Some upheld, recommendations

Summary

Ms C complained to us on behalf of her client (Ms A). Ms A met with a health visitor after registering with a local GP. Ms A advised the health visitor that her child had issues with feeding and as a result, had not really been introduced to solid foods. The health visitor noted that Ms A's child was well above the range of weight and length expected for a child of that age. A number of issues relating to the family resulted in the health visitor making contact with the social work department. Ms A's child was voluntarily put into the care of the child's father following a meeting with a social worker and a paediatrician.

Ms A complained about the health visitor's actions and said that she held the health visitor predominantly responsible for the child being removed from her care. Ms A also complained about the way that the board handled her complaint. The board said that the health visitor had carried out her role appropriately and explained that a health visitor cannot be responsible for the removal of a child from its mother's care as they do not have this statutory duty.

We took independent advice from one of our advisers, who is a health visitor. Our investigation found that the health visitor's actions were reasonable on the basis of the information available to her. Some issues around record-keeping were highlighted for professional development but the adviser had no concerns about the health visitor's actions. We did, however, find that the board's handling of Ms A's complaint was unreasonable as they had not fully addressed all her concerns in their response and had not followed their complaints handling procedure.

Recommendations

We recommended that the board:

• highlight the issues regarding record-keeping to the health visitor for professional development;
• apologise for failing to follow their complaints handling procedure in this case; and
• take steps to ensure the investigation and written response to a complaint is in line with their complaints handling procedure.

Summary

Mrs C complained to us about the care and treatment of her son (Mr A) at the Royal Edinburgh Hospital. Mr A was admitted to hospital under a short-term detention certificate when he was having an acute reaction to stress. He was discharged nine days later, but had ongoing contact with psychiatric services. He was readmitted to hospital the following month, and was an in-patient for a month. After he was discharged he continued to be in the care of psychiatric services, and engaged to varying levels with community based staff. Around ten weeks after his discharge Mr A committed suicide.

Mrs C complained that her son's care was not sufficiently coordinated between professionals and teams. She was also concerned that her son had been discharged without a care plan in place and with no support, and said that staff were unwilling to provide her with enough information for her to be able to support her son.

We took independent advice from two of our advisers - a psychiatric nurse and a psychiatrist. The advisers reviewed Mr A's care and treatment and said that Mr A's care had been appropriately coordinated. They said that information about a patient's care and treatment could not always be shared with all family members, but that information was passed on appropriately during Mr A's care. Mr A was given appropriate medication, but at times he had been reluctant to take this. The advisers also explained that, while the medication prescribed may have slowed Mr A down, it would not have lowered his mood. In relation to Mr A's discharge, the advisers said that the discharge process was properly planned and cohesive. On the basis of this advice, we did not uphold the complaint about Mr A's care and treatment.

Mrs C also complained that she had not received a full response to her complaints within a reasonable timescale. She had chased the board for responses, and felt that her concerns were not addressed honestly. She also met with board staff in an effort to get answers. It was nearly two years from when Mrs C first wrote to the board when they finally told her she could contact us. The NHS complaints procedures says that complainants should be told that they can approach us after 40 business days, even if the board have not provided a final response to the complaint by then. We upheld this complaint, as the timescales were not in line with the NHS complaints procedures. We also found that the responses lacked the detail that Mrs C was expecting and did not address all her concerns, which was not in line with good complaints handling.

Recommendations

We recommended that the board:

• apologise to Mrs C for their failure to address her complaints in a timely and appropriate manner.

Summary

Ms C, who is an independent advocate, complained on behalf of her client (Miss A) that the medical practice did not respect Miss A's wish to use an advocacy service. She also complained that the quality of communication from the practice was poor, and that they unreasonably removed Miss A from their patient list.

We took independent advice from a medical adviser and a mental health adviser. The mental health adviser said that Miss A had a right to use an advocacy service and that the evidence showed that, although the practice had tried to engage with Ms C, they had not properly understood the role of the advocacy service and had not respected Miss A's wishes. The medical adviser said that the standard of correspondence fell below a reasonable standard. Letters from the practice were emotive and unprofessional and the practice failed to maintain a professional level of distance. The mental health adviser said that in his view they had not taken enough account of Miss A's mental health issues. We, therefore, upheld the complaints about the practice's engagement with the advocacy service and that the standard of their communication was below that which Miss A had a right to expect. We also found that they failed to direct correspondence to Ms C, despite Miss A's clearly stated wish that this should happen.

We took the view, however, that the practice's decision to remove Miss A from their patient list was reasonable, noting that they had complied with the terms of the standard general medical service contract, by giving written warning to Miss A that they intended to take this action unless she provided them with an emergency contact phone number. We did not find this unreasonable, and did not uphold the complaint as we found that they acted in accordance with national guidelines.

Recommendations

We recommended that the practice:

• provide evidence that all staff have been reminded of the role of independent advocates;
• remind all staff of the need to use appropriate language when communicating in writing with patients;
• review their complaints handling procedure to ensure that complaint correspondence is clearly identified and that it signposts complainants to SPSO at the appropriate stage; and
• apologise for the failings that our investigation identified.

Summary

Mr C requires regular blood sampling due to the medication that he is prescribed. At one appointment there was difficulty obtaining a blood sample and Mr C was in pain. He attended his GP who referred him to a neurologist who diagnosed nerve damage, possibly caused by the attempt to take blood. Mr C complained that the board had not provided him with a reasonable standard of care and that they had not properly responded to his complaint.

We took independent medical advice on this complaint from our nursing adviser. Our investigation found that the board had apologised for the distress caused and had made arrangements for Mr C to have future blood samples taken by another team. We considered these actions to be reasonable and did not uphold the complaint. However, we did not consider the time taken by the board to respond to Mr C's complaint to be reasonable, so we upheld this aspect of his complaint and recommended that the board apologise to Mr C for the delay.

Recommendations

We recommended that the board:

• apologise to Mr C for the time taken to respond to his complaint.

Summary

Ms C complained that the association had not responded to her online enquiry form submissions and had not told her what was going to be done about the landscaped area in front of her property. Ms C also said that they had not kept her updated about her status on the housing transfer list or reminded tenants of their responsibility for their pets, following a noise complaint.

The association said that they had had problems receiving online form submissions, and recognised that one of Ms C's emails was received but not acted on. They went on to say that they had new gardening contractors and would be discussing with them the best way to manage the landscaping. The association said that they had sent Ms C reminder letters about her status on the transfer list, but as they were not responded to, they had removed her. They had, however, reinstated her once they became aware she wished to remain on the list. They confirmed that they had sent letters to tenants about their pets.

We found evidence that the association had written to tenants about their responsibilities for their pets, and we considered their actions about the landscaping reasonable. We, therefore, did not uphold these two complaints.

We recognised that the association had experienced problems with how they were managing incoming emails and the steps they had taken to correct that. However, it would have been appropriate for them to have apologised to Ms C for not following up on the email they had received from her. We also found evidence that they had incorrectly sent the transfer update letters to Ms C's previous address. We made recommendations to address these issues.

Recommendations

We recommended that the association:

• apologise to Ms C for failing to apologise to her in the original complaint response;
• apologise to Ms C for incorrectly addressing her transfer update letters;
• restore Ms C's position on the transfer list to the point she would have been at if she had not been removed; and
• update systems to ensure the correct address is used when issuing letters to tenants.

Summary

Mrs C's mother (Mrs A) had a history of urinary problems. She was referred for a CT scan of her kidneys in 2011 which highlighted a mass on her kidney. Further tests diagnosed cancer, and a plan was made to discuss this with Mrs A at her next scheduled appointment. Before this could happen, however, Mrs A became unwell and was admitted to Gartnavel Hospital, where a doctor told her about the cancer. A cystoscopy and uteroscopy (examinations of the tubes that carry urine and the kidneys, using a narrow tube-like telescopic camera) were performed but it was not possible to obtain tissue samples for further analysis. Mrs A was discharged home and attended follow-up clinics. Following a multi-disciplinary team discussion about Mrs A's case, it was decided that she should have surgery, but the operation she needed was not routine. Before it could be arranged, Mrs A was admitted to hospital again, as she had suffered a suspected stroke. A scan showed an acute intracerebral bleed (where blood suddenly bursts into brain tissue). Staff felt that this was indicative of a brain tumour, so they started radiotherapy (a treatment using high-energy radiation) and postponed treating Mrs A's kidney tumour. It was later found that Mrs A did not have a brain tumour. Mrs A died shortly afterward.

Mrs C complained that there were delays in diagnosing and treating Mrs A's kidney tumour. She also complained about the misdiagnosis of a brain tumour, explaining that this diagnosis caused Mrs A to enter a deep depression.

After taking independent advice from two of our medical advisers - a cancer specialist and a kidney specialist - we found that Mrs A's clinical treatment was largely good. We did find that there were unacceptable delays to two diagnostic scans, but there was nothing to suggest that this had any impact on Mrs A's overall prognosis (the forecast of the likely outcome of her condition). We accepted advice that, based on the evidence available to the clinical team, the diagnosis of a brain tumour was reasonable and that it was reasonable to start radiotherapy. That said, we were critical of the board's communication with Mrs A about her diagnosis and the treatment she received.

Recommendations

We recommended that the board:

• apologise to Mrs C that the overall time from the first suspicion of cancer to proposed treatment exceeded 62 days in her mother's case; and
• apologise to Mrs C that her mother was not advised sooner of the scan results.

Summary

Mr C complained about the NHS health centre at his prison. He said that the health centre doctors did not provide adequate care and treatment when he sought medical attention for stomach, testicular and rectal (bowel) concerns.

We took independent advice from one of our medical advisers, who is a GP. We found that Mr C had been appropriately examined and assessed in respect of the rectal issues. However, we upheld that part of his complaint because, although Mr C had not been presenting with a clinical picture that suggested bowel cancer, he had visited the health centre several times on the same matter. National guidelines on the diagnosis and management of bowel cancer recommend that a specific blood sample is taken for all patients with persistent or recurring rectal bleeding (bleeding from the anus). That was not done in Mr C's case. Doing this would have better equipped the doctor to decide on the urgency of the referral that he made to the hospital. We also found that the referral letter to the hospital was not sent until two months after the doctor decided on a hospital referral. Although the clinical picture was not suggestive of bowel cancer, the part that rectal bleeding can play in bowel cancer makes that delay worrying. In due course, Mr C attended hospital and was discovered not to have cancer.

We did not uphold Mr C's complaints about the other issues as his medical records showed that the health centre had appropriately examined and assessed him in relation to these and we had no further concerns.

Recommendations

We recommended that the board:

• arrange for the prison health centre to audit a representative sample of their hospital referrals to ensure they are being sent in a timely manner;
• arrange for the prison health centre doctor to undertake a specific educational activity related to anaemia and bowel symptoms, for the purposes of Continuing Professional Development; and
• arrange for the prison health centre doctor to include the case in his annual appraisal.

Summary

Mr C complained on behalf of his wife (Mrs C) who suffers from various life-limiting medical conditions, including Raynaud's Disease (a condition where the blood supply to the extremities is severely restricted, causing pain and ulcers). Mrs C receives regular infusions of a drug to help with this condition, and Mr C complained about the way this treatment was administered during one period of time. He also complained about the way the board handled his complaints about this.

Mrs C is admitted to Ninewells Hospital every three months to have a series of seven-hour infusions over a five-day period. Normally 17 hours of rest are allowed between infusions. However, the board's protocol for the treatments says that they can be given with a minimum of 12 hours between them. During one admission Mrs C's treatment was compressed according to this protocol, to allow her to be discharged from hospital earlier. Mrs C developed severe headache, nausea and vomiting, and asked that this should not happen again. Despite this, she felt that her treatment was compressed on her next admission.

Our investigation included taking independent advice from a medical adviser with experience in treating patients with Raynaud's Disease. The adviser said that there are no national guidelines on administering this treatment, but that the board's protocol was in line with normal NHS practice to give infusions over a six to eight hour period across three to seven days. The adviser reviewed Mrs C's treatment and found that the infusion was given after less than a 12 hour break only once - when one was given after 11 hours. However, the adviser was of the view that this was still within normal NHS practice. They also said that staff took appropriate action to address the side effects Mrs C suffered, and noted that headache, nausea and vomiting were common side effects. After considering this advice, we did not uphold Mr C's complaint about treatment as we were satisfied that, overall, this was reasonable. We also noted that Mrs C now has a patient-held treatment plan confirming that no compression will take place in future.

We did, however, uphold his complaint about the board's complaints handling, as there were unacceptable delays in their responses. Our investigation found that Mr C complained in August, September, and November 2012, and again in May 2013. The board responded by arranging a meeting in June 2013 and sending a written response two weeks after the meeting. Mr C then made a further complaint about that response, to which the board replied two months later. The board said that Mr C several times added new complaints before previous complaints had been responded to, which caused part of the delay as the response due dates were amended. However, they also acknowledged that there were some avoidable delays due to staff error and staff shortages and that it would have been better to have dealt with each complaint separately. They explained that they had since made changes in their complaints department to address the issues identified.

Recommendations

We recommended that the board:

• issue a written apology for the unacceptable delays that occurred in dealing with Mr C's complaints; and
• provide us with evidence of the improvements that have taken place within the complaints department since Mr C's complaint and evidence of the progress of any ongoing work to improve complaints handling.

Summary

Mr C complained that the prison inappropriately refused to provide him access to the library. Mr C was an untried prisoner located within an area of the prison that was for those requiring protection.

The prison rules confirm that prisons should make arrangements to allow prisoners to access library services, but also that privileges – including library access - can vary for different categories of prisoners, and for those detained in certain parts of the prison. The Scottish Prison Service told us that the council provided the main library service but that this facility did not extend to untried prisoners. Instead, untried prisoners could access an in-hall library. However, in the particular hall that Mr C was in, there were operational difficulties in granting him access to the in-hall library. He was unable to access either that or the main library (as he was an untried prisoner), which is why he complained. We noted that the prison's internal complaints committee had considered Mr C's complaint, and recommended that steps be taken to enable him to access a library service which the governor had accepted.

In light of the evidence available, we were satisfied the prison had the authority to restrict access to the main prison library for some prisoner groups. Because of that, we did not uphold Mr C's complaint about restricted access. However, we did uphold his complaint about complaints handling. We found that the response to his complaint should have more clearly outlined the prison rules and the reasons why Mr C did not have the same access to the main library as other prisoners.

Recommendations

We recommended that Scottish Prison Service:

• apologise to Mr C for the failures our investigation identified; and
• take steps to remind relevant staff that written responses to complaints should be clear and accurate.

Summary

Mrs C complained that a consultant at Forth Valley Royal Hospital dismissed an urgent referral from her GP for suspected lung cancer and failed to follow up the suspicion of lung cancer. Mrs C said that the consultant failed to take account of her medical history or a recent x-ray and that, as a result, diagnosis of and treatment for lung cancer were delayed.

Mrs C's GP referred her to the respiratory unit because she had a longstanding persistent cough. The consultant there reviewed the referral letter, and as he thought it unlikely that she had lung cancer he decided not to see her at his clinic. He suggested that she first stop taking medication that was known to cause coughs, to see whether this was the cause of her symptoms. After taking independent advice from one of our medical advisers, although we found it acceptable for referrals to be screened in this way we found that the consultant overlooked information in the referral about Mrs C's recent x-ray. Whilst we were satisfied that the advice to alter Mrs C's medication would have been the same had the information about the x-ray been taken into account, we upheld the complaint about the consultant's actions and criticised the board, as this was a key item of information and it was clearly overlooked.

We did not uphold the complaint about delay as we were satisfied that although there was some delay in diagnosis, this was not unreasonable in the circumstances. We did, however, uphold Mrs C's complaint about the board's complaints handling as we found that their investigation and response were not thorough enough.

Recommendations

We recommended that the board:

• apologise for failing to note that Mrs C had had a clear chest x-ray;
• draw our findings to the consultant's attention; and
• review their complaints handling procedures to ensure that detailed, impartial, investigations are carried out into issues raised by patients.