Some upheld, no recommendations

Summary

Mr C complained to us about the decision to stop his medication in prison. He said that he had been wrongly accused of concealing it in his mouth when it was given to him under supervision by nurses. He complained to us about the way in which he was supervised when taking the medication. We took independent medical advice on Mr C's complaint. We found that the way in which he had been supervised was reasonable. The decision by medical staff to stop the medication was also reasonable given their concerns that Mr C was not using the medication in line with his needs. We did not uphold these aspects of Mr C's complaint.

Mr C also complained to us about the response he had received from the board to his complaint. He said that this incorrectly stated that he had concealed medication four times in four months. Mr C's medical records showed that he had been caught concealing medication on three occasions. We upheld this aspect of his complaint.

Finally, Mr C complained to us that the board had failed to treat his ongoing pain effectively. We found that the care provided to Mr C in relation to pain after the medication was stopped had been reasonable. We did not uphold this aspect of Mr C's complaint.

Summary

Mr C complained about the care and treatment he received during his admissions to the Royal Infirmary of Edinburgh, in particular that the board failed to diagnose a brain injury and that they transferred him to another hospital for rehabilitation too quickly.

During our investigation we took independent advice from a consultant cardiothoracic surgeon and a consultant neurosurgeon.

Both advisers felt that the board did not fail to diagnose a brain injury and that there was no evidence of suspicion of a brain injury. In particular, the neurosurgery adviser having reviewed Mr C's brain scan carried out in November 2013 was satisfied that there was no evidence of head injury. They also added that a further scan of Mr C's brain carried out in 2015 showed no evidence of a previous head injury.

The board accepted that Mr C had been transferred from the Royal Infirmary of Edinburgh too quickly and that he was discharged without the necessary aids. We found that the action taken by the board in response to these failings was reasonable and appropriate and would ensure there was no recurrence in the future.

Summary

Mr C complained that an incorrect entry had been placed in his GP records which he had asked the practice to remove or mark 'to be disregarded'. He also complained that the board did not deal with his subsequent complaint in a timely manner.

Following investigation, we were of the view that the practice had taken reasonable action to try to establish the accuracy of the record which detailed a consultation alleged to have taken place between Mr C and a locum GP. As the locum no longer worked for the practice they were unable to speak to him. In order to establish if the record actually related to another patient the practice conducted a search of their records, including patients seen just before and after Mr C on the date in question. They also reviewed the records of patients with similar names and/or dates of birth. We considered that the practice had taken reasonable action to establish whether or not the record was inaccurate, but had been unable to do so. We did not uphold this complaint.

On the matter of Mr C's complaint to the board, we found that there had been delays in dealing with Mr C's complaint. However, Mr C had been kept informed during the process. Although we upheld this complaint, we did not make any recommendations on this matter.

Summary

Mrs C was a student at the college. She complained about the behaviour of a member of teaching staff towards her. She also said that the staff member failed to provide agreed reasonable adjustments, that they scheduled some assessments in an inappropriate location and destroyed some of her assessment work. Mrs C also complained that the college's handling of her complaint was inadequate.

We found that there was no independent evidence to support Mrs C's account of the staff member's behaviour; although this did not mean we did not believe her. However, given the lack of evidence, we could not reach a finding on this and, therefore, we could not uphold this aspect of her complaint. There was evidence to show that the staff member failed to provide agreed reasonable adjustments and scheduled some assessments in an inappropriate location, and we upheld these complaints.

We did not find that the staff member destroyed some of Mrs C's assessment work; rather, the college only retained Mrs C's work for as long as was required by the Scottish Qualifications Authority. In addition, we were satisfied that the college's handling of Mrs C's complaint was reasonable in the circumstances. We did not uphold these aspects of Mrs C's complaint.

As the staff member had left the college, we did not make recommendations about their actions, as this would have no effect. The college have reminded staff of what constitutes inappropriate practice and to follow college procedure at all times. We were satisfied that the college have taken responsibility for what happened, and that their actions provide an assurance that this should not happen to another student.

Summary

Mrs C complained that staff at the Victoria Hospital had failed to perform her hip surgery in an appropriate manner. We took independent advice on Mrs C's complaint from an adviser, who is a consultant trauma and orthopaedic surgeon. The adviser said that although the operation note in Mrs C's medical records indicated a completely satisfactory procedure, there were no images in the medical records to show the position of the implant in Mrs C's hip at the end of the operation. It was therefore impossible for the adviser to comment on the adequacy of the surgery carried out. However, they said that an image should have been taken to show the position at the end of the procedure and the fact that there was no such image in the records we received from the board amounted to a failure in record-keeping. We upheld this aspect of Mrs C's complaint for this specific reason and made the board aware of the adviser's comments.

Mrs C also complained that staff had failed to provide her with appropriate treatment following the hip surgery and this resulted in the amputation of her leg. It had been identified that Mrs C had sepsis (blood infection) at the time of her hip surgery. We found that the care and treatment she had received for this had been reasonable. The advice we received was clear that Mrs C's leg had been amputated due to a blocked artery and this had nothing to do with her previous hip surgery. Consequently, we did not uphold this aspect of Mrs C's complaint.

Summary

Mr C complained about the treatment he received from his dentist at an examination. He was also concerned that the dentist had not advised him that the practice was about to be sold and that a different dentist would be continuing his treatment at a subsequent appointment.

After taking independent advice on this case from a dental adviser, we did not uphold Mr C's complaint about treatment. The adviser considered that the examination was appropriate and that while further investigations could potentially have been carried out at the same time, overall, the care and treatment provided at the appointment in question was reasonable. We did, however, uphold Mr C's complaint regarding communication about the change of dentist. We found a lack of evidence that Mr C had been advised of the changes at the practice and received advice that General Dental Council Standards state that patients should be told who will be involved in their care.

Summary

Mrs C complained to us about the care and treatment provided to her late mother (Mrs A) in the Victoria Hospital. We took independent advice on Mrs C's complaints from a consultant geriatrician and a nursing adviser. Mrs C complained that the action taken in relation to the management of Mrs A's pain was unreasonable, particularly as Mrs A had dementia. We found that although there had been no clear cause of Mrs A's pain, medical staff had made reasonable attempts at diagnosing and managing the cause of her pain and it had been reasonably well controlled. There was also evidence in the nursing notes to indicate that nursing staff undertook very specific assessment and management of Mrs A's pain. We did not uphold this aspect of Mrs C's complaint.

Mrs C also complained about the action taken in relation to fluids and diet. We upheld this complaint, as we found that staff had not completed nutritional screening documentation when Mrs A was admitted and that she had repeatedly received the same types of meals. There was also no evidence that staff had taken action when Mrs A's dentures went missing. That said, we were satisfied that the board had apologised for these failings and had taken action to prevent similar problems occurring.

Mrs C also complained about the communication with the family. We found that this had been of an acceptable frequency and detail. We did not uphold this aspect of the complaint. In addition, we found that the end of life care provided to Mrs A had been reasonable and did not uphold Mrs C's complaint about this.

Summary

Mr C complained that he had been required by the council to pay an additional fee when renewing his taxi licence. The payment was for the provision of a taxi marshal service, which had then taken 22 months to provide. Mr C said he believed the council had acted unreasonably. Mr C also said his complaint on the matter had been ignored by the council.

We found that the payment was taken prior to the scheme being set up, as it was a requirement that taxi administration be self-funding. It was, therefore, unavoidable that there would be some delay between the payment being taken and the scheme starting. The council had provided evidence that the creation of the new position required a significant re-organisation of the operational area in which it sat. It had then subsequently been delayed by a change in legislation. We found that the council had kept the taxi liaison group properly informed during this period and that there was no evidence of widespread dissatisfaction with the scheme. We did not uphold this aspect of the complaint.

The council had acknowledged that their initial response to Mr C's complaint was late. We found that this was due to human error, rather than systemic failure and although we upheld this aspect of Mr C's complaint, it was not proportionate to make any further recommendations.

Summary

Mr and Mrs C complained that a consultant obstetrician and gynaecologist at Borders General Hospital unreasonably decided that Mrs C should undergo a caesarean section. Mrs C had previously given birth to two children by caesarean section, but was keen to have her third child by vaginal birth. When her waters broke, she was told that medical staff would allow 48 hours for the labour to progress before carrying out a caesarean section. However, she then saw the consultant who said that there would be high risks in waiting for another 48 hours and that a vaginal birth was unlikely anyway. He said that Mrs C should have the caesarean section as soon as possible.

We took independent advice on Mr and Mrs C's complaints from a medical adviser who is also a consultant obstetrician and gynaecologist. We found that it had been reasonable for her consultant to hold the view that Mrs C should undergo a caesarean section at that time, even if this conflicted with advice she had received from other medical staff who had been prepared to allow her to wait slightly longer. We did not uphold this aspect of Mr and Mrs C's complaint.

Mr and Mrs C also complained that the consultant had not communicated with them in a reasonable manner. We found that there was evidence, including a statement from a midwife, that the consultant's communication with the couple had not been reasonable and had lacked empathy. The consultant had also failed to acknowledge where his advice differed from others and the reasons for this. Whilst we upheld the complaint, we were satisfied that the board had apologised to Mr and Mrs C. They had also stated that this had been raised with the consultant and that the complaint would be included in his annual appraisal.

Summary

Mr C complained that the Scottish Prison Service (SPS) inappropriately failed to follow the correct process when placing him on disciplinary report. In particular, Mr C said the prison had given him a document that prisoners were not supposed to receive. He also said he had not received appropriate notification that he was being placed on disciplinary report. In addition, Mr C said the prison failed to respond appropriately to his complaint.

The SPS accepted that Mr C should not have been issued with the document and it should only have been made available to the adjudicator of his hearing. However, they did not consider that issuing the document to Mr C had impacted on the disciplinary process or resulted in him receiving an unfair hearing. We agreed with this position. In addition, the SPS were able to provide evidence that Mr C had received appropriate notification that he had been placed on disciplinary report. Therefore, we did not uphold this part of his complaint.

In looking at whether the SPS failed to respond appropriately to Mr C's complaint, we agreed that the response was dated incorrectly. However, we did not consider this error had affected the quality of the response. We accepted that the written response issued from the internal complaints committee (ICC) was confusing because it referred to a negative drug test result instead of a positive result. However, the chairperson of the ICC wrote to Mr C and agreed that they had incorrectly referred to a negative drug test result and apologised for any confusion caused. Given the administrative errors identified, we upheld this part of Mr C's complaint.