Some upheld, recommendations

Summary

Mr C told us that he had received a bill from the council for repair work on his tenement, carried out under an emergency statutory notice that the council had issued. He said that this was the first communication he had received about this, and that there was a four and a half year gap between the work being undertaken and when he and other owners were told about the cost. He said that neither he nor his neighbours were notified by statutory notice that work was to be carried out. He also said that when he first raised concerns about this and queried his share of the costs, the council told him that this would be investigated and that they would put the demand for payment on hold until this was done. However, during their investigations he was sent letters demanding payment. Mr C was also dissatisfied with the way in which the council investigated his complaint.

When we investigated this, the council acknowledged that there was no evidence that they had issued a statutory notice to Mr C. They also explained why the invoice for the completed work was not issued earlier, and we noted that they had already apologised to Mr C for this. We upheld Mr C's complaints about the failure to issue the statutory notice and about the demand for payment, and made a recommendation. As, however, we found that the council's investigation into the costs had been appropriate, we did not uphold that complaint.

Recommendations

We recommended that the council:

• consider whether, given the failure identified, they should rebate part of the fee levied against Mr C for his share of the costs of the council's administration on the contract.

Summary

Mr C, who is a landlord, said that he told the council in March 2012 that his tenant, who was in receipt of housing benefit, had not paid his rent and asked them to intervene in this. He complained that the council failed to take action, and did not deal properly with his correspondence and complaints.

We did not uphold his complaint that the council failed to act in March 2012, as Mr C was unable to provide us with any evidence that he had been in touch with them about this then. The first evidence of contact was in June 2012, when he sent them an email about it. The council said that this was when he first brought the issue to their attention. Despite extensive enquiries, we did not find any documentary evidence that Mr C contacted the council earlier than this, so we were unable to conclude that they failed to take appropriate action.

We did, however, uphold his complaint about correspondence and complaints handling. The evidence showed that Mr C contacted the council on numerous occasions over an 11-month period with his concerns about his tenant and communicated with various teams in the revenue and benefits department. In general, the council did respond to his communications. However, we were critical of them for failing to confirm their understanding of his concerns with him at an early stage and for failing to explain the services the different parts of the council could provide. They also did not advise Mr C of the outcome of their initial investigation when he asked that they start to make housing benefit payments directly to him, as landlord, and of any right of appeal against this decision. Mr C's first formal complaint was not considered appropriately under the council's complaints procedure and he was not advised how to escalate his complaint. There was also an unreasonable delay of two months in responding to a letter from Mr C's MSP and the council did not send updates or explain the delay.

Recommendations

We recommended that the council:

• ensure that they advise a landlord requesting a review of a housing benefit decision of the outcome of the review and of any statutory right of appeal;
• ensure that staff deal with formal complaints under the council's complaints procedure appropriately and advise complainants how to escalate their complaint, should they remain dissatisfied;
• consider making a payment to Mr C of an amount equivalent to the June 2012 housing benefit payment; and
• provide Mr C with a written apology for the failings identified in this case.

Summary

Mr C is a landlord of a property classed as a house of multiple occupancy. When he asked the council to uplift bulk waste he says he was told that he had to pay for the service, as his premises were commercial. Mr C disputed this and said that he paid council tax and if his premises were being classed as commercial he should have been paying business rates. He told us that it took the council three months to respond to his enquiries and complaints about the matter, and he still did not have a satisfactory explanation. He complained to us about the classification of his property and about the council's complaints handling.

We found that the council had not in fact classified Mr C's property as commercial, and we did not uphold that complaint. We did find, however, that he had been given misleading information that caused him to believe this.

We upheld Mr C's complaint about the council's complaints handling. We noted that they had written to him apologising for the delay in providing their written response, and that the information he had been given about a charge was inaccurate. They confirmed that there would be no charges involved in arranging a bulk uplift. They also arranged for the correct procedural information to be given to senior management at the call centre he had contacted, which was to be communicated to all staff dealing with the public to ensure that customers are accurately advised in future.

Recommendations

We recommended that the council:

• ensure that call centre staff are reminded of how to deal appropriately with complaints; and
• apologise to Mr C for the poor service he received from the call centre.

Summary

Mr C complained on behalf of a local action group about the council's handling of a planning application to build on a site occupied by a commercial property. Mr C said the council unreasonably failed to implement a planning clause requiring replacement of a tree; failed to respond appropriately to concerns about the protection of another tree; and unreasonably failed to obtain information on the appearance of proposed garage doors. He also said the council wrongly claimed that, at a Scottish Government Reporter's meeting, the roads department representative did not support a proposal for planters along the pavement at the front of the new building; and that the council unreasonably delayed in responding to letters about the development.

We took independent advice from one of our planning advisers. He explained that the council could not have used the planning condition to require the replacement of the tree as it was not located in the application site, so we did not uphold this complaint. However, he said that the council could have used different provisions to require another company (that owned the land where the tree was located) to replace it. We were not satisfied that the council took appropriate steps to secure the replacement of the tree, or that they took all appropriate steps to safeguard the other tree. In both cases, we were also critical of the council's failure to provide this office with actual evidence of their actions, and we made recommendations to address all these failings.

Our adviser explained that no public consultation was required about the detail of the garage doors and the council's planning officer was entitled to deal with this under delegated powers. On the matter of what was said at the Scottish Government Reporter's meeting, there was insufficient objective evidence of what the roads department representative actually said. We did not uphold these complaints.

We upheld the complaint that the council delayed in providing information to the action group and local councillors on the health of the second tree, and in responding to Mr C's complaint, and we also criticised the standard of their response.

Recommendations

We recommended that the council:

• make relevant staff aware of our findings on the complaints about the trees;
• ensure that, as a consequence of this complaint, staff in future keep full records of their actions as detailed by our adviser;
• confirm to the Ombudsman when replacement trees will be planted; and
• issue Mr C with a written apology for failing to respond to a letter within a reasonable time and for failing to address the new issues raised.

Summary

Mrs C complained to us about the care and treatment of her late mother (Mrs A) while she was in the care of St Michael's Hospital. She raised concerns about her mother's oral health care, and her enteral tube feeding (she was fed by a percutaneous endoscopic gastrostomy (PEG) tube into her stomach, also known as 'enteral tube feeding').

We took independent advice from one of our advisers, who is an experienced nurse. We found that Mrs A was an in-patient for 13 months. A care plan was put in place when she was admitted, which identified her oral health care needs, and we found that this was followed. However, it was not reviewed and updated on a monthly basis, and did not take into account Mrs A's increased risk of mouth problems due to the enteral tube feeding. Mrs A was also given a mouth wash on an ongoing basis, as she had a painful mouth due to gum disease. Our adviser pointed out that the guidelines for the use of the mouthwash indicate that it should only be used for seven days, after which its use should be reviewed. This did not happen.

In relation to Mrs A's enteral tube feeding, Mrs C raised concerns that the care and management of her mother's tube was insufficient, and that on occasion she was fed while lying flat. This then led to her aspirating (breathing in foreign material) her food, and contracting aspirational pneumonia (inflammation of the lungs and airways from breathing in foreign material). Mrs A died of aspirational pneumonia. Our investigation found that Mrs A's enteral tube feeding was in line with her care plan. However, the documentation of this care was on an 'exceptional' basis, in that staff only recorded events that were outside the normal care provision. The evidence indicated that Mrs A had not been laid flat to feed, and that when she was found flat, appropriate action was taken to remedy the situation. We found that the board's actions in relation to Mrs A's tube feeding were reasonable, but that their care in relation to her oral health was inappropriate.

Recommendations

We recommended that the board:

• ensure that staff are aware of the need for monthly reviews of oral care plans and the level of detail that should be recorded; and
• provide a written apology for the failure to provide appropriate oral health care for Mrs A.

Summary

Mrs C complained about the care and treatment that the Royal Infirmary of Edinburgh provided to her late mother (Mrs A) who passed away 12 days after being admitted there after having had a stroke. Mrs C was also concerned about poor staff communication about Mrs A's deteriorating condition, and the way in which the board dealt with her complaint.

After taking independent advice on Mrs C's complaints from one of our medical advisers, we did not uphold her complaint about her mother's care and treatment. The adviser said that although Mrs A’s condition was complex, the care and treatment she received was in line with national guidance recommended by the Scottish Intercollegiate Guidelines Network on the management of stroke patients. We found evidence that accident and emergency (A&E) staff assessed Mrs A and arranged a brain scan in a timely manner. Furthermore, A&E staff sought prompt advice from specialist staff. Although aspirin could have been given to Mrs A sooner, it was administered within the 48 hour guideline recommended by NHS Quality Improvement Scotland, and the adviser thought it unlikely that Mrs A's outcome would have been any different even had it been given sooner. We also concluded that Mrs A was promptly assessed by both physiotherapy staff and speech and language therapy staff after she was transferred to the stroke ward. In addition, frequent medical reviews were carried out and appropriate monitoring and treatment of her heart rate to help keep it under control.

We did, however, uphold Mrs C's other complaints about communication and complaints handling. When the board met with Mrs C to discuss her complaint, they apologised for the lack of information about Mrs A's deteriorating condition on the day of her admission to A&E and accepted that there were significant communication problems when Mrs A was transferred to the combined assessment unit and then to the stroke ward. They said that they were taking steps to address this.

The board accepted that there were mistakes in their written response to Mrs C's complaint. They apologised for these, issued an amended version of the correspondence, and reimbursed Mrs C for the money she had to pay to receive their letter, which had insufficient postage on it. We also found that, although Mrs C told the board that they had written to her at the wrong address, there was a delay of three months before she received a further letter from them responding to her complaint as they had used the incorrect address again. We also established that: they had not responded within the 20 working day target set out in the Scottish Government's complaints procedure guidance; contrary to that guidance, the board's internal complaints policy permitted them to suspend the 20 working day response target when the person complaining accepted the offer of a meeting, and they had not kept Mrs C updated about when their response would be issued.

Recommendations

We recommended that the board:

• provide evidence to support the action they have taken to improve communication between staff and relatives regarding patients who have suffered a stroke;
• feed back to relevant staff the importance of ensuring timely and accurate responses to complaints, and of providing updates when the 20 working day timescale cannot be met, in accordance with the Scottish Government's complaints guidance; and
• review their internal complaints policy to ensure that it is in line with the Scottish Government's complaints guidance.

Summary

Mr C, who is a prisoner, complained that the board failed to arrange for him to see the prison psychiatrist following a suicide attempt. Mr C had been treated in hospital and said that the psychiatrist there told him that he would be seen by the prison psychiatrist when he returned to prison. After taking independent advice from one of our medical advisers, our investigation found that there was no evidence that Mr C was told this, and that the hospital discharge summary said no psychiatric action was required at that time. In addition, Mr C was reviewed by the clinical manager in mental health when he returned to the prison, and this review was then discussed with the prison psychiatrist. In view of this, we found that that it was reasonable that Mr C was not seen by a psychiatrist on his return to prison.

Mr C also complained that the board failed to provide him with appropriate treatment for blood loss after he self-harmed when he returned to prison. We found that the immediate follow-up care provided to him was reasonable in many aspects. The records also showed that Mr C had refused medical treatment on at least one occasion. However, he had lost a significant amount of blood. We found that the failure to clearly state that his haemoglobin (a protein found in the red blood cells that is responsible for carrying oxygen around the body) should be monitored and to specify the timing or frequency of the monitoring in his care plan was unreasonable. Mr C's haemoglobin was not checked until two weeks later, at which time he was immediately transferred to hospital for treatment. Staff also failed to record his vital signs (signs of life including the heartbeat, breathing rate, temperature, and blood pressure) and his nutrition and fluid intake. We upheld this aspect of Mr C's complaint.

Finally, Mr C complained about the board's handling of his complaint. We upheld this complaint too, as the board had failed to respond to all the points Mr C had raised. We also found it inappropriate that in their response to his complaint the board criticised Mr C's behaviours, while noting that these were discussions that clinicians and others would clearly be entitled to have with him in another context.

Recommendations

We recommended that the board:

• issue a reminder to the staff involved in Mr C's care that care plans should clearly document the interventions planned and when/how frequently they are to be implemented;
• issue a reminder to the staff involved in Mr C's care that they should chart a patient's vital signs and nutrition/fluid when this is indicated; and
• make the staff involved in the handling of Mr C's complaint aware of our findings.

Summary

Mrs C, who is an advice worker, complained on behalf of her client (Ms A) about the care and treatment she received at two hospitals, the Royal Infirmary of Edinburgh (RIE) and Roodlands Hospital. Ms A had had keyhole surgery (a surgical procedure that allows a surgeon to access the inside of the abdomen and pelvis through a small hole in the skin), but felt that because of her ethnicity and the fact that she had existing scar tissue from a previous operation, she should instead have had open surgery. She was also unhappy about the level of post-operative aftercare she received and said that she was discharged inappropriately from the RIE hospital when she was suffering from low blood pressure. She complained about the level of care she received when she attended Roodlands Hospital's unscheduled care service complaining of pain and discharge from her wound.

To investigate the complaint, we considered all the relevant documentation, including the complaints correspondence and Ms A's medical records. We also obtained independent advice from three of our advisers (two doctors and a nursing adviser). Our investigation found that the decision to perform keyhole rather than open surgery was reasonable and we did not uphold that complaint. We found, however, that the board failed to provide a reasonable level of post-operative aftercare and that the nursing decision to discharge Ms A had been unreasonable. Our advisers said that Ms A's vital signs should have been recorded more frequently and acted upon, her high pain score should have been acted on and that a surgical review should have been requested before deciding to discharge Ms A. They said that actions indicated by the Scottish Early Warning System score (SEWS - a scoring system used as an early warning of deterioration) did not appear to have taken place.

We also found the board failed to provide a reasonable level of care when Ms A attended the unscheduled care service. The advice we received was that there was no evidence that the member of staff who saw her there had taken a separate history of what had happened, or that the examination carried out was of a reasonable standard in terms of assessing post-operative complications.

Recommendations

We recommended that the board:

• apologise to Ms A for the failings identified in these complaints;
• investigate the post-operative care given to Ms A and report back to the Ombudsman with the results of this review;
• provide the Ombudsman with evidence about the education and training currently in place for nursing staff to ensure they are aware of and are following SEWS protocols; and
• ensure that as a learning requirement the nurse involved undertakes a clinical update in the history and examination of a post-operative patient and in particular abdominal examination. This should be discussed with the nurse's line management to confirm these competencies.

Summary

Mrs C complained about the care and treatment that her late father (Mr A) received at Raigmore Hospital. Mr A was admitted there after having been unwell for around three weeks and having been treated by his GP for a chest infection. His condition had deteriorated and he was found to have pneumonia and kidney damage. Mr A had a past medical history of lung cancer and an abdominal aortic aneurysm (a bulge in a blood vessel caused by a weakness in the vessel wall). At first, he responded well to treatment in the high dependency unit. He was moved to a ward, but his condition deteriorated. Mr A got much worse six days after moving to the ward and did not recover. No post-mortem was carried out, but his deterioration was consistent with the aneurysm having burst. Mrs C said that although the treatment in the high dependency unit was exemplary, she felt that staff took too long to establish that Mr A's aneurysm had ruptured. She felt that the treatment provided in the ward was poor and that staff did not communicate adequately with Mr A's family. She was also unhappy with the board's handling of her complaint.

We found that Mr A's aneurysm had been scanned early in his admission and was found to be enlarged, but intact. However, doctors agreed that, in the event of a rupture, no surgery could be performed. We took independent advice from one of our medical advisers, who said that the clinical records showed that staff treating Mr A on the ward were aware of this and that their decision-making would be affected by the fact that no treatment could be provided for the aneurysm. On the day of Mr A's deterioration, staff clearly considered a ruptured aneurysm as a possible cause. However, they also considered his symptoms to be consistent with constipation. As Mr A could be treated for constipation, we found it appropriate that this was done in the first instance. Once he deteriorated further, staff concluded that a ruptured aneurysm was the most likely diagnosis and Mr A was made comfortable and treatment was withdrawn. We found this to be reasonable and did not uphold Mrs C's complaint about his care and treatment.

We were, however, critical of the board's communication with the family. A number of conversations between staff and relatives were not documented and there was little evidence to suggest that the family were made aware of the treatment being carried out, or involved in conversations about Mr A's care. With regard to the board's complaints handling, we were generally satisfied with the thoroughness of their responses. However, some incorrect information was included in their first letter to Mrs C and they failed to contact her when their investigation carried on longer than expected.

Recommendations

We recommended that the board:

• apologise to Mr A's family for failing to communicate adequately with them;
• remind their nursing and clinical staff of the importance of informing and involving relatives in the patient's care and of properly recording all discussions held with relatives; and
• apologise to Mr A's family for their poor handling of the family's formal complaint.

Summary

Mr C's late wife (Mrs C) had chronic obstructive pulmonary disease (a disease affecting the lungs). She was admitted twice in one month to Forth Valley Royal Hospital with pneumonia and treated with antibiotics. The following month she was admitted for another two days with vomiting and diarrhoea. During this last admission, tests showed abnormal temperature and blood results. On the day of her discharge, Mrs C felt very unwell and an advanced nurse practitioner found a wheeze in her right lung, but the consultant who reviewed Mrs C decided to discharge her. Mrs C's condition continued to deteriorate and she was admitted to another hospital five days later where pneumonia was again diagnosed. After being discharged from there, she developed a severe infection and irregular heartbeat and was diagnosed with an inflammatory condition of the bowel. She sent us her complaint but died before we could investigate it, and her husband carried it on on her behalf.

Mr C complained that the consultant's decision to discharge Mrs C after the episode of vomiting and diarrhoea was unreasonable in light of her symptoms, and said that further investigations should have been carried out. He also complained that the advanced nurse practitioner's findings were unreasonably dismissed and that these failures led to a prolonged period of suffering for Mrs C before she was properly diagnosed and received appropriate treatment. Finally, Mr C complained about the board's complaints handling.

We took independent advice on Mr C's complaint from one of our medical advisers, who agreed that Mrs C's discharge should have been delayed for further investigation of her symptoms, and of the abnormal temperature and blood test results. We found that Mrs C was discharged with no clear diagnosis and that she endured symptoms for longer than she should have before she was diagnosed and treated appropriately. The adviser said that the consultant who discharged Mrs C had to make a difficult decision, and was seeing Mrs C for the first time. He said that responsibility for the decision should be viewed as an overall system failure involving several healthcare professionals who had been responsible for Mrs C's care.

We found that the board at first failed to fully respond to the complaints, but then fully addressed them after receiving a further letter from Mrs C. We appreciated that Mr C disagreed with the board's response and, as indicated above, we reached a different view to that of the board on the reasonableness of Mrs C's discharge. However, that is not evidence in itself of administrative fault by the board in their complaints handling, and we were satisfied that the board's interpretation of the complaints was reasonable. We, therefore, found that on the whole the board reasonably investigated the complaints.

Recommendations

We recommended that the board:

• review the ward round procedures to investigate and address why medical staff were unaware of Mrs C's temperature and why it was not discussed;
• review the investigation process to ensure that abnormal results are highlighted and considered; and
• apologise to Mr C for the failures identified.