Some upheld, recommendations

Summary

Miss C complained about various aspects of the way in which the council handled her complaint about comments in her daughter's school learning report. She said that she was given incorrect information that a discussion had taken place between staff at the school. She also complained that the council had not followed their complaints procedure and that the relevant head of service had not responded to an email.

We could find no evidence of what was discussed at the meeting where Miss C said the incorrect information was given, so we were unable to conclude whether this had happened and we could not uphold her complaint. There was evidence that the head of service had responded to her email, so we did not uphold that complaint. However, we upheld the complaint about complaints handling, as we found a number of areas where the council failed to follow their complaints handling procedure. This included that they did not appropriately recognise a stage 1 and stage 2 complaint (and so failed to meet the procedural requirements for each stage); they wrongly told Miss C that she had to meet with the school before she could complain; and they failed to record a meeting with Miss C which was part of their investigation into her complaint.

Recommendations

We recommended that the council:

• apologise to Miss C for the failings identified in the handling of her complaint; and
• feed back to education services staff the importance of complying with the council's complaints handling procedure.

Summary

Mr C owns a property in a building where the council administer a tenement management scheme (TMS). He was unhappy about the way in which the council billed him for various emergency works there. He also said that there was a delay in issuing invoices, the council did not ensure that invoices and final notices were printed and delivered in a timely manner, and that an incorrect date of payment received was referred to in responses to his complaint.

We made enquiries of the council, and received their comments and relevant paperwork. They accepted that there was an unreasonable delay in issuing the invoices, and we found that they did not appear to have told Mr C or other residents about their normal practice in dealing with these. We upheld this element of his complaint, as well as the incorrect date of payment being shown, which the council also acknowledged. In relation to Mr C's concerns about the printing and issuing of invoices and final notices, we saw no evidence that the delay was caused by the council's mail processing, and so we did not uphold this aspect of his complaint.

Recommendations

We recommended that the council:

• apologise to Mr C for the delay in issuing invoices for work undertaken at his property;
• review their invoicing procedure under the TMS, specifically in relation to the timely issuing of invoices and how residents are kept informed of when invoices will be issued; and
• apologise to Mr C for the errors in two of their letters.

Summary

Mr C moved into a property as part of a house swap. He said that it was not habitable because of damp, condensation and mould, and that this affected his and his family’s health. He told us that the council delayed in sorting out the problems and in responding to his complaints, and did not decant (temporarily move) them into another property. Mr C also complained that when he sent an insurance claim to the council for items damaged by damp and mould, the council and/or their insurers did not take full account of his evidence when they assessed the damage. He eventually moved his family to a privately rented property.

Our investigation found that, although no solution was found while the family were in the property, the council did not delay in trying to address the problems, so we did not uphold that complaint. We did uphold the complaint about decanting. The council told us that they considered moving the family, but decided it was not necessary because the type of work needed did not require this. They could not, however, show us evidence to support their decision.

Although we cannot look at the amount of an insurance award, we can look at the decision-making process that led to it. After a considerable amount of discussion with the council, in which both we and they took legal advice, they provided us with evidence about that process in relation to Mr C's claim. Having reviewed this, we took the view that the insurers had given the council all the relevant information. We did, however, find some failings and delays in responding to Mr C's complaints.

Recommendations

We recommended that the council:

• consider reviewing and adapting the documentation on requests for major repairs to allow for discussions and/or consideration of decanting to be recorded; and
• issue a written apology for the failings identified during our investigation.

Summary

Mrs C was concerned by the care and treatment provided to her late mother (Mrs A) by a GP at the medical practice. Mrs C was unhappy that although Mrs A was complaining of pain and discomfort in her leg, the GP failed to consider the possibility of deep vein thrombosis (DVT - a blood clot in a vein). A month later, Mrs A died of a bilateral pulmonary embolism (a clot in the blood vessel that transports blood from the heart to the lungs).

To investigate the complaint, we carefully considered all the relevant information (including the complaints correspondence and Mrs A's relevant clinical records) and obtained independent advice about Mrs A's care and treatment from one of our medical advisers, who is a GP. We found that the GP's treatment of Mrs A was reasonable and that the records showed why he had not suspected DVT, given the symptoms that Mrs A had at the time. The adviser said that a clinical picture may at the time not be as clear cut as when looking back and considering a matter with hindsight. In the circumstances, the adviser thought that it was reasonable for the GP not to consider DVT. We noted that, since Mrs C's complaint, the GP had clearly reflected on what had happened, and had reviewed local guidelines in attempt to prevent this happening again. Although we did not uphold the complaint, we made recommendations that the GP takes further steps to ensure good clinical practice.

We upheld Mrs C's complaint about complaints handling, as we found that timescales were not met when responding to her letters.

Recommendations

We recommended that the practice:

• ensure that the GP considers the available national guidelines and includes his reflection on these in his next annual appraisal;
• ensure that the GP considers how he completes his clinical notes and seeks advice to do so;
• make a formal apology for their delay in dealing with the complaint; and
• implement and adhere to NHS guidance on dealing with complaints.

Summary

Mrs C 's late husband (Mr C) had a pancreatic cancer operation, and afterwards agreed to have chemotherapy treatment (a treatment that uses medicine to kill cancerous cells). She complained that the board had failed to tell her husband the true survival rate after chemotherapy. She said that had he been given full information of the survival rates he would never have contemplated having chemotherapy, the side effects of which had made him very ill. Mrs C also said that the board failed to conduct scans at appropriate intervals during Mr C's chemotherapy, and she was concerned that there was a delay in starting treatment for blood clots in his lung.

As part of our investigation, we obtained independent advice from one of our advisers, who is a consultant clinical oncologist (cancer specialist). After taking this advice, we found that it was appropriate for the board to offer chemotherapy, which does improve survival after surgery for pancreatic cancer. Our adviser explained that communicating information about this cancer is an extremely sensitive area, as death rates from it are very high. Most oncologists do not give patients the blunt statistics unless specifically requested and, given General Medical Council guidance on how to communicate with patients, this is appropriate. However, we were satisfied that, in line with good medical practice, Mr C was made aware that there was a high risk of recurrence and of the high risk nature of the disease, and that, on balance, consent for the treatment was appropriately sought. Our adviser also explained that routine scanning has not been shown to improve the outcome in such circumstances. An earlier scan would not have altered the fact that Mr C struggled with the side effects of chemotherapy, nor would it have shown any earlier that the cancer had come back. The adviser confirmed that Mr C was reviewed properly, and according to the appropriate cancer guidelines. We did not uphold these elements of Mrs C's complaint about her late husband's treatment. However, we found no evidence that Mr C was told about the likely side effects of the drug, or that his tumour markers (substances found at higher than normal levels in the blood, urine, or body tissue of some people with cancer) remained slightly elevated, and we made a recommendation about this.

Finally, the board accepted that, when the blood clots were identified, Mr C was not told about this immediately. Our adviser said that the delay in starting treatment for them did not affect his overall condition. We were, however, critical that there was a delay, and upheld this element of Mrs C's complaint.

Recommendations

We recommended that the board:

• review the guidance and revised consent form to satisfy themselves that adequate information about side effects and the risk of disease recurrence is given; and
• take steps to ensure there is no recurrence of such a delay in commencing treatment.

Summary

Mr and Mrs C's son (Master A) has numerous complex medical conditions and needs constant care. They complained about a number of issues, including the care and treatment provided to their son during a series of admissions to hospital. Their concerns included that their son was not observed frequently enough, signs of deterioration were not detected, medication was not given at the right time, he developed infections and there was a general failure to assess his cognitive ability or communicate with him.

Having taken independent advice from our nursing and medical advisers we found that, generally, the medical and nursing care provided to Master A was appropriate and demonstrated effective management of his symptoms and conditions. We did not find evidence of many of the concerns raised by Mr and Mrs C. However, we upheld the complaint on the basis that there was evidence that Master A had been left unattended in a cubicle and, as a child with a tracheostomy (an artificial airway), this was a potentially unsafe practice.

Mr and Mrs C also complained that the board failed to provide appropriate home nursing care for their son. However, we did not uphold that complaint as we found that the care package provided was in line with national guidelines for children with exceptional healthcare needs. We also found no evidence to reconcile a difference in opinion between the board and Mr and Mrs C about the number of nursing shifts that had not been covered.

Finally, Mr and Mrs C had complained that they were not involved in discussions and decisions about their son's care, and that staff at the board had victimised and bullied them. Again, we could not find evidence of this. We did find evidence of good levels of communication from the clinical and nursing staff involved in Master A's care - in terms of updating Mr and Mrs C, taking into account their views, and discussing care and treatment. Although we did not uphold these complaints, we pointed out to the board that some of the steps they had taken during the latter stages of their contact with Mrs C demonstrated potentially unreasonable restrictions.

Recommendations

We recommended that the board:

• apologise to Mr and Mrs C and Master A for failing to ensure Master A was supervised at all times; and
• remind staff who may be caring for children with tracheostomy of the need to ensure constant supervision of these children, with reference to the guidelines provided by Great Ormond Street Hospital.

Summary

Mrs C's late mother (Mrs A) was admitted to Hairmyres Hospital on numerous occasions during 2012 due to heart problems. She was admitted from mid September to early October with unstable angina and, following admission to another ward a week later, she was under the care of a cardiologist (heart specialist) who thought she might have a chest infection and said that antibiotics should be prescribed. Mrs C said that while on this ward Mrs A was unable to eat and was prescribed large amounts of medication for heartburn and acid reflux. On the day of her discharge, Mrs A was seen by a dietician who noted that her food intake was poor and that Mrs A disliked hospital food. Antibiotics were not prescribed. Shortly after discharge, Mrs A's GP diagnosed her with a chest infection, and prescribed antibiotics. Mrs A was re-admitted to hospital by emergency ambulance three days after being discharged and died six days later. The death certificate stated the cause of death as infection of unknown origin, acute kidney injury (abrupt loss of kidney function), chronic renal impairment (gradual loss of kidney function), recent myocardial infarction (heart attack) and ischaemic heart disease (when the arteries narrow).

Mrs C complained that when Mrs A was discharged, she was already suffering from the infection that contributed to her death, and that communication by staff was inadequate. She was also concerned about what she described as the appalling meals being served to vulnerable people and said that it was unacceptable that families had to feed their relatives in hospital.

We found the board unreasonably failed to carry out a test and to prescribe antibiotic treatment, so we upheld this complaint. However, we noted the independent advice of our medical adviser who said that, although not prescribing antibiotics was a significant medical failure, even if they had been prescribed earlier they would not have had a significant effect on the outcome. Nonetheless, this caused a great deal of distress to Mrs C who was left with uncertainty about its impact on Mrs A's death. Problems with communication also meant that it appeared Mrs C and her family were unaware of how unwell Mrs A was during her second last admission to hospital.

In relation to the complaint about dietary requirements, we found no evidence of any shortcomings in respect of food and nutrition. Our investigation found that Mrs A was referred to a dietician at the right time, was seen within a reasonable time and that food and fluids charts were started when appropriate.

Recommendations

We recommended that the board:

• carry out a significant event analysis to address why a c-reactive protein test was not carried out, why antibiotics were not commenced and the communication failure; and
• apologise to Mrs C for the failures identified.

Summary

Mr C, who is a Member of Parliament, complained on behalf of his constituent (Mrs B) about the care and treatment that her father (Mr A) received at Kilsyth Victoria Cottage Hospital. The hospital is a rehabilitation facility, and medical cover is provided by GPs from a local medical practice. Mr A was admitted to the hospital because of general weakness and after having fallen at home. He remained there for approximately six weeks before being discharged to a nursing home. Mrs B was dissatisfied that her father was given dihydrocodeine (strong pain relief) for a chest infection, which she felt made him unwell. Mrs B also felt that her father was discharged from hospital too early.

In responding to the complaint, the board explained that the dihydrocodeine had been prescribed for pain relief and not for a chest infection. They also said that Mr A's discharge was appropriate as his observations (including his temperature, blood pressure, pulse and oxygen levels) were satisfactory.

We took independent advice on Mr A's case from our GP medical advisers. Our investigation found that the records made by medical staff about why dihydrocodeine had been prescribed were poor. The drug prescribing sheet recorded that it was prescribed for pain, but there was no record showing where the pain was located or how bad it was. However, the board provided further evidence that Mr A had sustained a fracture after falling several months earlier and was prescribed dihydrocodeine four times a day for this, indefinitely. We concluded that it was reasonable to prescribe dihydrocodeine and that the dosage was appropriately changed to an 'as required' basis, and so we did not uphold this complaint.

In terms of Mr A's discharge from hospital, we found a lack of detailed entries by the GPs to show that they assessed Mr A's condition properly during his admission, and that he was not reviewed by a GP on the day he was discharged, despite having had a high temperature for three days. We were critical of this, and also noted that although the board told us that Mr A's observations were satisfactory they also said that they were not within his usual range. We, therefore, upheld this complaint as we could not conclude from the evidence that Mr A's discharge was reasonable.

Recommendations

We recommended that the board:

• emphasise to GPs at the hospital the necessity of clearly recording the reasons for prescribing medication in the clinical records, and that the nursing staff accurately record a patient's level of pain;
• apologise to Mr C for the failings identified in our investigation;
• draw to the attention of medical staff at the hospital the importance of ensuring discharge paperwork has been checked and signed by medical staff; and
• carry out an audit of clinical records at the hospital to ensure the medical staff are recording sufficient information regarding a patient's medical history, general condition and examinations carried out.

Summary

After an accident, Mr C was admitted to the emergency department at University Hospital Ayr with a suspected broken collarbone. He was in severe pain and had been given pain relief by ambulance paramedics. The medical records showed that he was placed in an 'urgent' triage category, with a target time of having a medical assessment within one hour of admission. (Triage is the process of deciding which patients should be treated first based on how sick or seriously injured they are.) However, Mr C was not assessed by an orthopaedic doctor (dealing with conditions involving the musculoskeletal system) until several hours later. The doctor ordered an x-ray and while at the radiology department, a healthcare professional adjusted Mr C's position and he felt a shooting pain. After the x-ray was taken, Mr C said the doctor told him that he had no broken bones, and that the arm might have been dislocated, but popped back into place. Mr C was told to take pain relief and soak in a hot bath, and was discharged with pain relief medicine an hour later. Nine days later, he returned to work. The next day, while involved in manual labour, he suffered a further injury and went back to the emergency department. Tests showed that he had a fracture of the neck of the shoulder blade.

Mr C complained about the time it took before he saw a doctor on his first visit, and said that the doctor did not make him aware of the severity of his injury. Mr C also said that although the board said in their response to his complaint that the use of a sling had been discussed with him and that he had a full range of movement when he left hospital, he did not agree with this. He said that he had felt relief when he returned from x-ray, but this was due to the medication. Mr C also complained about the board's complaints handling.

After taking independent advice from one of our medical advisers, we found that Mr C's wait was well within the national target timescale (four hours from admission to completion of management), particularly as dislocation of the shoulder was not initially suspected and there was no evidence to support that it had been dislocated. We also noted that, while Mr C was waiting, the emergency department had to deal with three emergencies that required more immediate medical attention than he did. Our adviser said that the care and treatment and discharge advice Mr C received was reasonable. An x-ray was performed (the results of which the adviser said were normal), and an assessment of the range of movement in the shoulder was carried out and noted. The advice Mr C received when he was discharged was, therefore, reasonable in light of the evidence of his injury, as was the doctor's decision not to provide a sling. In view of all of this, we did not uphold Mr C's complaints about his care and treatment.

We did, however, uphold the complaint about the board's complaints handling. We found that there were delays and that they did not respond all the elements of Mr C's complaint. We were also concerned that Mr C was not told that he could approach us (as he should have been) when the board contacted him about the delay in responding to his complaint.

Recommendations

We recommended that the board:

• review their complaints handling process in the light of our findings, and raise the shortcomings identified with relevant staff; and
• apologise to Mr C for their failure to fully address the complaint he raised.

Summary

Mr C complained that Business Stream delayed issuing their invoice to him and was unhappy with their charges. Business Stream originally billed Mr C for water, waste water and drainage. However, when his landlord told them that Mr C paid water charges to him they amended their invoice to drainage charges only. Mr C was unhappy that the drainage charges were based on his property’s rateable value rather than his actual usage.

In terms of the time taken to issue their invoice, Business Stream confirmed that their wholesaler, Scottish Water, had given them Mr C’s details in December 2010. However, Business Stream did not take the necessary steps on receipt of this information and Mr C’s account was not opened until November 2012, when they sent him an invoice backdated to December 2010.

Our investigation found that although Mr C might not have known that Business Stream were the default provider of water services, that did not in itself make their charges invalid. However, we saw no evidence that Business Stream took any significant action when they were given Mr C’s details in December 2010 and on balance we upheld his complaint about the delay in issuing the invoice. In terms of charges, Business Stream showed us that they had acted in accordance with their policy by invoicing Mr C on the basis of his rateable value, and we did not uphold his second complaint.

Recommendations

We recommended that Business Stream:

• apologise to Mr C for the delay in issuing their initial invoice.