Some upheld, recommendations

Summary

Mrs C complained that the council had not followed proper planning procedures when they approved the building of a house on a site near her property. Mrs C said that proper consultation had not taken place and that the objections she and others raised at planning committee were not reasonably considered. She also complained that the decision was not in line with the development plan for the area, and that this was not adequately explained and recorded by the council.

Our investigation considered all the correspondence between Mrs C and the council and their responses to her complaints. We also examined relevant planning regulations, policies and development plans, and the papers presented to the committee that approved the planning application, including the planning officer's report and the minutes of the committee meeting. We also took independent advice from one of our planning advisers. We did not uphold Mrs C's complaint about lack of community involvement and consultation, but we did uphold her complaint that the council did not properly follow procedure. We found that the planning application approval was not accurately documented as a departure from policy, as required by regulations, and we made recommendations to address this.

Recommendations

We recommended that the council:

• apologise for not clearly recording the approval as a departure from policy; and
• consider how best to ensure such exceptional planning approval decisions are accurately documented.

Summary

Mr C complained to the council's environmental health department about an out-of-date food product he had bought in a supermarket. He was unhappy with the way the council handled this, and complained to us of delay and failure to deal with his complaint properly and fully.

Our investigation found that there had been an initial delay, and the council had not responded within two working days - the timescale required under their complaints handling procedure. However, in their investigation the council acknowledged this and had already apologised to Mr C for it. We found that their investigation into the food safety issue was thorough and followed council procedures and relevant legislation, and that they had sent Mr C a detailed decision letter. Overall, we did not find evidence of unreasonable delay. Our investigation did, however, find that they had not responded fully to Mr C's further representations, including that they notified the supermarket of their decision before telling Mr C.

Recommendations

We recommended that the council:

• offer a formal apology to Mr C for failing to address all of his points fully; and
• review their practices on the timing of informing parties of the decision taken by the council with regard to complaints about food safety issues.

Summary

Mrs C's children had been placed on the child protection register, and she complained that the head teacher at her son's school had made unsubstantiated allegations to the council's social work department about her parenting ability. Mrs C also complained that the head teacher had unreasonably failed to ask for the social work department's record to be corrected, despite later claiming that her remarks about the situation had been recorded inaccurately. The head teacher had also refused to meet with Mrs C to discuss her complaint.

The council said that as the head teacher disputed the accuracy of the records and as she had not had the opportunity to view them before Mrs C complained, the council did not consider them accurate. They said, however, that the remarks were not the substantive reason for placing Mrs C's children on the register. The council's investigation found that the head teacher's decision not to meet with Mrs C was based on advice from senior colleagues in the education department. The council also said that due to the personal nature of Mrs C's correspondence, the education department had been preparing to deal with the matter as a formal complaint, but this was overtaken by events, when Mrs C formalised her complaints. They said they recognised that it was inappropriate for formal records of conversations not to be agreed by all parties, and so they had taken steps to improve inter-department communication. They were, however, unable to share with Mrs C any details of actions taken in respect of the head teacher.

Our investigation found that it was not possible to determine the accuracy of the record, as it was disputed by the head teacher. The evidence did, however, show that the head teacher's remarks were not the reason that the children were placed on the register. We found that the education department had failed to request that the record be amended, despite being aware that the head teacher disputed the remarks attributed to her, and that child protection proceedings were underway. We also found that, although the council should have told Mrs C why the head teacher would not meet with her, the decision not to do so was one that the head teacher was entitled to make, and was not something that we could look at.

Recommendations

We recommended that the council:

• consider adding an addendum to the social work department file to confirm the head teacher disputes the statements attributed to her; and
• apologise for the failure to correct the social work department record at the earliest available opportunity.

Summary

Mrs C complained to us about the care and treatment provided to her late father (Mr A) before his death. Mr A had been admitted to Wishaw General Hospital with mobility problems. He was known to have a number of medical conditions, including cancer and cirrhosis (scarring of the liver due to liver disease). He was diabetic and had right pleural effusion (a collection of fluid between the lung and chest wall). He was initially given diuretics (substances that increase urine excretion) for the plural effusion, but it was then agreed with the family that these would be stopped. Mr A was then transferred to a hospice. His condition improved and he was discharged home. However, several weeks later, he was readmitted to the hospital. He stayed there for two weeks before being transferred to an NHS long-term care facility in a care home. Mr A died in the care home a month later. Mrs C complained about Mr A's clinical treatment in the hospital and the care home. Although we cannot normally look at complaints about care homes, we were able to investigate in this case, as Mr A was in an NHS long-term care facility.

We took independent advice from one of our medical advisers. We found that Mr C had received reasonable treatment for MRSA (meticillin-resistant staphylococcus aureus, a bacterial infection that is resistant to a number of widely used antibiotics) in the hospital and that communication with him and his family there was reasonable. We also found that there had been regular consideration of Mr A's symptoms in the care home and there were appropriate responses, in terms of treatment and communication with the family. It had also been reasonable for staff in the care home to withdraw Mr A's insulin. However, we found that a decision was made in the hospital that the fluid in Mr A's chest was related to his cirrhosis. This was done without more consideration of contrary evidence that this could have been a pleural effusion related to his cancer. There was no evidence that the doctor who prescribed the diuretics for this had considered the pleural effusion in sufficient detail. (There was, however, no suggestion that Mr A's health was unduly affected by this treatment.) This was a balanced decision, but in view of this specific failing and taking into account that the pleural effusion was the main abnormality on admission, we upheld this aspect of Mrs C's complaint.

Mrs C also complained that staff had failed to respect the wishes of Mr A and his family that diuretic medication and morphine were not to be administered. Mrs C had sent the board an email requesting this whilst he was in the hospital. Her request was shared with medical staff and after this Mr A was not given these again in hospital. However, when he was admitted to the care home staff started to give him morphine again. Although we found that it had been reasonable to provide Mr A with small doses of morphine to manage his pain, in view of the request in the email, this should have been discussed and agreed with the family. This did not happen, because hospital staff did not communicate that request to the care home. In view of this communication failure, which occurred at a difficult time for the family and was about an issue they had already raised, we upheld this complaint.

Mrs C also complained about the nursing care provided to Mr A in the hospital and the care home. However, we found that this had been reasonable.

Recommendations

We recommended that the board:

• issue a written apology to Mrs C for the failings identified in relation to the diagnosis of the cause of Mr A's pleural effusion and for the failure to communicate to the care home the family's request that Mr A was not to be given diuretics or morphine; and
• make the staff involved in Mr A's care and treatment aware of our decision.

Summary

Mrs C, who is an advice worker, complained on behalf of her client (Mr A) that his medical practice had failed to properly assess his symptoms and provide him with further tests to determine his increased risk of stroke. Mr A had attended the practice on a number of occasions with various symptoms. There was a history of heart and circulatory disease in his family and he was concerned that he had had a stroke.

We obtained independent medical advice on the complaint from one of our medical advisers. Although Mr A did subsequently have a stroke, the advice we received was that the symptoms with which he had presented to the practice did not suggest that he had suffered a stroke at that time. The adviser said that his symptoms were reasonably explained by other, more likely, diagnoses. Although we found that Mr A's concerns had not been fully addressed, the practice properly assessed the symptoms he presented with and arranged the appropriate tests. We found that they had acted reasonably and did not uphold this aspect of the complaint.

Mrs C told us that Mr A later did have a stroke and phoned the practice as soon as he realised what had happened. The practice recorded that he said that he was struggling to hold a cup in his left arm and was now having to drag his leg. They recorded that there was no mention of his arm being affected in the previous notes and that he might have suffered a stroke. They arranged an appointment for him later that day. However, Mr A instead went to hospital and was admitted to the stroke unit. We found that, based on the record of the phone discussion with Mr A, the correct course of action in line with relevant national guidance would have been for the practice to phone a blue light ambulance to take him to hospital. If the practice considered that there were good reasons for not doing so, at the very least, they should have recorded the reasons and arranged to examine Mr A immediately. The action they took was not appropriate and so we upheld this aspect of Mrs C's complaint.

Recommendations

We recommended that the practice:

• issue a written apology to Mr A for inappropriately telling him to attend an appointment later that day, when it was recorded that he had potentially suffered a stroke;
• make the GP that Mr A spoke to aware of our decision on this matter; and
• confirm that the matter will be discussed at the GP's next annual appraisal.

Summary

Mrs A registered with the medical practice when she moved into a care home. She had several ongoing medical conditions and was seen by GPs from the practice on a number of occasions. A number of months after moving into the care home, Mrs A became quiet and was not drinking enough fluids. Staff contacted the practice and were advised to keep her under close observation. A call back was arranged for a short time later at which time the care home staff reported that Mrs A was much better and was drinking fluids. As they also advised the practice that Mrs A had very strong, foul smelling urine, an antibiotic was prescribed to treat any underlying infection. Later that night, however, Mrs A's condition deteriorated and she was admitted to hospital later that night. She died some days later.

Mrs A's daughter (Mrs C) complained that the GPs had not provided Mrs A with appropriate medical care while she was resident at the care home. In considering this complaint, we took independent advice from one of our medical advisers, who is a GP. Having reviewed Mrs A's medical records, our adviser said that she had received reasonable care and treatment from the practice. The GPs had reviewed and amended her medication, referred her to specialists in old age psychiatry and speech and language therapy, and responded to requests for advice from the care home staff as well as monitoring her general health. We did not uphold this complaint.

However, Mrs C also complained that the practice took too long to respond to her complaint. We reviewed their complaints handling procedure and agreed that the complaint had not been dealt with within their published timescales. We also noted that their complaints handling procedure had not been updated to reflect the introduction of new legislation, so we upheld this complaint and made recommendations.

Recommendations

We recommended that the practice:

• apologise to Mrs C for failing to respond to her complaint in a timely manner; and
• update their complaints handling procedure.

Summary

Mr C visited his dentist because he had toothache. The dentist found an abscess that was discharging pus from the gumline of the third and fourth teeth on the lower right side of Mr C's mouth. As Mr C was already taking a course of antibiotics prescribed by his GP, the dentist said that he should let the inflammation settle before returning to have the teeth extracted. Mr C returned and his teeth were extracted but the pain and swelling continued. He went for an emergency appointment, and the abscess was found on the first lower right tooth. Mr C was referred to local maxillofacial surgeons (specialists in the diagnosis and treatment of diseases affecting the mouth, jaws, face and neck) who provided intravenous antibiotics before removing all his lower teeth.

Mr C complained that his dentist did not provide reasonable treatment during the first consultation. He said he was not already taking antibiotics and that these were prescribed when he found it necessary to visit his GP having been unable to secure an emergency appointment with his dentist.

We found clear evidence that the antibiotics were prescribed before Mr C visited his dentist. Based on the information available at that time, we were satisfied that the dentist could not provide any immediate treatment, and we did not uphold this complaint. We were, however, critical that the dentist did not take additional x-rays to identify the true location of Mr C's abscess. The failure to do so delayed treatment by around two weeks and so we upheld the complaint that the care and treatment was unreasonable. However, we were satisfied that the two teeth that were extracted had to come out in any case. We found no evidence to suggest that emergency appointments were requested and refused and did not uphold that complaint.

Recommendations

We recommended that the dentist:

• apologise to Mr C for the delay to the treatment of his abscess; and
• take note of the adviser's comments regarding the need for additional x-rays with a view to identifying any points of learning for future treatment.

Summary

Mrs C raised a number of concerns about the care and treatment that her late mother (Mrs A) received at the Victoria Hospital during two separate admissions. Mrs A was taken to hospital with symptoms suggestive of a stroke. Tests showed that she had a lung tumour, and a biopsy (tissue sample) was taken several days later. She was discharged, but was readmitted four days later having suffered a major stroke. Mrs A died three months later.

We took independent advice on this case from our nursing adviser and one of our medical advisers, who is a GP. The GP adviser identified that a number of aspects of Mrs A's medical care fell below a reasonable standard. At the time of the first admission, more consideration could have been given to the stroke diagnosis and treatment, and there was an unreasonable delay in the lung biopsy being processed although we took the view that the board had since taken reasonable steps to address this. In respect of the second admission, the GP adviser said there was a lack of communication between specialist stroke staff and the family. We also found that, although Mrs A's medication was managed well on a daily basis, there was a need for more strategic consideration of this. There was delay in providing medication to address Mrs A's high calcium levels and her low mood. In addition, medication for nausea was stopped, and there was no reason for this given in the medical records. Our GP adviser was also critical that there were a number of undated entries in relation to blood results.

We noted that the board had acknowledged Mrs C's concerns that Mrs A's dignity was compromised and that on one occasion she was not properly clothed, and our nursing adviser was satisfied with the measures the board took to address this. In relation to the management of incontinence, pain levels, involvement from speech and language therapy and dieticians, along with Mrs A's care planning and rehabilitation work, there was evidence in the medical records to support that the overall nursing care was of an acceptable standard.

Recommendations

We recommended that the board:

• apologise to Mrs C for the failings we identified; and
• review the comments of our GP adviser on this complaint and reflect on the decision-making processes used by GPs individually and collectively in assessing Mrs A, and provide us with evidence of this reflection having taken place and its outcome.

Summary

Mr C complained that the board failed to provide him with appropriate ongoing psychiatric treatment and support after he was admitted to a hospital psychiatric unit. After taking independent advice from one of our medical advisers - a consultant psychiatrist - we found that Mr C was treated appropriately whilst he was in the hospital. However, several months after he left there, he was diagnosed with borderline personality disorder. We found that psychiatrists had failed to adequately document a detailed medical history, and that the diagnosis was not adequately founded or justified. It was not made with sufficient rigour and was not reviewed appropriately.

There was no evidence that assessment for psychological treatments was carried out so that Mr C could be offered treatment promptly. His care and management were not coordinated and there was no evidence that his care plan had been reviewed. In addition, it was not clear whether the findings of a scan were adequately communicated to him. We found that this delayed Mr C's treatment for a number of months. In view of all of this, we upheld the complaint. However, we found that a psychiatrist who had later taken over Mr C's care had been following an appropriate plan of further investigation in collaboration with Mr C's GP.

Mr C also complained that staff had failed to admit him to the psychiatric unit when he was discharged from another hospital after attempting suicide. The discharge letters from the other hospital, however, did not say that Mr C should be admitted to the unit. We found that it had been reasonable for the board not to readmit Mr C at that time and did not uphold this aspect of his complaint.

Recommendations

We recommended that the board:

• issue a written apology to Mr C for the delay in providing him with appropriate psychiatric treatment and support;
• review his current treatment to ensure that it is appropriate;
• take steps to ensure that clinicians are more rigorous in the way that they diagnose personality disorders and that appropriate treatment is provided; and
• take steps to ensure that care management for psychiatric patients is co-ordinated.

Summary

Mr C complained because he had concerns about the safety of the area that he and other prisoners worked in and he did not think the prison had addressed these properly. He also complained that he was not being paid weekly, and because he felt that the prison had not considered his circumstances appropriately when allocating work to him.

In his complaint to the prison, Mr C said he had not received appropriate inductions and he made a number of observations about the work being carried out. He also raised concerns about an incident that had taken in place in which another prisoner was injured. In response, the prison confirmed that all reported accidents were fully investigated and records kept. They told Mr C that he was required to work. We considered that the prison appropriately addressed his concerns about the incident involving the other prisoner. We also considered that it was unreasonable for Mr C to complain about not receiving the appropriate inductions, because he had refused to attend work. However, the prison did not respond at all to his observations of the work being carried out and we felt they should have, so we upheld this aspect of his complaint and made a recommendation.

Prison rules require prisoners to work. However, Mr C had made it clear to the prison that he was not prepared to attend work. The prison provided evidence to show us the steps they had taken to consider Mr C's circumstances before allocating work to him and we found these to have been appropriate. We, therefore, did not uphold Mr C's complaints about this.

Recommendations

We recommended that the Scottish Prison Service:

• apologise for not responding fully to the concerns Mr C raised in his complaint.