Some upheld, recommendations

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.

Summary

Mr C complained that the council did not address or adequately handle his complaints about antisocial behaviour and noise pollution involving neighbours who were council tenants.

At the start of our investigation the council explained that although they had investigated Mr C's complaint, he had not made a formal complaint through their complaints handling procedure. We considered, however, that the council should have applied their complaints handling procedure in the first instance.

In investigating Mr C's complaint about noise pollution, we found that the council had followed the relevant procedures and had dealt with this reasonably, and we did not uphold his complaint. The council's investigation found that the building predated the relevant building regulation and that there was an issue with sound insulation. Although there was no requirement to bring the sound insulation up to modern-day standards, the council agreed to do so, and to share the costs with Mr C. Various options were still being considered when Mr C brought his complaints to us.

In relation to other antisocial behaviour that Mr C complained about, however, which included graffiti on his property, alleged illegal activity and accumulation of rubbish in the garden, we found that the council had not taken reasonable steps to address his concerns. We upheld his complaint, as we were not satisfied that the process for dealing with rubbish had been followed as, although a verbal warning had been given to his neighbour, there was no written warning as detailed in the council procedure. We also did not consider that they had explained their procedure on graffiti to Mr C or advised him to contact the police in relation to alleged criminal behaviour, although we did find that they had recommended he contact the police in relation to any breach of the peace that took place.

Recommendations

We recommended that the council:

• consider taking further action to address the noise transference issue if the agreed works are judged to be unsuccessful;
• take steps to raise awareness of their complaints handling procedure, particularly the definition of a complaint, with the relevant service area staff;
• record Mr C's complaint and provide an apology for failing to use the proper complaints handling procedure in the first instance; and
• apologise to Mr C for their failure to fully address all his concerns about antisocial behaviour and provide him with an assurance that their estates management framework, which includes their procedures for addressing antisocial behaviour, will be followed as appropriate in future.

Summary

Mr A was a tenant of the association. Mrs C, who is a support worker, complained on his behalf that the association did not deal competently with his complaints about gas safety concerns. From the evidence we saw, however, we were satisfied that the association acted appropriately to deal with these.

Mrs C also complained that the association did not provide adequate and appropriate assistance to Mr A when there was no heating or hot water in his home over a weekend in October. They had offered Mr A a small amount in recognition of the inconvenience caused to him, which he had not accepted. Our investigation found that Mr A had undergone surgery, which required him to be careful about his personal hygiene, and he also had temporary care of his young son. The association were aware of his personal circumstances and Mrs C had raised concerns with them about the lack of heating or hot water in Mr A’s property that weekend. The association’s response was to suggest that Mr A should contact family or friends to see if he could stay with them and/or use their washing facilities or use the local swimming pool over the weekend. They also supplied him with two temporary heaters.

Given the time of year, Mr A’s state of health and the fact that he had his son in his care, we considered Mr A’s situation to be an emergency. We found that the association had failed to properly appreciate the adverse effects the problem had on him and his son and had not taken all reasonable action to help him, and the recommendations we made reflect this.

Mr A also claimed reimbursement for additional gas usage, which the association refused based on the evidence he gave them. We were satisfied that this decision was reasonable, although we made a recommendation as we thought that the association should have been more proactive in communicating the findings to Mr A or Mrs C.

Recommendations

We recommended that the association:

• review how they communicated with Mr A and ensure any improvements identified are taken forward when dealing with tenancy repairs;
• issue Mr A with an apology for the failings identified; and
• pay Mr A the the maximum amount payable under their policy for unreasonable delay in completing an emergency repair.
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Summary

Ms C complained that the association had not reasonably investigated her complaint or offered her support during a neighbour dispute about noise disturbance. During our investigation we found that the association had not thoroughly investigated Ms C's complaint as they had not spoken to all the parties involved. We, therefore, upheld this part of Ms C’s complaint.

We found, however, that the association had followed their policy in supporting Ms C by offering her mediation and suggesting a practical solution, and we did not uphold this part of her complaint.

Recommendations

We recommended that the association:

• take steps to ensure that in future they keep better records to justify their decisions; and
• apologise to Ms C for the failings we identified.

Summary

Mr C complained about the care and treatment provided to his late mother (Mrs A) by her medical practice over a three-year period before she died in 2012. Mrs A had a complex medical history with many severe and debilitating conditions, which had been present for a number of years. Mr C raised a number of issues about the care and treatment provided for his late mother's conditions, including the treatment she received for leg ulcers, chronic kidney disease (CKD) and epilepsy, dietary issues, and nursing infection control methods. Mr C also complained that the GP had not communicated adequately with him and/or Mrs A.

Our investigation, which included taking independent advice from one of our medical advisers, found that the care and treatment provided to Mrs A was reasonable, appropriate and timely. The adviser reviewed Mrs A's medical records and found no evidence (other than one lapse in monitoring kidney function) that her care and treatment was deficient. National guidance on the management of CKD says that kidney function should be monitored at least every three months, and there was at one point a gap of six rather than three months in testing Mrs A's kidney function. There was no explanation for this gap but the adviser said that it had no detrimental effect on Mrs A's overall condition.

We did, however, identify failings in communication and upheld Mr C's complaint about that. We found that some of the written communications from the GP to other healthcare professionals contained subjective comments about Mrs A and her lifestyle. After Mr C complained to the practice, the GP acknowledged that the comments were not appropriate and apologised to Mr C for the distress this had caused him. The adviser agreed that the comments were not appropriate and said that they had detracted from the GP's otherwise professional approach to Mrs A's care. The adviser was also concerned that at times the GP appeared to make unilateral decisions about Mrs A's care without discussing them with her and/or Mr C.

Recommendations

We recommended that the practice:

• ensure that the GP reflects on their practice in relation to communication and discusses any learning points at their next appraisal.

Summary

Ms C complained that a consultation that her late husband (Mr A) had at his medical practice was unreasonable, and was unhappy with their handling of her subsequent complaint. Mr A had been suffering from a cough and loss of appetite, and was due to see his GP but as his condition had worsened he arranged an earlier emergency appointment. The GP examined him and diagnosed pneumonia. He prescribed an antibiotic (a drug used to fight bacterial infections), took blood samples for testing, completed a referral form for Mr A to take to his local hospital for a chest x-ray later that day and planned to review Mr A again in one week, or earlier if his condition deteriorated. Mr A returned home, and, sadly, his teenage son found him dead there some three hours later. Ms C complained to the practice in July and September 2013 and the GP responded in July and October 2013. Ms C was dissatisfied with the responses and asked us to look at her complaint.

Our investigation, which included taking independent advice from one of our medical advisers, found that there were some failings in the GP's actions and his recording of the consultation and we upheld this part of Ms C's complaint. The adviser said that although the GP had noted some observations, other key observations (such as blood pressure, temperature, and respiratory rate) were not recorded. The adviser said that, although there was no indication that Mr A needed to be immediately admitted to hospital, the lack of these recordings were of concern where a patient had been diagnosed with pneumonia.

The adviser also noted that guidance on the management of lower respiratory tract infections (SIGN 59), issued by the Scottish Intercollegiate Guidance Network (SIGN) recommended that two different, but complementary, types of antibiotic should be prescribed for patients with suspected pneumonia. SIGN 59 also recommended review in 48 hours rather than the one week planned by the GP. Overall, the adviser was of the view that immediate hospitalisation might not have changed the outcome for Mr A. He said that bronchopneumonia (acute inflammation of the lungs) - which was identified as the cause of Mr A's death - can progress rapidly and aggressively. Because of the failings in the records of the consultation, however, it was impossible to say this for certain. We noted that the practice had conducted a significant events analysis (a process of examining what happened and identifying what, if anything, went wrong and what, if any, remedial action is needed). The adviser said that this had picked up some, but not all, of the learning points from this complaint.

Our investigation found that the practice acknowledged and responded to Ms C's complaint within the timescales in their complaints process, which mirrored the national guidance on complaints handling. The first acknowledgement was incorrectly dated but the practice manager had apologised for this in a later letter. Although we appreciated that Ms C was not happy with the practice's handling of her complaint, we considered that the timescales had been met and all the issues she raised were addressed - albeit not to her satisfaction. Because of this we did not uphold this part of her complaint.

Recommendations

We recommended that the practice:

• ensure that the GP reflects on his practice in relation to these events, in particular in relation to SIGN 59 and clinical note-taking, and discusses any learning points at his next appraisal;
• review their procedure for conducting a significant event analysis to ensure that all learning points are recorded and addressed; and
• issue a written apology for the failings our investigation identified.

Summary

Mr C was referred to Dumfries and Galloway Royal Infirmary. After tests and surgery, it was confirmed that he had prostate cancer, and he was started on hormone therapy. Mr C later had a scan of his abdomen and pelvis, and it was thought that the cancer was spreading and that he might also have Crohn's disease (a long-term condition that causes inflammation of the lining of the digestive system). In the meantime, Mr C was required to have a bone scan.

Mr C complained that in carrying out his surgery, the board did not follow his wishes about the use of anaesthetic, and did not tell him about the use of hormone therapy, that he might have Crohn's disease or that he needed a bone scan. He also complained about the delay in arranging a colonoscopy (examination of the bowel with a camera on a flexible tube) and in receiving radiotherapy.

We obtained independent advice on the complaint from one of our medical advisers, who is a consultant urological surgeon (a specialist in problems of the urinary and male reproductive systems). We took all relevant information into account, including the complaints correspondence and Mr C's medical records.

Our investigation found that, in accordance with his wishes, Mr C had a spinal anaesthetic when he had surgery. However, in association with this, he had been given some sedation to relieve anxiety. Although Mr C said that he had been explicit about the use of sedation, there was nothing in his notes to confirm this and we did not uphold this complaint. Mr C also said that there was a delay in providing him with a colonoscopy and the evidence showed that after a scan (made as a result of an urgent referral and which suggested possible Crohn's disease) it was ten weeks before a request for a colonoscopy was made. It took a further month for this to be carried out and it was only then, when a diagnosis was confirmed, that radiotherapy could be considered. Mr C's complaint about delay was, therefore, upheld. Furthermore, we found nothing to show that hormone therapy had been discussed with him, or that he had been told that he could have Crohn's disease. We upheld his complaints about this as well as about general communication during his treatment. We also found that the board did not deal with his complaints within a reasonable timescale.

Recommendations

We recommended that the Board:

• apologise to Mr C for their failure to discuss his medication with him properly;
• ensure that relevant staff are made aware of the findings of this complaint and if necessary undertake relevant training;
• emphasise to relevant staff the importance of completing timely and appropriately detailed medical records;
• specifically apologise for their failure to discuss the possibility of Crohn's disease;
• ensure that relevant staff are reminded of their responsibility to keep patients appropriately informed of their medical condition;
• apologise for the delay in sending a response to the complaint.
• share my comments with the clinicians involved, including those involved in multi-disciplinary team meetings, to ensure that CT scan results are considered and acted upon promptly; and
• provide a written explanation about the two different decisions taken in relation to radiotherapy treatment.