given to Ms A about flowers being allowed on wards.

Recommendations

We recommended that the board:

• share with relevant nursing staff the need to ensure that nursing records are in line with Nursing and Midwifery Council guidance and, in particular, that any necessary amendments made to records are unambiguous, appropriately initialled and dated; and
• apologise to Ms A for the conflicting information given about whether flowers were allowed on wards.

Summary

Mr C was being treated at the Beatson Cancer Centre when his cannula became dislodged causing chemotherapy to leak into the surrounding tissue and skin. He was taken to Glasgow Royal Infirmary and a procedure was carried out to remove the chemotherapy. Mr C complained that the nursing staff had not properly inserted the cannula or monitored his treatment. Mr C also complained that staff did not appear to know what to do following the incident, and he raised concerns about the length of time it took to be referred to plastic surgery.

We took independent advice from a nursing adviser. We found that whilst Mr C was aware that he had to report any problems with his cannula to staff, the nursing staff had not documented having given this advice. The board had acknowledged this failure in record-keeping when responding to the complaint and advised of the action they had taken to address the matter. We identified further evidence of poor record-keeping which was not in line with Nursing and Midwifery Council guidance in terms of the accuracy of information documented and that several nursing care entries were not timed.

We did not find clear evidence to show that the nursing staff had failed to properly insert or monitor the cannula. In addition, we identified that there was evidence to demonstrate that the appropriate action was taken following the incident to address the leakage. We also found that there was no undue delay in Mr C being transferred to Glasgow Royal Infirmary. We did not uphold the complaint.

Recommendations

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

• Staff should ensure full and accurate records are documented in line with Nursing and Midwifery Council 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

Ms C, who works for an advocacy and support agency, complained on behalf of her client (Mr A). Mr A said that his medical practice had not provided him with reasonable care and treatment regarding blood tests and referral for specialist opinion. Mr A attended the practice from 2011 with a low platelet count and a lymphocyte (a type of white blood cell) count that was intermittently rising but still within the range that would be considered normal.

Mr A was referred to the haematology department in 2012. He then attended the practice for blood tests several times from 2012 to 2015. The practice had requested advice from haematology in relation to follow-up and further tests but had not received this advice. The results of the blood tests carried out at the practice were similar to those in 2011 until 2015 when the lymphocyte count increased and tests indicated possible lymphoma (a type of cancer).

We took independent medical advice from a GP adviser and found that the practice had acted reasonably in relation to blood taken and analysed at the practice, so we did not uphold the complaint.

The practice had carried out an analysis of the events surrounding Mr A's case. The outcome of this was that advice requests to specialists would now be made in a way that would ensure a response regarding follow-up and advice.

Recommendations

What we asked the organisation to do in this case:

• The practice should issue a written apology to Mr A for failing to refer him to haematology to investigate abnormalities in blood test results.

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 a postgraduate student at the university. Two pieces of work he submitted were judged to have been plagiarised due to the style of citation and referencing used. Academic misconduct penalties were applied to the pieces of work following an investigation by the college academic misconduct officer. Mr C was unhappy with this decision and appealed to the university. Mr C was not satisfied with the outcome of this appeal and so brought his concerns to us for further investigation. Mr C complained that it was inappropriate to investigate him for academic misconduct, that the appropriate procedures had not been followed and that the penalties were unreasonable.

After making enquiries with Mr C and the university, we did not uphold these complaints. We found that the academic judgement of university staff was that there had been misconduct, and the appropriate procedures had been adhered to when investigating this. We found that the penalties applied to Mr C's work were in line with the these procedures. We did identify two areas in relation to the provision of information to students that we considered could benefit from review, and we made two recommendations.

Recommendations

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

• Students should be made fully aware of the findings of academic misconduct investigations.
• There should be consistent guidance for students regarding referencing.

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 on behalf of his daughter (Miss A), who was a third year student at the university. At the end of the year, Miss A received her final results, which showed that she had not submitted several assignments. Miss A queried this with the school office as she said she had submitted the work electronically. However, the university could find no record of this, and they told Miss A she had to withdraw from the course. Miss A appealed against this decision but the appeal was not upheld. Miss A appealed again and provided copies of the missing assignments. While the university marked some of these, they did not uphold Miss A's appeal.

Mr C complained about the conduct of the appeals process, and that Miss A had not been notified earlier about the non-submissions. He said the university gave Miss A unhelpful advice on what to include in her appeal, which meant that one of her papers was not marked. He was also unhappy that another paper was not marked (as the creation date of the electronic document was after the due date). He said Miss A had previously provided evidence of the correct creation date (in hard copy), but the university lost this. Mr C said the university should have provided more support to Miss A in making her appeal and kept her updated throughout the process.

After investigating these issues, we did not uphold Mr C's complaints. We found that the university had provided appropriate support and advice, and kept Miss A updated throughout the process. We considered the university's reasons for not marking two of the papers were adequate, as one of the papers was not included in the appeal, and there was no evidence the other was created before the due date. We also found the university had no duty to notify Miss A of non-submissions as their policies and guidance made it clear that students were responsible for submitting all work in hard copy and electronic format. However, we found that a member of staff gave Mr C inaccurate information about this and we recommended that the university apologise for this.

Recommendations

We recommended that the university:

• apologise to Mr C for giving him incorrect information.

Summary

Mr C complained about the council's response to a report from the police about his daughter (Miss A). Miss A had been involved in an incident following which she was charged with an offence. Shortly afterwards, Miss A and her mother both received letters from the council suggesting that Miss A may be referred to the Scottish Children's Reporter Administration (SCRA) if she had any further involvement with the police.

The police later apologised for the way they handled the matter, dropped the charge and apologised to Miss A and her family. Mr C complained that the council's response had been unreasonable. He considered that the letter his daughter received had been threatening and inappropriate in the circumstances.

Following our review of the council's policies and procedures we concluded that the council had acted correctly and accordingly we did not uphold this complaint. However, we did note that whilst we considered it to be correct for the council to highlight to Miss A the possible consequences of further involvement with the police, the council could have used a more empathetic tone in correspondence.

Recommendations

We recommended that the council:

• apologise to Miss A, and to her parents, for not having handled this matter more sensitively; and
• reflect on this complaint, and consider how matters could have been handled more sensitively.

Summary

Mr C complained that staff at the A&E department at Glasgow Royal Infirmary failed to provide him with appropriate treatment for his reported symptoms of acute eczema. The issues raised by Mr C included that his concerns about his condition were dismissed and that the registrar in emergency medicine who attended to him only glanced at his acute eczema when assessing him. Mr C said his eczema was infected and needed immediate proper treatment. Mr C also said the registrar failed to forward medical documentation about his eczema to his GP.

We obtained independent medical advice from a consultant emergency physician. The adviser explained that the registrar's visual inspection of Mr C's eczema was in accordance with relevant guidelines and was an assessment of the severity of his condition. The adviser said that Mr C's temperature, respiratory and heart rate were all normal and there was no clear indication from his medical records that he required immediate treatment for his eczema. It was noted that the registrar discussed Mr C's condition with him, gave him advice, prescribed medication to help ease the itching and advised him to see his GP for review and ongoing management. The adviser said there was no evidence that Mr C's treatment was inappropriate. The board acknowledged that a discharge summary did not appear to have been completed and sent to Mr C's GP, and the board apologised for this omission.

On balance, we considered that the board did not fail to provide Mr C with appropriate treatment and we did not uphold his complaint. However, we made a recommendation for action by the board regarding the forwarding of medical documentation about Mr C's eczema to his GP.

Recommendations

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

• A process for discharge summaries should be in place for when patients are discharged from A&E. This process should require staff to complete discharge summaries and send them to the patients' GPs.

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 raised a number of concerns about the care that her mother (Mrs A) received from her medical practice. Mrs A had been diagnosed with terminal pancreatic cancer and was receiving care in her home from a multi-disciplinary team including her GP, district nurses and a Macmillan nurse. Once Mrs A's care needs increased, her GP referred her to a specialist palliative care facility, where she died.

We found that in response to Mrs C's complaint, the practice had reflected on the care they had provided to Mrs A and had identified a number of learning points to take forward and act on. We took independent advice on the case from a GP adviser who noted Mrs C's concerns about communication, but did not find evidence that the practice had communicated unreasonably with Mrs C or Mrs A. The adviser was satisfied that the practice had provided appropriate care and treatment for Mrs A's symptoms, and that the GP's role in an investigation into potential diabetes was reasonable. The adviser did not consider that the GP unreasonably delayed visiting Mrs A after she suffered a fall, and considered that the assessment performed at the subsequent home visit and referral to a specialist palliative care facility were reasonable. We did not uphold this complaint.

Mrs C also expressed concern about the level of support and information the practice provided to her in her role as a carer. We found that the practice did not send Mrs C the range of leaflets and resources that they usually send to individuals who have been identified as carers in terms of the practice's protocol. The adviser did not consider that this was unreasonable as it was the responsibility of Mrs C's GP, rather than Mrs A's GP, to provide this information. The adviser noted that the practice had provided some information at a late stage to Mrs C and considered the practice might want to consider taking steps to ensure that any information that is provided in these circumstances is provided at an earlier stage. We did not uphold this complaint, but made a recommendation.

Recommendations

We recommended that the practice:

• feed back the findings of this investigation to practice staff to ensure that information for carers is provided at an early stage.