Some upheld, recommendations

Summary

Ms C complained that the care and treatment provided to her late mother (Mrs A) by two hospitals was unreasonable. She said that Mrs A's transfer between the two was delayed; she had to wait some hours for a bed once transferred; she was not treated for possible blood clots; she was not given enough pain relief; and that nursing care was poor.

Mrs A had had a stroke and was undergoing rehabilitation, firstly in Ayr Hospital (a general hospital) and then in Ailsa Hospital (a mental health hospital). When Mrs A's condition started to deteriorate in Ailsa Hospital, her daughters were concerned and asked for a medical review with a view to transferring Mrs A back to Ayr Hospital. Ms C thought that Mrs A might have suffered another stroke. Mrs A was not, however, examined by a doctor (in this case, a psychiatrist) until that evening when, after consultation with Ayr Hospital, it was decided not to transfer her. The following day Mrs A's condition had deteriorated further and she was transferred, with the receiving doctors noting that she was very unwell and treating her for an infection. The board's standard admission documentation has a section for doctors to complete saying whether or not the patient is thought to be at risk of blood clots (deep vein thrombosis - DVT), but this was not completed.

Our investigation included taking independent advice from two of our advisers - a doctor specialising in elderly medicine, and a nurse. We found that there were problems with Mrs A's care in both hospitals, and we upheld some of Mrs C's complaints. Our advisers said that there was delay in obtaining a medical review in Ailsa Hospital, and that when the review did take place it was inadequate. There was also a delay in arranging to transfer Mrs A. The medical adviser said that when Mrs A was admitted to Ayr Hospital, consideration should have been given to her susceptibility to blood clots. National guideline 122 issued by the Scottish Intercollegiate Guidance Network (SIGN) recommends that patients who have mobility problems and illnesses such as infection - as in Mrs A's case - should be treated with preventative drugs to minimise the risk of developing blood clots. This did not happen in Mrs A's case, and she went on to develop blood clots.

We did not uphold Ms C's complaints about pain relief and general nursing care. Both advisers said that there was no evidence to demonstrate that these aspects of Mrs A's care were unreasonable.

Recommendations

We recommended that the board:

• provide the Ombudsman with evidence that staff training referred to in the board's response has now taken place;
• ensure that all staff involved in this complaint at Ailsa Hospital reflect on their practice in this area and discuss any learning points at their next appraisal;
• confirm that all the medical staff involved in this complaint at both hospitals reflect on their practice in this area and discuss any learning points at their next appraisal;
• as a matter of urgency, take steps to ensure that medical staff at Ayr Hospital complete admission documentation in relation to DVT and fully take into account SIGN guideline 122 in their clinical practice; and
• ensure that relevant staff are reminded that complaint responses should accurately reflect the clinical situation of the patient involved.

Summary

Ms C, who was a student, complained about the way a lecturer behaved towards her, the support provided to her, and how the college dealt with her complaint.

We upheld Ms C's complaint about their complaints handling, as our investigation found that the college initially investigated her concerns about the lecturer through their employee disciplinary procedure. This meant that Ms C was given no information about their findings or any action they had taken. Although we accepted that it was important to maintain confidentiality in relation to the disciplinary investigation, we were critical of the college for failing to respond to Ms C's concerns separately under their complaints procedure. We also considered that their communication with her throughout the investigative process was poor. We noted that they are reviewing their process, and made recommendations about this.

We did not, however, uphold her other complaints. We did not find enough evidence to be able to conclude that the lecturer had acted inappropriately toward Ms C. We were also satisfied that the college took her complaints seriously and worked with her to provide a range of appropriate adjustments to support her through the remainder of her studies.

Recommendations

We recommended that the college:

• provide the Ombudsman with details of the outcome of their internal review of their complaints handling processes; and
• ensure that their complaints handling processes allow for complainants to receive a response to their complaints in cases where disciplinary issues are also being investigated.

Summary

Mr C's company occupied two sites, one of which contained two buildings - a factory and separate offices. The bills for both sites were issued to the factory site address. The factory itself had been derelict since 2006 and was demolished in 2011. When it was demolished, Mr C paid Scottish Water to install a new supply point and a new water meter for the offices there. In November 2011, however, he received a separate bill for water usage at the site, backdated five years. Mr C complained to Business Stream that he had been incorrectly billed. He said the bill was inaccurate and showed a level of water usage that was far too high. He said that he had always paid bills promptly and that the company had not noticed they were only receiving bills for one site, instead of two. He also complained that Business Stream failed to deal with his complaint appropriately, as he repeatedly had to phone them to chase the complaint and Business Stream had taken many months to respond. He said that when Business Stream did issue the final response it was incorrect and they had to issue a revised bill. This had taken a further four months and Business Stream had not apologised for this.

Our investigation found that the bill issued to Mr C was supported by meter readings. It was also lower than an estimated bill from the last full year of billing in 2006. Business Stream explained that they had been unaware of the site as the account had been closed in error in 2006 when the factory was abandoned. As, however, the water meter also served the offices on the site, which had remained in use, the account should not have been closed. This had happened before Business Stream existed, and they were not responsible for that initial mistake. We did not uphold this complaint, as we concluded that the amount was not excessive and that Business Stream were entitled to issue a bill for the water usage on the site.

We did, however, find that Business Stream had failed to deal with the complaint appropriately. Mr C had disputed the invoice as soon as he received it and had repeatedly phoned to chase this up, but had not received a written response for nine months. Business Stream had taken over a year to send their final response, which was then inaccurate. We found that Business Stream had not established the facts around the case before trying to close it and had failed to treat the matter as a complaint, prolonging the case unnecessarily.

Recommendations

We recommended that Business Stream:

• apologise for the failings identified in our investigation; and
• credit Mr C's account with a payment of ten percent of the outstanding bill in recognition of the time and trouble caused to him in pursuing this matter.

Summary

Mr C, who is a prisoner, complained that some of his property went missing when he was transferred between prisons. He was unhappy that he was not given the opportunity to check his property immediately after the transfer, and said that the prison had withheld a substantial amount of canteen (food and drink) items. Mr C was also unhappy with the way in which the prison handled his complaint, saying that they did not respond to all of the large number of forms he submitted.

We did not uphold his complaint about the property, as our investigation found that there is no requirement under the prison rules for the Scottish Prison Service (SPS) to make a written record of any property a prisoner purchases in prison, or property that is perishable or edible. Whilst Mr C was not given the immediate opportunity to check his property after the transfer, neither the prison rules nor the prison's protocol on handling property specify a precise timescale within which this should take place. Although it would have been better if Mr C had been able to check his property sooner, there is no requirement for the SPS to make a written record of the canteen items he said went missing.

However, we did have some concerns about the way the prison handled Mr C's complaint. We found that they had not retained sufficient information to show how they had responded to some of his complaint forms.

Recommendations

We recommended that SPS:

• take steps to put in place an appropriate system for recording, monitoring and tracking prisoner complaints in the prison in line with their complaints procedure guidance.

Summary

Mr C's child exhibited behaviour that led to a guidance teacher suggesting that the child be assessed for Asperger's syndrome disorder. Meanwhile the school worked on a protocol to manage the child's behaviour in class. Before this could be put in place, however, the child was involved in an incident that led to a referral to an Additional Needs Tribunal. The tribunal said that the council had not made reasonable adjustments under the Equality Act. Mr C then requested a coordinated support plan for his child but this took over eight months to finalise.

Mr C complained to us that in planning his child's education the council did not apply policy and procedures to meet the additional support needs required, and failed to ensure that the school communicated with him and his wife appropriately and adequately. He also complained that they did not ensure that the school maintained adequate record-keeping, and that problems with his child's attendance were not promptly addressed.

We upheld three of Mr C's four complaints. We found that the guideline for providing a support plan is four weeks, and that the council had taken far too long to provide this at a particularly important time in the child's education. We also found that communications were inappropriate and that on three occasions records were inadequate. We did not uphold the complaint about attendance, as we did not find sufficient evidence to do so.

Recommendations

We recommended that the council:

• apologise for the failings identified in our investigation; and
• demonstrate that relevant staff are reminded of the policies, procedures and timescales to be adhered to when a coordinated support plan is requested.

Summary

Miss C complained about the care and treatment she received when she was admitted to the Royal Infirmary of Edinburgh with acute appendicitis. She complained about a procedure that was carried out when her wound became infected and was reopened on the ward several days after surgery. Miss C complained that excessive force was used during the procedure and that her pain was not adequately managed. She also complained about the level of scarring she suffered, and said that the board failed to explain the procedure or obtain her consent for it, and had failed to respond appropriately to her complaint.

We took independent advice from one of our advisers, who is a consultant surgeon. There was no evidence to allow us to comment on how much force was used or about the management of Miss C's pain, although there was evidence of three types of pain relief being prescribed that day. Our adviser said that it was reasonable for the procedure to be carried out on the ward without anaesthetic, as local anaesthetic is much less effective in infected tissue. He also said that it would be expected that staff would consider, as part of the implied consent for the procedure, whether it would be appropriate to provide pain relief in advance. He said that there was no need for this consideration to be documented. We also found that it was unlikely that the procedure was the source of the scarring that Miss C suffered, which was more likely to result from the wound infection. We did not, therefore, uphold her complaint that the procedure was not carried out appropriately.

Although our adviser said that written consent was not required for this type of procedure, we upheld Miss C's complaint about failure to explain, as we were concerned that she was not given enough information on how the procedure was to be carried out. We did not make any recommendation as the board had already taken action to address this for the future.

Finally our investigation showed that, while the board's initial response failed to address all of the issues Miss C raised, they had later met with her and provided a further response. We did not uphold this complaint.

Recommendations

We recommended that the board:

• ensure that the senior specialist registrar reflects on how implied consent is taken and how it might be recorded; and
• ensure that the senior specialist registrar reflects on this episode to guide future practice in relation to the consideration of a patient's comfort, analgesia and overall experience of care.

Summary

Mrs C's 85-year-old father (Mr A) suffered from dementia, and had a history of heart problems and abdominal cancer. Mrs C complained that he was twice discharged from the Royal Infirmary of Edinburgh when he was not fit for discharge. She also complained about a lack of communication within the healthcare team, and between staff and Mr A and the family.

In November 2012 Mr A was admitted to hospital for treatment of blood clots in his wrist and arm which were surgically removed. After five days in hospital Mr A was discharged. Mrs C came to collect him but, as they were leaving the ward, Mr A fainted. He was re-admitted and discharged again four days later. Two weeks after the second discharge Mr A was admitted again to treat an infection in his arm where he had had the surgery. This time he was in hospital for five days before being discharged.

Our investigation, which included taking independent advice from our medical and nursing advisers, found that both discharge decisions had been reasonable, in that Mr A was clinically stable and the various investigations and observation results were within the normal range. Both advisers commented that Mr A's collapse on leaving the ward following the first discharge could not have been predicted, as it was due to his existing heart condition, which could cause sudden and unpredictable symptoms.

On the matter of communication, however, we did find some failings. Both advisers expressed concern at some of the verbal and written communication, and in particular about an event when Mr A was taken alone by ambulance to the hospital's emergency department. Ambulance staff had noted that he was confused and unsteady on his feet. When he arrived at the hospital Mr A was reviewed by a triage nurse (who assesses a patient's condition and the urgency of treatment required) who noted that he had dementia. Despite this, he was moved several times during the 80 minutes he spent in the emergency department, and our medical adviser said that this would have added to Mr A's confusion. In addition, when he was moved there was no evidence that information about him was shared between members of the healthcare team. Mr A later left the department unaccompanied and arrived home as Mrs C was preparing to go to hospital to see him. Although a staff member had seen Mr A leaving alone in a taxi, no one had contacted Mrs C to alert her to this.

Recommendations

We recommended that the board:

• apologise for the failings identified in our investigation;
• consider putting in place a protocol for the monitoring and supervision of dementia patients within the accident and emergency department; and
• feed back to the staff involved in this complaint the importance of effective communication between staff and patients' families / carers.

Summary

Mrs C complained that when she was in labour in the Royal Infirmary of Edinburgh, a doctor conducted an intimate examination without introducing herself or obtaining Mrs C's consent for the examination. Mrs C also complained that the examination was very painful, and that although she asked the doctor to stop, she did not do so right away. The doctor told Mrs C that she needed a forceps delivery (where a specially designed instrument is used to assist with the delivery of the baby) and would need to go to theatre. The baby was successfully delivered but Mrs C had been hoping for a natural birth and complained that she was not offered any alternative options.

Mrs C wrote to the board three months after the birth to complain about her care and treatment. Although the letter of complaint was acknowledged promptly, she then waited almost three months for the response. Before she received the response, Mrs C brought her complaint to us. She also complained that, while she was still waiting for the board to respond, she had to attend an out-patient appointment. She was upset to be met there by the doctor about whom she had complained. We also investigated this additional complaint.

Our investigation included taking independent advice from a consultant in obstetrics and gynaecology. We upheld Mrs C's complaints about her care and treatment during the delivery. The adviser was of the view that Mrs C had been unable to give informed consent for the examination or the forceps delivery, due to her level of pain and distress and the lack of information about alternative options. The adviser was also critical that, when asked to do so, the doctor did not immediately stop examining Mrs C. The adviser considered that there was no immediate danger to Mrs C or her baby at the time of the decision about forceps delivery, and said that she should have been given time to have additional pain relief and then consider all the options, including no treatment or intervention.

On the matter of the out-patient appointment, the NHS guidance on complaints handling says that information about complaints should not normally be kept in a patient's clinical records. Because of this, neither the board nor the doctor concerned could have anticipated that Mrs C would been seen at the clinic by the doctor about whom she had complained. When the doctor realised who Mrs C was, she arranged for her to be seen by the consultant instead. That was appropriate and we did not uphold this complaint.

In regard to the delays in complaints handling, the board acknowledged the delay and that Mrs C had not been kept informed about this or about the reasons for it. We upheld this complaint, but noted that the board have since made changes within the complaints department.

Recommendations

We recommended that the board:

• ensure that all relevant staff are reminded of the guidance on taking consent from women in labour (in particular the need to record oral consent) and, where necessary, provide refresher training;
• provide a copy of our decision to the doctor involved to allow her to reflect on her practice in relation to the complaints and discuss any learning points at her next appraisal;
• provide the Ombudsman with evidence to demonstrate that the changes put in place within the complaints department have improved response timescales; and
• issue a written apology for the failings identified during this investigation.

Summary

Miss C complained that the medical and nursing care and treatment provided to her late mother (Mrs A) was inadequate. She also complained about inadequate communication between staff and her late mother and the family. Mrs A was admitted to hospital suffering from a blood clot in the intestine which then caused problems with her bowel. She had surgery several times while in hospital and was transferred to the intensive care unit (ICU), where she died some three weeks after being admitted.

In relation to the medical treatment, Miss C complained that when Mrs A was taken into hospital with sudden abdominal pain, there were delays in obtaining a diagnosis; in undertaking investigations; and in addressing her level of pain. Miss C also complained that it was unreasonable to have transferred Mrs A from the Accident and Emergency department to the Surgical Observation Unit before transferring her to an in-patient ward. During our investigation we took independent advice from one of our medical advisers, an experienced surgeon, who was of the view that Mrs A's medical care and treatment had been reasonable. The blood clot had caused tissue in Mrs A's intestine and bowel to die, and the adviser said that diagnosis of this condition is largely one of elimination of possible causes and that there had been no unreasonable delays in investigating and treating Mrs A's condition. The adviser said that the condition can be very painful but that strong painkillers can mask physical symptoms and so it was not unreasonable that it took some time to get Mrs A's pain under control. We did not, therefore, uphold Miss C's complaints about her late mother's medical treatment.

In relation to the nursing care and treatment, we also took independent advice from our nursing adviser, who had concerns over some of the issues Miss C had raised. In particular she was concerned about monitoring and observations, record-keeping, pain scoring, and communication by nursing staff. There were also problems with the communication of a decision to reverse a Do Not Attempt Resuscitation decision (DNAR - a decision taken that means a doctor is not required to resuscitate the patient if their heart stops) from medical staff. While the medical adviser was satisfied that both the original DNAR decision and the reversal decision were appropriately taken, only the original decision was discussed with the family. While such decisions are clinical ones and do not require approval or consent from the patient or family, it is good practice to discuss these issues where possible. Overall, we upheld Miss C's complaints about nursing care and communication.

Recommendations

We recommended that the board:

• apologise to Miss C and her family for the failings identified during this investigation;
• provide evidence that the standards of record-keeping meet the required professional standards across the wards/units involved in this complaint and, where necessary, provide training to meet these standards;
• ensure that there are robust systems for handover between the clinical departments identified when patients are transferred;
• ensure that the knowledge and skills of the nurses involved in this complaint when performing clinical observations, including pain assessments, meet the relevant local guidance;
• ensure that staff on the ICU ensure that alternative support strategies are in place for families/carers when visiting arrangements are reviewed; and
• remind all staff involved in this complaint of the importance of good communication between staff and patients and their families/carers.

Summary

Ms C, who is an advice worker, complained on behalf of her client, Ms B. Ms B's late fiancé (Mr A) had died a few days after being admitted to Glasgow Royal Infirmary with severe jaundice. Ms B had told Ms C that the board provided inadequate nursing care, and that hospital staff failed to communicate adequately with Mr A's family, including about the severity of his condition, which she said caused Mr A and his family unnecessary distress and suffering. Ms C also complained about the board's complaints handling.

During our investigation, we reviewed Mr A's clinical records and took independent advice on his care from our nursing adviser. We found that at the heart of the complaint was Ms B's view that nursing staff acted insensitively towards Mr A. In cases where people are unhappy with the attitude of staff, it is often difficult to find evidence to support the complaint. This is not to say that we do not believe the accounts given; rather we find there are differing recollections, and often no independent evidence of behaviour or attitude. In Mr A's case, we could not reach a finding on whether nursing staff were insensitive.

Based on the evidence in the clinical records, we did not uphold the complaints about nursing care and communication. The records showed that Mr A was attended to regularly, and our adviser did not have any concerns about nursing care, noting that the board had since taken steps to support a person-centred care approach. The adviser also said the records showed that staff had tried to communicate the seriousness of Mr A's condition. The board had, however, acknowledged that some aspects of communication should have been better and had put improvement measures in place. In terms of how the complaints were handled, however, we upheld Ms C's complaint, as we found gaps in the records, and unreasonable delays in resolving the complaints.

Recommendations

We recommended that the board:

• reflect on staff's practice of introducing phone calls by saying 'do not worry', to determine whether they think it is appropriate as routine wording in all cases; and report back to the Ombudsman;
• ensure that, wherever possible, complaints (whether informal or not) are progressed in the absence of staff on sick leave;
• remind staff of the need to make records of informal complaints, in line with guidance; and
• ensure staff record when they tell complainants about the formal complaints process.