Some upheld, recommendations

Summary

Mrs C complained about the care given to her husband (Mr C) during two admissions to St John's Hospital. In particular, she was unhappy with the content of the discharge letters and complained that the content of these had adversely influenced her husband's treatment. She was also unhappy with the board's handling of her complaints about this.

As part of our investigation, we obtained independent advice from one of our advisers, who is a consultant physician in acute internal medicine. After taking this advice we found no evidence that Mr C had not received appropriate care during the admissions and that there was no evidence that his treatment was in any way influenced by the discharge letters. Our adviser said that the discharge letters were medically appropriate, and that Mr C had been thoroughly examined, investigated and diagnosed before each discharge. The decisions to discharge him were also reasonable and appropriate.

The board accepted that, while they had responded to Mrs C's initial complaint in line with their complaints procedure, they had not met their time standards in responding to her second complaint, and they apologised for this. We also found that although, in response to Mrs C's continuing concerns, they had obtained a second opinion about Mr C's clinical care, they had failed to address all the issues she raised in her complaint.

Recommendations

We recommended that the board:

• remind staff of the need to adhere to the timescale for responding under the NHS complaints procedure; and
• ensure that complaint responses address the issues raised in a complaint.
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Summary

Mrs C complained about the treatment she received from her dentist when she attended with a broken tooth. She complained that the dentist removed a remaining part of her tooth without her consent, that he used a local anaesthetic, which she had asked not be used, and that he performed root canal treatment and inserted a crown poorly. She also complained that her complaint about this was inadequately handled.

After taking independent advice from our dental adviser we found that the remaining part of Mrs C's tooth could not be saved and it was reasonable for the dentist to remove it. No formal written consent was required for this, but we noted that the dentist did not seek verbal consent, which would have been good practice. We were satisfied with the choice of local anaesthetics he used and found that an alternative was used because Mrs C said she had had an adverse reaction to the standard anaesthetic. However, we were critical that the dentist did not properly document his use of this, and of the work he carried out to prepare Mrs C's tooth for a crown. The root canal filling did not fill the entire root, leaving space for infection. Furthermore, the dentist perforated the filling material with the post that was inserted to hold the new crown. We upheld Mrs C's complaints about these aspects.

We also found that Mrs C's complaint was not handled in line with the complaints procedure in place in the dentist's practice at the time. However, that procedure was not fit for purpose and Mrs C's complaint was actually handled in line with the level of service that we would expect patients to receive. As such, we found the complaints handling to be reasonable.

Recommendations

We recommended that the dentist:

• apologise to Mrs C for the issues highlighted in our decision letter;
• reimburse Mrs C any charges for her dental treatment on the dates in question;
• take note of our adviser's comments about Mrs C's root canal treatment, post preparation, and the recording of the use of local anaesthetics with a view to identifying any points of learning for future treatment; and
• ensure that his current procedure for handling complaints is in line with NHS Scotland guidance.

Summary

Mr C complained on behalf of his wife (Mrs C) and his son (Mr A) that the mental health care and treatment the board provided was inadequate. In particular, he said that after being placed on the waiting list, the board delayed in providing his wife with a mental health assessment, cancelled this meeting without explanation and that the replacement meeting (and others) were not specific to her needs. He also said that they did not provide Mr A with the psychiatric support he needed and that, despite a number of appointments, they failed to get to the root of his problems and provide a proper diagnosis. The board, however, said that Mr A did not have a mental illness. Mr C also said that the board had released confidential information about the complaint to Mr A, and failed to deal properly with all of his complaints.

In investigating this complaint, we carefully considered all the complaints correspondence and relevant medical records. We obtained independent advice from a consultant forensic psychiatrist, which we also took into account.

Our investigation found that there was a delay in providing Mrs C with psychological treatment. The eventual appointment was then cancelled without explanation, and replaced by a form of treatment about which Mrs C had no input. Our adviser said that the way the treatment was carried out was not patient focused and did not appear to have any benefit.

During the same period of time, Mr A was provided with reasonable care and treatment. A thorough assessment was completed and an appropriate treatment plan was established. However, Mr A was given information about correspondence from Mr C without Mr C's permission. When Mr C complained about this, the board delayed in dealing with his complaint, contrary to their stated complaints handling process.

Recommendations

We recommended that the board:

• make a further apology to Mrs C for the failures our investigation identified;
• emphasise to relevant staff that the treatments they offer to patients should be patient centred and take the patient's (and carer's) views into account in providing this care and treatment;
• emphasise to relevant staff that psychological interventions should follow an established model to ensure focus;
• emphasise to staff concerned the importance of seeking appropriate permission before releasing 'third party' information;
• apologise to Mr C for their shortcomings; and
• emphasise to staff the importance of following their complaints procedure.

Summary

Mrs C complained about the care and treatment that her mother (Mrs A) received in the Glasgow Western Infirmary. Mrs A was admitted to hospital after a fall at home. She was treated for a chest infection, but tests found that she also had a cancerous tumour on her lung which had spread to her liver. Clinical staff decided that active treatment for this was not appropriate and that palliative care (care provided solely to prevent or relieve suffering) should be provided. Although discussions took place around potential discharge options for Mrs A, her condition deteriorated and she died in the hospital within two weeks of her admission. Mrs C complained about the nursing care that Mrs A received, discharge planning, nutrition and hydration and communication from staff.

We took independent advice on this case from a medical adviser and a nursing adviser. The clinical records indicated that Mrs A had varying levels of confusion throughout her admission, which made it difficult for staff to assess the extent to which she could consent to treatment or take part in discussions about her care. Generally we were satisfied that Mrs A's formal consent was not needed for the tests that she underwent, and we found that staff clearly recorded information about her preferences in terms of discharge arrangements and what she wanted to know about her diagnosis. We found that Mrs A's wishes about this were ultimately respected, and that all of the clinical treatment she received was appropriate. However, we were critical of some aspects of her nursing care. We found that staff failed to properly assess what additional support Mrs A might have needed during her admission. Mrs A had experienced problems early in her admission and we found that staff later kept drinks and snacks out of her reach to avoid spillages, rather than providing suitable utensils to help her eat and drink when she wished. We took the view that help with this might have made her time in hospital more comfortable, and that failure to provide this was poor practice. Overall, we found that the board failed to take adequate account of Mrs A's specific personal needs and upheld this complaint. We also upheld Mrs C's complaint that the board's responses to her formal complaints were unreasonably delayed.

We did not, however, uphold Mrs C's complaint about communication. Although we recognised that she was unhappy with the level and quality of communication from staff, we generally found this to have been reasonable. That said, we were critical of the board for failing to provide a private room for discussions about Mrs A's diagnosis.

Recommendations

We recommended that the board:

• apologise to Mrs C for the issues highlighted in our investigation;
• provide us with up-to-date details of the action they have taken to improve nursing staff's compliance with completion of patient admission and assessment documentation, including the provision of suitable utensils for patients with special needs;
• remind relevant staff of their responsibilities in obtaining patient consent to discuss care and treatment with family members;
• apologise to Mrs C for their poor handling of her complaint; and
• take steps to ensure their investigations and responses are not unreasonably delayed.

Summary

Mrs C complained about the care and treatment her late mother (Mrs A) received at the Western Infirmary, Gartnavel General Hospital and Victoria Infirmary. Mrs A was initially admitted to the Western when she fell and fractured her hip. She had a hip replacement operation and was transferred to Gartnavel. Mrs C said that as Mrs A had developed pressure ulcers on her foot she was discharged home too soon, only to be admitted to the Victoria two days later, having fallen again. Mrs C had further concerns about the care of the pressure ulcers and a lack of physiotherapy, and said that her mother was again discharged too soon because she then had several more falls and had to go back to hospital.

We took independent advice on this case from three of our advisers (specialising in nursing, physiotherapy and acute medicine for older people). Mrs A had been assessed as being at high risk of developing pressure ulcers, but we found no evidence that nursing staff at Gartnavel and Victoria hospitals monitored her for this. Although a special pressure relieving boot was provided after the pressure ulcer was identified, staff did not start a wound chart to monitor and assess the ulcer as they should have done. We concluded that the nursing care in both these hospitals fell below a reasonable standard, and was not in accordance with guidance issued by NHS Quality Improvement Scotland. The board also acknowledged a delay of around 12 days in Mrs A starting physiotherapy in the Victoria after she had a short period of illness. We said that this was unreasonable, and prolonged her stay there.

In relation to Mrs A's discharge from Gartnavel, our adviser said that in itself a fall shortly after discharge would not mean the discharge was inappropriate. Although we were highly critical of the board for having lost some of Mrs A's medical records, we decided that evidence from the physiotherapy, occupational therapy and nursing records showed that Mrs A's mobility was reasonably assessed, and no significant changes were noted before she was discharged. In addition, there was evidence showing that the second discharge from the Victoria was appropriate and referrals had been made for Mrs A to continue to have her needs assessed at home.

Recommendations

We recommended that the board:

• audit a sample of patient records at Gartnavel General Hospital and the Victoria Infirmary to ensure skin risk assessments are being conducted, and appropriate care plans are in place in accordance with NHS Quality Improvement Scotland guidance;
• ensure patients in the Victoria Infirmary are promptly reviewed by physiotherapy after a period of sickness;
• apologise to Mrs C for losing Mrs A's medical records and for failing to identify that they were missing when responding to the complaint;
• review their practice on the storage of patients' medical records to prevent a recurrence of failing to store medical records securely; and
• ensure patients are referred in good time to the appropriate community rehabilitation team in preparation for discharge from Gartnavel General Hospital.

Summary

Ms C, a former student, said that the university had not made reasonable attempts to resolve issues she raised about resources. She complained to them about this, and about their decision not to accept future applications from her on the grounds of inappropriate conduct. The university did not uphold her complaints and she complained to us.

Our investigation found that the university had tried to informally resolve the issues she raised and had carried out a thorough investigation. However, they had not given her the opportunity to respond to the allegations about her conduct, and had not followed their disciplinary procedure. We, therefore, found it unreasonable that the university decided to refuse her applications without giving her the opportunity to respond to these allegations.

Recommendations

We recommended that the university:

• consider either extending the scope of the existing student disciplinary policy to include a broader range of unreasonable actions, or implement a specific unreasonable actions policy to assist staff in managing communications with students where necessary; and
• apologise for refusing to accept future applications on the basis of behaviour when they had not followed their own procedures for managing student behaviour.

Summary

Mr C, who is a prisoner, complained that the Scottish Prison Service (SPS) were not following their book-purchasing procedures. He then complained to us, but our investigation showed that this was not the case.

He also complained, however, that the internal complaints committee (ICC) chair did not meet him before the ICC heard his complaint. This hearing is part of the SPS complaints handling process. At that stage, a prisoner may request specific witnesses to be called for the hearing. Prison rules state that an ICC chair can refuse a witness if they have discussed this with the prisoner and are reasonably satisfied that the evidence the witness would be likely to give would be of no relevance or value in considering the complaint. In such a case, the chair must tell the prisoner of this decision before the hearing. However, there is no requirement on ICC chairs to produce any written note, either to confirm that a discussion took place before the hearing or to record what was said at it. This lack of evidence can make it difficult to consider such complaints. In this case, we concluded that there had not been a pre-ICC hearing and that the ICC chair had not, therefore, complied with the prison rules.

We were concerned that this difficulty in determining complaints where there is a lack of evidence about pre-ICC discussions was a recurring theme in complaints to us. We had previously made recommendations to the SPS to try to address this problem and had asked the SPS to tell us what they intended to do to address the issue. Given that recent recommendation, we decided to make no further recommendation about that on this complaint.

Recommendations

We recommended that the SPS:

• apologise to Mr C for the shortcomings our investigation identified.

Summary

Mr C complained to the Care Inspectorate about a care provider used by his mother. He was not satisfied that they investigated his complaint effectively, as he said they had not responded to all his concerns. He also had ongoing correspondence with them after they completed their initial investigation and complained that they did not handle this reasonably.

Our investigation found that the Care Inspectorate had thoroughly investigated the issues Mr C raised in his complaints, and responded to each of them. They did not respond to every individual query that he brought to them, but we considered that they took a reasonable approach to their handling of his complaints.

We did, however, consider that after their initial investigation they were not clear enough in their correspondence with Mr C. The should have provided him with consistent information about his complaint and what to do when he was still not satisfied with the outcome.

Recommendations

We recommended that the Care Inspectorate:

• remind staff to explain to complainants at the outset the remit of an investigation, and clarify the ability to respond to any questions or concerns raised; and
• apologise to Mr C for the lack of clarity in their decisions and in correspondence with him in relation to the information he requested.

Summary

Mr C complained that the council left his daughter (Ms A) without a smoke detector for some time following a repair to her ceiling, and that this had endangered her life. He was concerned that they had failed to recognise the importance of his initial complaint about this, which he made as soon as he became aware of the situation. In responding to his complaints about this, and other matters, he said the council had not answered his specific points and that he had not been able to speak to the chief executive.

The chief executive, in responding to the complaint, had said that a tradesperson left a card when they could not gain access to the house, and Ms A had not responded. However, the council told us that they had now established that this information was incorrect and no such card was left. We upheld Mr C's complaint about the failure to ensure that a smoke alarm was fitted, and made two recommendations for improvements to the procedure for gaining access to a tenant's property when earlier attempts have been unsuccessful.

We found that the council had addressed all the issues Mr C had raised, within the 20 working days set out in their complaints handling procedure. We confirmed that the chief executive was correct in telling Mr C that it is not possible for him to deal personally with every complaint addressed to him, and confirmed we would not expect him to speak directly to a complainant except in very exceptional circumstances. We did not uphold the complaint about complaints handling.

Recommendations

We recommended that the council:

• apologise to Mr C for the inaccurate information in the chief executive's letter about the leaving of 'no access' cards at Ms A's home and his reliance on circumstantial evidence to support that information;
• review and revise, if appropriate, the process/procedures for what a tradesperson who cannot gain access to a tenant’s home should do given that, as access to the property was presenting a difficulty, the matter should have been referred to the local housing office; and
• provide evidence to show the change in their procedures which reflects that where a hard-wired smoke detector needs to be disconnected to enable repair works, and the works cannot be completed in a single visit, a battery-operated smoke detector will be fitted as a temporary measure.

Summary

Ms C complained that the council had not properly investigated her complaints after she raised a number of concerns with them. The complaints we looked at were not about the underlying issues, but were about how the council handled Ms C's complaints about them.

The evidence we saw indicated that the council had considered, investigated and replied to Ms C through their complaints procedure, so we did not uphold her complaint about the investigation. However, it was clear that they had not responded within the appropriate timescales and, in the absence of evidence to indicate why this had happened, we upheld that aspect of her complaint.

Recommendations

We recommended that the council:

• confirm to us the steps they have taken to ensure acknowledgements are issued more promptly.