Some upheld, recommendations

Summary

Mr C, who is a prisoner, complained that the board refused to prescribe him suboxone (a prescription medication used to treat opiate addiction). Mr C had been prescribed methadone, but he felt that suboxone would assist in his final recovery from drug addiction and told the board that he wanted to switch to this. However, the board told him that there was no absolute right for any patient to receive a specific form of treatment simply because they requested it. They said that what was important was the prescriber's clinical judgement that a treatment choice was appropriate for the individual, and whether they were at the correct stage of their recovery to support a change of treatment.

In their response to our enquiries, the board said that all patients within the addictions service are regularly assessed using both national and local guidance. They said that some patients may not be offered the drug of their choice, and that Mr C was receiving the most appropriate treatment for his clinical condition. They also explained that they had produced new guidance for prescribing suboxone in the prison after Mr C complained.

We did not uphold the complaint, as we found that the board had acted reasonably in deciding to maintain Mr C on methadone and that this decision had been based on a clinical assessment.

Mr C also complained that the board had not provided a written response to his 'feedback, comments or concerns' form. During our investigation the board accepted that there were failures in their communication with Mr C, and apologised for this.

Recommendations

We recommended that the board:

• formally apologise to Mr C for the handling of his complaint.

Summary

Mr C complained about the board's treatment of his daughter (Miss A). When Miss A was two, she drank some of the contents of a bottle of Calpol (paracetamol-based medicine) and was taken to the emergency department at the Victoria Infirmary. National guidance for paracetamol poisoning requires staff to calculate the amount of paracetamol ingested (taken) per kilogram of the person's body weight (calculated as mg/kg). If the patient is thought to have taken more than 75mg/kg of paracetamol, blood tests should be taken four hours after ingestion to check for paracetamol levels. If more than 150mg/kg has been taken, the patient should be treated immediately with n-acetylcysteine (a drug used to treat paracetamol poisoning) without waiting for blood test results. Based on the available evidence, staff estimated that Miss A had likely taken less than 75mg/kg of paracetamol, and she was discharged home with advice to return if she started to vomit. Later that evening, Miss A vomited and was taken back to the hospital. Staff re-estimated how much paracetamol she might have ingested. Believing she might have had more than 100mg/kg, they arranged for her to be transferred to the Royal Hospital for Sick Children. There, staff assumed the worst case scenario and immediately started treatment with n-acetylcysteine. Blood tests taken later showed that she had ingested a non-toxic amount of paracetamol.

Miss A had a severe anaphylactic (allergic) reaction to the n-acetylcysteine. This was treated successfully, but she was kept in hospital, and later had a seizure. This affected her eyesight. Miss A was diagnosed with cortical blindness (blindness caused by damage to the brain). Mr C complained that the board's staff did not do enough to establish the extent of his daughter's paracetamol poisoning when she first went to the Victoria Infirmary. He felt that, had a blood test been carried out then, his daughter would not have required treatment with n-acetylcysteine, would not have had an allergic reaction and would not have developed cortical blindness.

We found that the national guidance recommended that patients should only be discharged when there is absolute certainty that they have not ingested more than 75mg/kg of paracetamol. After taking independent medical advice on Miss A's case, we did not consider that it was possible for staff to be absolutely certain and as such, blood tests should have been carried out to confirm how much paracetamol she had ingested. This would have shown that she had ingested a non-toxic amount; n-acetylcysteine treatment would not have been required and her anaphylactic reaction would have been avoided. We also found that the n-acetylcysteine had been administered incorrectly, with the first dose being administered over a period of 15 minutes. The national guidance had changed some months earlier and it should have been administered over one hour, specifically to reduce the likelihood of allergic reaction. We were critical of the board's processes for sharing medication guidance updates with clinical staff.

We accepted advice, however, that Miss A's anaphylactic reaction was not the most likely cause of her subsequent seizure and cortical blindness. Whilst this could not be ruled out entirely, we accepted that a virus that Miss A had been suffering from was the more likely cause.

We also investigated a further complaint from Mr C about delays to the board's handling of his formal complaint, and were satisfied that they handled it in line with their complaints procedure.

Recommendations

We recommended that the board:

• apologise to Miss A and her family for their poor treatment of her suspected paracetamol poisoning; and
• review their mechanisms for communicating updated guidance to ensure that staff in all departments are aware of, and working to, the most up-to-date guidance at all times.

Summary

Mr C complained on behalf of his uncle (Mr A) for whom he holds power of attorney (a legal document appointing someone to act or make decisions for another person, with their permission) as Mr A suffers from dementia. Mr A also suffers from a condition that affects his spine and neck and can cause loss of function in the upper limbs. Because of where he lives, Mr A had to travel, accompanied by Mr C, to another health board area for orthopaedic assessment (assessment of conditions of the musculoskeletal system) and treatment. Mr C complained that an operation was cancelled without any alternative treatment being offered or discussed; that a six-month follow-up appointment did not take place until twelve months after Mr A's cancelled operation; that some expenses incurred were not refunded; and the board failed to respond to complaints within a reasonable timescale.

Mr A was assessed by a locum (temporary) consultant orthopaedic surgeon in June 2012 and was told that he needed life-saving surgery for his condition. His operation was scheduled for August 2012, by which time a permanent consultant orthopaedic surgeon had been appointed. When Mr A went to hospital for the operation he was reviewed by that surgeon, who took a different view from the locum and said that more conservative, non-surgical management of Mr A's condition was appropriate. Mr A was told this without his nephew being present, despite Mr C's specific request that no clinical discussions take place without him there. Mr A was discharged the same day and sent home with a promise of a follow-up appointment in six months' time.

Our investigation included taking independent advice from an orthopaedic surgical adviser, who was of the view that the decision not to operate and to review Mr A again in six months was reasonable. The adviser said that the threshold for surgical intervention can vary between consultants, and when a patient is managed by more than one consultant this kind of experience is always a possibility. The adviser was of the view that neither the locum's nor the surgeon's approach was wrong, and we did not uphold the complaint about the cancellation.

We did, however, uphold Mr C's other complaints. When no follow-up appointment date was given, Mr C chased this up but it was not until after he contacted us in April 2013 that an appointment was arranged. This eventually took place in August 2013 - almost a year after the operation was cancelled. Although our adviser was able to reassure Mr C, Mr A and us that Mr A's condition had not progressed in that time, and so the delay had not had a detrimental effect on his condition, we found this delay unacceptable.

On the matter of the expenses, the board acknowledged that as the operation was cancelled at such a late stage Mr C and Mr A had incurred unnecessary expenses, and told us that they were prepared, as a gesture of goodwill, to refund these. However, this did not happen until we chased this up some eight months later.

On the final complaint, our investigation found that the board had not responded to Mr C's complaints within the national or local guidance for complaints handling in place at the time. The board acknowledged this and apologised to Mr C about the handling of his complaints.

Recommendations

We recommended that the board:

• ensure, and provide the Ombudsman with confirmation, that all staff involved in this complaint are made aware of the importance of adhering to the national and local guidance on dealing with patients suffering from dementia;
• consider putting in place a monitoring system for orthopaedic appointments to prevent a recurrence of such a delay in future;
• urgently take action to ensure that Mr C and Mr A's applicable expenses are now refunded;
• ensure that all relevant staff are reminded of the need to keep complainants informed where there are unavoidable delays in the complaints process in accordance with the NHS Complaints Handling Guidance; and
• issue a written apology for the failings identified during this investigation.

Summary

Mrs C's mother (Mrs A) has a long history of various mental health illnesses, including dementia. In August 2008, Mrs A was detained in the Royal Cornhill Hospital under the Mental Health Act. She was there until January 2010, although planning for her discharge began in early 2009. Mrs A was initially discharged to a care home for respite care with a view to going to live with one of her daughters, but this turned out not to be possible, and she was transferred to another care home, where she currently resides.

Mrs C complained that the board failed to carry out appropriate assessments on Mrs A's eligibility for funding for NHS continuing health care (continuing care). She also complained that when she lodged an appeal about the decision not to grant funding, the board unreasonably failed to provide evidence to support their decision.

Our investigation, which included taking independent advice from a specialist adviser on continuing care, found that appropriate assessments of Mrs A's physical and psychiatric conditions were undertaken while she was in hospital and before her discharge, and we did not uphold this complaint. The adviser said that the assessments were used to inform the decision-making process, in line with national guidance on the application of decisions on funding for continuing care, and that there was no evidence that the decision-making process was not properly carried out.

We did, however, uphold the complaint about the information provided to Mrs C after the appeal decision, as we found that insufficient information was provided to Mrs C at both the initial decision-making stage, and the appeals stage. The adviser said that the lack of information provided to Mrs C meant that the process had not been clear and open as required by the national guidance.

Recommendations

We recommended that the board:

• review their NHS continuing health care decision-making process to ensure that it complies with the guidance, in particular in relation to the information provided to patients, carers, and relatives;
• provide Mrs C with all the relevant supporting information upon which the inital decision and the appeal decision were based; and
• issue a written apology for the failings identified during this investigation.

Summary

Mr C, who had previously surrendered his driving licence for medical reasons, complained that a consultant at Dumfries and Galloway Royal Infirmary delayed in writing a report for the Driver and Vehicle Licensing Authority to confirm that he was medically fit to drive. Mr C also complained about the board's response to his complaint.

We found there was an unacceptable delay in writing the report in support of Mr C's licence application, and upheld this part of his complaint. The board explained that there was an administrative backlog, and that the report had to be written by a doctor (as opposed to an administrator). Mr C did not believe this because he was not told about the backlog when he spoke to his consultant's secretary. Our investigation established that there was a backlog, and that the report was something that only a doctor could deal with. The consultant had explained in an internal email that they could not easily delegate completion of the report, due to lack of medically qualified support.

While we took the view that it might have been helpful if the board had given Mr C some of this additional information, we did not uphold his complaint about their response, as we found that it was acceptable. The board also told us they would have expected Mr C to have been kept informed when there was a delay in replying. This did not happen, and the board did not tell us what they have done to stop this happening again. So, although we did not uphold that part of Mr C's complaint, we made a recommendation about this.

Recommendations

We recommended that the board:

• ensure that relevant secretarial and administrative staff keep members of the public updated where there is a delay in dealing with correspondence.

Summary

Mrs C complained about the care and treatment provided to her late brother (Mr A). She said that in summer 2012 his GP urgently referred him to the ear, nose and throat (ENT) department at University Hospital Crosshouse. Mr A had a history of heart disease and ulcers but over recent months had been having difficulty swallowing. An ENT consultant arranged tests, the results of which appeared to be normal, and the consultant wrote to Mr A reassuring him and saying that she did not intend to follow him up. However, Mr A's symptoms did not improve and he was seen again as an emergency in October 2012. He was found to have a large mass in his neck. This was later confirmed to be an extensive tumour, and Mr A died some seven months later. Mrs C complained that Mr A's care and treatment were inadequate and that there had been a lack of urgency to progress this and a failure to diagnose him.

We obtained independent advice on the complaint from one of our medical advisers, and took all the available information into account, including Mr A's relevant clinical records and the complaints correspondence.

Our investigation found that Mr A's lifestyle indicated he was at very low risk from this type of illness and confirmed that initial tests did not reveal anything untoward. It was also clear, however, that although the ENT consultant had later reassured Mr A about his condition, this proved to be a false reassurance. The consultant had since told the board that, with hindsight, it would have been better if she had arranged to see Mr A again. Our adviser agreed that this would have been advisable and said that, when deciding whether to see him again after the tests, the ENT consultant only had sight of a copy of her letter to Mr A's GP and not his notes, in which it was clear she had noted that she intended to see him again. Her letter did not accurately reflect what she had written in the notes and what she had intended, and so we upheld this complaint. Mrs C also complained about the board's response to her written complaint but we did not agree with her that this was inappropriate.

Recommendations

We recommended that the board:

• apologise to Mrs C for the additional stress and anxiety caused; and
• ensure that the ENT consultant discusses these events at her next formal appraisal.

Summary

Mrs C complained on behalf of her late brother-in-law (Mr A) that the medical practice delayed twice in referring him to hospital. Mr A visited his GP nine times between September 2011 and November 2012, with various symptoms, including a sore throat. He was finally referred to the ear, nose and throat (ENT) department in November 2012, and was diagnosed with throat cancer, for which he had surgery and radiotherapy.

When he then reported ear pain to the ENT surgeons he was told that this was likely nerve damage following his treatment. He continued to experience pain and in May 2013 went to his GP. The GP found evidence of inflammation, prescribed various drops, and told Mr A to come back if the pain did not resolve. Mr A went back to the practice the next week and saw a locum (temporary) GP who diagnosed nerve damage and prescribed a drug for nerve pain. He also advised Mr A to come back if the pain did not stop. Mr A contacted the practice by phone a week later and told another GP that he was still in pain. The GP made an urgent referral to ENT that day, and Mr A was seen by an ENT consultant some four days later. After further investigations he was diagnosed with inoperable throat cancer in July 2013 and he died in January 2014.

Our investigation included taking independent advice from one of our medical advisers, who is a GP. We did not uphold the first complaint as the adviser said that there was no unavoidable delay in making the first referral to ENT. The clinical records showed that although Mr A reported throat pain on some occasions, this was not a constant feature and there was evidence that at times certain treatments resolved or improved this. When, however, Mr A reported a 'red flag' symptom (a symptom especially likely to indicate a particular serious illness) in November 2012, the GP had spoken to an ENT specialist and urgently referred Mr A that day.

On the second complaint, the adviser found that there was a delay of one week between Mr A being seen by the locum GP, who appeared to have considered making an urgent referral, and the referral actually being made after Mr A's phone call. The adviser said that in view of Mr A's recent medical history, the locum should have referred him immediately. It was not clear from the records whether the locum prepared the referral but it was not sent, or if the referral was not made until later. Either way, there was an avoidable delay of one week on the part of the practice and we upheld this complaint.

Recommendations

We recommended that the practice:

• take steps to ensure that such delays in urgent referrals do not occur again.

Summary

Mr C, who is a prisoner, complained that he was issued with mail on a Sunday, when it should have been issued on a Saturday. He also complained that the prison failed to ensure that staff adhered to the procedures regarding cell searches, as well as those for handling and responding to his complaints.

We asked the prison about mail deliveries, and it was clear that mail should not be delivered on a Sunday, unless there are exceptional circumstances. As Mr C had clearly received mail on some Sundays, which was evidenced by more than one complaint to the prison about this and by the prison's responses, we upheld this complaint.

On the matter of the cell search, our investigation found that the Prisons and Young Offenders Institutions (Scotland) Rules 2011 give the SPS the right to search a prisoner's cell, and any items of property in their possession, at any time. Although the SPS has this right, it is moderated by the requirement to carry out a search quickly and decently and with proper regard for a prisoner's dignity. There were, however, no records of the search that Mr C complained about and in the absence of such evidence, we could not uphold this complaint.

The prison staff dealing with Mr C's initial complaints did not offer to speak to him within 48 hours of receiving the complaints, as required. In dealing with his complaint about mail delivery, the prison also did not provide an explanation for the delay at any stage of the complaints process. As we would expect this to be provided, and the complaints process to be followed, we upheld this complaint.

Recommendations

We recommended that Scottish Prison Service:

• provide the Ombudsman with evidence that mail delivery is now part of the weekend duty manager's checks;
• provide the Ombudsman with records to demonstrate that mail delivery has taken place on Saturdays; and
• remind residential first line managers of the need to provide a summary of their investigation and the evidence to support their decision, as stated on the prisoner complaints form.

Summary

Mr C's property was included in the council's housing improvement programme, which involved comprehensive works. Mr C became unhappy after work started on his home, and following a Freedom of Information request about the programme, he complained that the contract was being undertaken in-house, without going out to tender. As part of his complaint, he asked that his concerns about this were brought to the attention of council members. Mr C also complained that he had not been consulted in advance about the proposed work in accordance with the council's Tenant Handbook.

Our investigation found that the requirement for the council to go out to compulsory competitive tendering had ended in 2003, and the decision became a delegated matter. The programme had been approved by the full council and the decision that the refurbishment works would not be put out to tender was made by the Head of Service under delegated powers. We did not find anything to suggest that the council's advice about this to Mr C in response to his complaint was incorrect, nor that there was a requirement to bring his concerns to the attention of council members. However, we saw no evidence that his request for this to be done had been responded to, and we made a relevant recommendation.

With regard to Mr C's complaint about lack of consultation, the council acknowledged that their Tenant Handbook did say that individual tenants would be consulted about the programme. However, this was not done because it was not considered appropriate. The council provided evidence that confirmed that a range of methods had been used to provide tenants with advice about what would happen and when. However, because it was unclear how the decision not to carry out individual consultation was arrived at, we were unable to conclude that it had been taken appropriately.

Recommendations

We recommended that the council:

• reply to Mr C about his request that council members were made aware of his concerns about tendering for the housing improvement programme; and
• consider Mr C's comments about consultation as part of a procedural review.

Summary

In 2002, Mr and Mrs C purchased a flat in Edinburgh. The flat was the subject of a statutory repairs notice the following year, but Mr and Mrs C said that they were unaware of this as the council had not served the notice on them, but on the previous owner. They told us that they had seen scaffolding go up on part of the property, but the first they knew about repairs being undertaken under a statutory notice was when they received a bill for their share of the costs in 2013. Mr and Mrs C questioned the delay in issuing the invoice, and the costs. They complained that the council had failed to conduct conservation works on their property in such a way that they could evidence that their invoice was justified, and that the council did not handle their complaint in accordance with the complaints procedure.

Our investigation found that, although there was a long delay between the work starting and the issue of the invoice, there was evidence that the council sent notices about this to Mr and Mrs C's property. These were addressed to the owner or occupier, even if they were not then passed to Mr and Mrs C. Although this was unfortunate, we took into account that Mr and Mrs C were aware that there was scaffolding on the building, and we considered that it would have been reasonable for them to have asked neighbours and/or the council about this. Although Mr and Mrs C thought the documentation was inadequate, the council had provided them with the final account, detailing the works. We did not uphold their complaint, as we concluded that, whilst the documentation was sparse, Mr and Mrs C's complaint came down to a dispute about their liability for their share of the costs, and we were not able to adjudicate on this. Where we had found fault was not with the contract, but with the delay in issuing the account. The council had apologised to Mr and Mrs C for this, and we decided that it would not be reasonable to ask for a reduction in the invoice, as Mr and Mrs C's liability had not increased as a result of the delay.

We upheld the complaint that the council did not handle Mr and Mrs C's complaint in accordance with the council's procedure. We found that it was not dealt with appropriately in terms of timescale, agreement of the complaint or what was being sought as an outcome. We also found that there was a lack of updates and Mr and Mrs C were not asked to agree the timescale for investigation of the matter being extended.

Recommendations

We recommended that the council:

• issue a formal apology to Mr and Mrs C for the council's failure in their service standards for complaints handling.