Some upheld, recommendations

Summary

Mrs C experienced numerous troubling symptoms over a number of years including impaired vision and muscle wasting. She underwent a range of investigations with the board's neurology department to establish the cause of her symptoms. Mrs C then complained about the standard of her care and treatment. She felt that, although her symptoms were getting worse, staff did not take her case seriously, dismissed her as anxious and provided contradictory information. Mrs C told us that she decided to have an MRI scan (magnetic resonance imaging scan: a detailed scan of her brain) carried out privately, which identified a small focal lesion (an area of tumour or other tissue damage) on her brain. She complained that this had been missed in scans taken by the board some years previously.

We took independent medical advice from a consultant neurology adviser, and we found that the focal lesion had been present in the earlier scans, but was not easily identified. MRI scanning technology advanced in the intervening period and the lesion was more readily identifiable in the more modern scan. It was only with hindsight and knowledge of its location that radiology staff could identify it in the earlier scans. We did not find the board's actions to be unreasonable in this respect and were satisfied that a number of relevant and appropriate investigations were carried out to establish the cause of Mrs C's symptoms. Ultimately, we found that the treatment she received was in line with that which would have been provided had her lesion been identified from the outset.

That said, we were critical of the board's handling of Mrs C's complaint and their failure to provide an independent review of her MRI scans, as had been promised during their investigation of her complaint.

Recommendations

We recommended that the board:

• apologise to Mrs C for their inadequate communication about her complaint;
• contact Mrs C as a matter of urgency to discuss possible further actions to be taken to review her MRI scans outside of the board area, or provide us with evidence that this has been addressed; and
• review their handling of Mrs C's complaint to ensure that action points from meetings are properly recorded and followed-up and that the NHS complaints handling procedure is properly followed.

Summary

Mr C operates his business from three units in a business centre. He contacted Business Stream when he moved in and, following a visit, an account was opened and he set up a direct debit to pay monthly bills. He told us that it was agreed with Business Stream that he would be billed for all three premises in one invoice. Some three years later Business Stream invoiced him separately for one of the units but then cancelled this, having been advised by Mr C that he was being billed for all three units. In 2013, Business Stream invoiced Mr C for outstanding services provided to two of his units since 2010. Mr C believed that he should not have to pay for the error in 2010 when his account was set up. He also complained of delay in the handling of his complaint.

From our investigation we found that there was evidence of the account being opened for one unit, but no evidence of an agreement to pay for the three units under one account, so we did not uphold this complaint. However, we did uphold Mr C’s complaint about how his enquiries and complaint were dealt with. We found there were periods when there was no action, updates were not provided, and there was a failure to send a form to Scottish Water within a reasonable time, as well as delay in responding to the complaint.

Recommendations

We recommended that Business Stream:

• formally apologise and credit Mr C's account with a sum in recognition of the poor handling of the matter;
• review their handling and credit Mr C's account with 50 percent of the difference between the unmeasured rateable value water charges and his reassessed charges for the appropriate period, if it is established that there were unexplained delays by them; a
• ensure that lessons learned from review of the case are passed on to staff.

Summary

Mr C complained that he had to pay a service charge while he was in temporary accommodation. He also complained that the council did not process his medical assessment form in line with their procedure, and did not communicate properly with him about an offer of housing.

The council said that the service charge was in line with their policy and is for maintaining temporary accommodation, which has a higher turnover than the main housing stock. They said that they had responded to Mr C about his medical assessment application and explained how medical points are awarded. They also apologised for not being proactive in contacting him about his offer of accommodation.

As we found that the service charge was in line with the council's policy, we did not uphold Mr C’s complaint about this. The level of the charge is a discretionary decision for the council to make. However, we found that the council took longer than the four weeks specified in their policy to process his medical assessment application and did not let him know that there was a delay, so we upheld that complaint. We also found that they had failed to correctly categorise the property Mr C was offered, as empty (void) properties such as that one, which need work that will take more than 15 working days should be recorded as 'not offerable'. They had also allowed Mr C to accept the offer as 'subject to viewing' which contravened their void management procedure. In light of these findings, we also upheld Mr C's complaint about the council's communication.

Recommendations

We recommended that the council:

• issue Mr C with an apology for failing to process his medical assessment application in line with their procedure;
• revisit their policy on processing medical assessment forms and ensure that if they are unable to meet the four week deadline that they advise applicants of the delay;
• issue Mr C with an apology for failing to process his offer of accommodation in line with their procedure; and
• revisit their procedure on void management, and remind all staff that properties requiring works of more than 15 working days should be recorded as 'not offerable' and that properties cannot be accepted 'subject to viewing'.

Summary

Mr C complained to us about the care and treatment his mother (Mrs A) received from the medical practice after a GP visited Mrs A's home as she had abdominal pain. Mr C told us that the GP examined his mother, gave her a injection for pain and called an ambulance. He said that the GP spent approximately 15 minutes with his mother before leaving. Mr C said that the ambulance arrived two and a half hours later and during this time his mother's pain worsened. He said that the ambulance crew expressed shock at Mrs A's condition and gave her more pain medication before taking her to hospital. When he went to the practice to complain, he felt that the GP was aggressive towards him. He also said that he asked for information on making a complaint and was told there were no specific forms and that each practice is different.

The practice said that they provided proper care and treatment. The GP said that as Mrs A had family support and her condition was not considered life threatening, it was appropriate to leave and return to other patients at the surgery. The practice said that Mrs A's family did not call them to say that she was worse. They apologised for confusion about the complaints form and explained that although they do not have such forms they do have a procedure, and complaints can be made in writing. They said that they were not aggressive towards Mr C – they in fact felt that he had been aggressive towards them, and they had sent him a formal warning.

We took independent advice from one of our GP advisers, who said that the GP provided reasonable care. Our adviser was of the view that the pain relief given and the decision to request an ambulance within a two hour window were reasonable. The Scottish Ambulance Service provided evidence during our investigation that their crew that day had no recollection of criticising the GP and or of expressing shock at Mrs A's condition. We did not uphold this complaint.

We did uphold Mr C's complaint about the practice's complaints handling. Although they responded to his complaint well, he had asked for complaints handling information and been told there was none. They should have referred to the NHS Scotland 'Can I help you?' guidance and provided information on the process they would use to deal with his complaint.

Recommendations

We recommended that the practice:

• ensure that all practice staff are aware of the NHS Scotland 'Can I help you?' guidance and ensure that the practice leaflets on the complaints handling process, detailed on the practice website, are available to patients and staff.

Summary

Mrs C complained about the care and treatment that her late husband (Mr C) received at Wishaw General Hospital. Mr C had advanced cancer and was admitted to the hospital because he was vomiting blood. He was in the hospital for about a week before being transferred to a hospice, where he died shortly after. Mrs C complained that the hospital did not adequately assess and treat her husband's bladder and bowel problems and failed to take adequate precautions to prevent him from falling out of bed. She also complained that neither she nor Mr C had been involved in discussions about the withdrawal of his medical treatment and his future management plans.

We took independent medical advice from an experienced hospital doctor, who reviewed Mr C's records. Our adviser said that although it was clear that Mr C was most unwell when he was admitted, there were a number of steps the hospital should have taken sooner. Viewed as a whole, he said that Mr C's care fell below a reasonable standard and we upheld this complaint.

We also took independent advice from our nursing adviser, who said that a falls assessment was completed when Mr C was admitted. This indicated that he was not at risk of falling and, in her view, there was no reason for the hospital to have suspected he might do so. Our adviser said the hospital's assessment was reasonable and the board had acted reasonably, based on the information available at the time. In her view, Mr C's fall could not have been avoided, and we did not uphold this complaint.

In terms of Mrs C's complaint about the lack of discussions, our medical adviser pointed to an apparent lack of clarity around the approach being taken with Mr C's care. He was moved to the hospital's high dependency unit for treatment – despite the notes indicating he would not be moved – but it was then decided to move him onto palliative care (care provided solely to prevent or relieve suffering). Our adviser said that this decision was appropriate but should have been discussed sooner than it was. We took the view that the evidence showed a lack of certainty over the direction of Mr C's care and that his family were given mixed messages. We considered this unreasonable and upheld this complaint.

Recommendations

We recommended that the board:

• discuss this case at the next departmental meeting to ensure early recognition of kidney dysfunction and infection, so appropriate steps are taken in such cases;
• ensure that the failings in care and treatment identified are fed back to the relevant staff;
• provide us with a copy of their local action plan for the relevant Scottish Government guidance and confirm the steps in place in acute wards to support patients and families receiving end of life care including staff communication;
• use this case in Mr C's consultant's appraisal with reflection on the issues identified, including the decision on when to move to palliative care, communication and consultant supervision; and
• apologise to Mrs C for the failings we identified.

Summary

Ms C complained that, during her pregnancy, the board failed to give her reasonable care and treatment and that there was a failure to diagnose placental insufficiency (a complication in pregnancy where the placenta is unable to deliver an adequate supply of nutrients and oxygen to the fetus), or that her baby was too small. Ms C's baby was stillborn.

We took independent medical advice from a consultant obstetrician, who told us that while ultrasound (a scan that uses sound waves to create images of organs and structures inside the body) provided the best estimate of fetal size, unfortunately it was not always accurate. Other tests (including measurements of the abdomen and blood flow in the umbilical artery) did not always pick up that a baby was small. Scans and other tests were also used to detect problems with the placenta but again were not foolproof. In Ms C's case, as she had already had two healthy births and had no apparent risk factors, all appropriate and reasonable steps were taken to properly monitor her pregnancy. While our adviser noted that with earlier delivery the baby would likely have survived, there was no indication for her to have been delivered earlier. Based on the evidence, we did not uphold Ms C's complaints about her care and treatment.

Ms C also complained about the way her complaint was handled. We upheld this complaint, as we found that there had been numerous delays, and that these had added to her distress.

Recommendations

We recommended that the board:

• make a formal apology for their delay and for any further distress caused; and
• remind those staff involved in responding to complaints (including any clinical staff) of the necessity of providing timely replies and demonstrate to us how this was done.

Summary

Ms C complained on behalf of her client (Mr A) who suffers from a delusional disorder (a mental health disorder where sufferers hold irrational beliefs). Mr A went to A&E in Lorn and Islands Hospital as he wanted them to check a mark on his leg. Staff were concerned about his mental wellbeing and spoke to the duty psychiatrist at another hospital who decided that he should be transferred and admitted there. In the event that Mr A was unwilling to go, it was agreed that his admission be facilitated with the use of an Emergency Detention Certificate (EDC). Documentation had to be completed for this and, before arrangements could be made for transfer, Mr A left Lorn and Islands Hospital. He was later brought back, handcuffed, by the police, sedated and transferred.

Ms C complained that Mr A was not adequately assessed at A&E. She also said that staff did not follow the correct process/procedures in relation to the EDC and there was unreasonable delay in transferring Mr A between hospitals. She subsequently complained of the delay in responding to her complaint about this.

We took independent medical advice from one of our psychiatric advisers. We found that, while it had been reasonable to prioritise Mr A's mental health over his concerns about his leg, the board had not first tried to establish whether he was a risk to others or himself, nor attempted to discuss his condition with his usual psychiatrist and review his records before deciding that he needed to be tranquilised. They also failed to follow the correct procedures (in terms of assessment and proper completion of the appropriate forms) for issuing an EDC. This led to Mr A being sedated against his will. Furthermore, the board delayed in dealing with Ms C's complaints. We, therefore, upheld these complaints.

Ms C had also complained that the board delayed in transferring Mr A between hospitals, but we did not find evidence to confirm this, and did not uphold her complaint.

Recommendations

We recommended that the board:

• apologise to Mr A for the shortcomings in assessing him;
• ensure that the circumstances of the complaint are brought to the attention of the on-call psychiatrist and ensure that it is considered at his next formal appraisal;
• make a formal apology to Mr A for failing to follow correct procedures;
• review the training given to medical staff working in A&E to ensure that they understand what is required before detaining people under an EDC and how to complete the appropriate paperwork;
• should formally apologise to Ms C and Mr A for their failure to respond in a timely manner; and
• should emphasise to the staff involved in this complaint the importance of responding to complaints in accordance with the board's stated response times.

Summary

Mrs C's stepfather (Mr A) was diagnosed with advanced bowel cancer in 2011 and had chemotherapy (a treatment where medicine is used to kill cancerous cells). In 2012, he was admitted to Aberdeen Royal Infirmary twice. Mrs C said that during the second admission a doctor told Mr A his chemotherapy had been positive but that he would not receive any more in view of problems with blood clots. Mrs C said that they later found out that it was stopped because his cancer had progressed. Mr A was admitted to hospital for a third and final time several weeks later. Mrs C said that staff failed to provide a discussed and implemented care plan about support throughout Mr A's illness and end of life care. She said that Mr A wanted to be with his wife (Mrs A) and receive end of life care at home, but was not consulted about his wishes or where he preferred to die. Mrs C said a doctor said that the aim was to get Mr A's pain under control and discharge him home. However, Mrs A received a phone call several days later telling her that he would be transferred to Peterhead Community Hospital under the care of his medical practice. Mrs C said that Mrs A was not told before the transfer that her husband was deteriorating significantly. He died six days later.

Mrs C said that clinical staff at Aberdeen Royal Infirmary failed to involve Mr A and his family in the transfer decision and failed to discuss the likely outcome for him, or the possibility that he could be cared for at home. In relation to her complaint about nursing staff at the community hospital, Mrs C said that they failed to provide a reasonable standard of care in terms of communication, personal care and dignity.

After taking independent advice from two of our advisers - a GP and a nurse - we found that staff failed to involve Mrs A and the GP in the decision to transfer Mr A to the community hospital. Given Mr A's condition, we were also concerned that he was not in a position to have an informed and reasoned discussion with medical staff about the transfer or to let them know his end of life care wishes. Although there was evidence that the likely outcome was discussed with Mr A and his family, there was no detailed record of Mr and Mrs A's understanding of this, as there should have been. Nor was there an anticipatory care plan which would have contained their wishes about where Mr A would prefer to die.

In relation to Mrs C's complaint about Mr A's personal care in the community hospital, we could not reconcile the differing accounts of what happened. Our nursing adviser said that the overall standard of care was reasonable, although in the absence of evidence we could not reach a judgement on Mr A's levels of hydration (fluid replacement). Having considered the medical records, we were satisfied that these clearly showed that the level of communication about Mr A's condition was reasonable. Similarly, we were satisfied that the care and support from district nurses was reasonable although there was no evidence that staff completed or referred to an end of life care plan. However, our nursing adviser said that a district nurse would not be expected to write an end of life care plan alone.

Recommendations

We recommended that the board:

• bring the failures our investigation identified to the attention of the relevant health care professionals involved in the transfer decision;
• provide evidence of how they intend to address the failings in relation to anticipatory care planning for end of life;
• bring the failures our investigation identified to the attention of the relevant health care professionals involved in discussions with Mr A and his family, and ensure they are raised as part of their annual appraisal; and
• provide the results of their review into their processes and procedures around communication and end of life care.

Summary

Mrs C had a history of longstanding abdominal (stomach) pain. She complained that, despite an operation, she had never been given an explanation for her pain or for the procedures she had subsequently undergone and she had not been given a definitive diagnosis. Mrs C said that she remains in pain and suffers panic attacks and depression. She complained to the board who said that there was no surgically treatable cause for her ongoing pain and symptoms, and that she had been referred to a pain clinic to try to help her. They did, however, acknowledge some problems with communication and said procedures had been put in place to avoid this happening again.

We took independent advice from a surgeon about this case. Our adviser said that since her operation all Mrs C's treatment had been reasonable and appropriate. Despite many investigations, however, it had not been possible to determine the exact cause of her pain, and our adviser confirmed that there was no surgically treatable cause. However, there was evidence that communication between the board and Mrs C was confused and that there had been a delay in informing her of the outcome of a scan, so we upheld this aspect of her complaint.

Recommendations

We recommended that the board:

• make a formal apology to Mrs C for their shortcomings; and
• confirm to us that they are satisfied that the new procedures put in place will prevent such a recurrence.

Summary

Mr C was a college student, studying for a degree offered by a university in collaboration with the college. Mr C complained that the college did not provide him with support on the day of his final degree exam, as had been agreed. Mr C was also unhappy with how they dealt with his complaint.

Mr C said a college tutor told him they should meet up 15 minutes before the exam, so the tutor could tell him where the exam was being held. The tutor said they did not make this arrangement. We did not find any written evidence that the arrangement had been made. In any event, Mr C found the exam room on time, and during the exam was provided with the support that had been agreed with the college. We, therefore, did not uphold this complaint.

We found that the college carried out a thorough investigation of Mr C's complaint. However, their letter to him did not deal with the specific issues he raised and did not explain why they decided not to uphold his complaint. This is not good practice, and not in keeping with the model procedure developed by our Complaints Standards Authority. In addition, the college did not explain to Mr C that they were dealing with his complaint at stage two of their procedure. Therefore, we upheld this complaint.

We also found, as the college did during their investigation, that there was a lack of clarity about telling students where their exams were being held, and so we made a recommendation to deal with this issue.

Recommendations

We recommended that the college:

• revise their procedures to ensure that all students on the collaborative programme receive information, from a specified source, about the location of their examinations in good time, in line with the university's expectations;
• provide us with a copy of their further guidance for staff on more formality in relation to email responses; and
• remind relevant staff that complaint responses must be in line with the model complaints handling procedure.