Some upheld, recommendations

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.

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.