Some upheld, recommendations

Summary

Mrs C's mother (Mrs A) suffered a stroke after undergoing surgery for a fractured hip. Mrs C complained that the operation had taken too long and that her mother was not provided with a reasonable level of care during and after the surgery. She also believed that her mother did not receive adequate treatment after the stroke was diagnosed, as she did not receive a scan to confirm the diagnosis and was not moved onto a stroke ward.

After taking independent advice from one of our medical advisers, we upheld the first complaint as we found that the operation to repair Mrs A's broken hip did not follow best practice. She was not operated on within the 24-hour time limit set out in Scottish Intercollegiate Guidance Notes (SIGN), and the fit of the artificial hip was not properly checked, which meant the operation took 45 minutes longer than planned and unnecessarily increased the risks to Mrs A during surgery. We found that the board had not acknowledged or investigated these failings sufficiently in their investigation of Mrs C's complaint.

We did not uphold Mrs C's other complaints as we found no evidence to show that Mrs A was inappropriately discharged from the recovery room to a ward when she failed to recover from the anaesthetic, nor that her treatment was not reasonably managed when it was realised that she had suffered a stroke.

Recommendations

We recommended that the board:

• provide evidence that staff have been reminded about the importance of using trial stems prior to the insertion of cement during arthoplasties (a surgical procedure that restores the function of a joint);
• remind all staff of the importance of the 24-hour safe period set out in SIGN guideline 111;
• remind all staff of the importance of making clear, accurate notes for all clinical decisions; and
• apologise in writing for the failings identified in our investigation.

Summary

Mr C attended a hospital emergency department, with a badly cut hand. He was assessed by an emergency nurse practitioner. Following an examination, the nurse noted that he had superficial cuts to the second, third and fourth knuckles which were treated with steri-strips (adhesive strips that can be used to close small wounds). Mr C was referred to a consultant orthopaedic surgeon three weeks later as he noticed that he had poor extension (straightening) of his middle finger. The consultant and a specialist orthopaedic registrar reviewed Mr C and said that the function of the finger was recovering. They did not arrange a further review, but some eight months later, Mr C was reviewed again at his request. The consultant suggested a night resting splint for six months, and discharged him back to the care of his GP. Mr C was only able to use the splinting for a month because he found it uncomfortable, and the GP referred him again for a further assessment. Mr C was reviewed some six months later, when again the consultant discharged him back to the GP saying that he was happy to see Mr C again if he wanted to talk things over further or reconsider the outcome of their discussion.

Mr C told us that he now has a bend in his finger, which is very sore. He complained that the nurse should have conducted a more thorough assessment or asked a doctor for advice. He was also concerned about the follow-up treatment he received.

After taking independent advice from a surgical adviser and a nursing adviser, we found that the record-keeping of the initial assessment was not of a reasonable standard. It did not show that the nurse carried out a full and extensive examination of the injury including, significantly, movement and wound base of the cuts. We also found that there were failures in discharge planning. Our nursing adviser said that it was difficult to know from the records if there was evidence of a further injury that would have meant he should have been referred to a specialist. However, as we have to reach a decision based on the evidence available, we upheld Mr C's complaint about his treatment after the injury occurred, given the failures in record-keeping in relation to the assessment and discharge plan.

In relation to the follow-up treatment the advice we were given, which we accepted, was that this was reasonable. We were satisfied that he was seen appropriately on three occasions, and our medical adviser explained that the treatment plans and discharge arrangements for these consultations were reasonable.

Recommendations

We recommended that the board:

• ensure that the findings of this complaint are discussed with the nurse and that it is used as a learning tool in terms of their professional development for carrying out examinations of this nature;
• bring the failures in record-keeping to the attention of the nurse; and
• apologise for the failures identified.

Summary

Mr C complained about the quality of his care after he had a kidney removed. He said that he was not provided with adequate pain relief, his call buzzer was not working during his stay so he could not call for assistance, and he was inappropriately discharged, despite displaying symptoms of an infection. Mr C was readmitted with a wound infection six days after being discharged. He also complained that there was a delay in transferring him to an appropriate specialist unit and that he received poor care, resulting in an infected vein. Mr C did not believe that the board had taken adequate steps to prevent these problems happening again.

After taking independent advice from two of our medical advisers - on nursing care and the clinical decisions made - we found that the board had failed to provide adequate pain relief during Mr C's first admission to hospital and that the standard of care of intravenous cannulas (needles used to give drugs and fluids to a patient) was unreasonable. We also upheld his complaint that the buzzer was not repaired during his stay. We found, however, that although with hindsight he most likely had an infection when discharged, the actions of staff at the time were in line with acceptable clinical practice, that his second admission was handled appropriately and that the delay in his transfer was beyond the board's control.

Recommendations

We recommended that the board:

• apologise in writing for their failures; and
• carry out a serious critical incident review into the failure to provide adequate pain relief.

Summary

Mrs C was due to have gynaecological surgery in hospital. When she arrived before the operation, she was seen by her consultant, who discussed changing the planned procedure to a more extensive operation. Mrs C was not given extra time to consider the implications of this, but consented to it. She complained that she did not receive adequate care after the surgery and that symptoms of complications arising from it were overlooked. Mrs C said that as a result of these complications, she lost the function in her left kidney. She also complained that there was an unreasonable delay before the board provided a response to her complaint.

After taking independent advice from two of our medical advisers, we did not uphold the complaint about Mrs C's care, as we found that the board had done all that could be reasonably expected in arranging care after surgery. The advisers said that the medical records showed that there had been no obvious symptoms of the complications, and staff had acted appropriately in discharging her. While considering that complaint, however, we noted that Mrs C was not given enough time to reflect on the changes to her surgery, which had serious implications for her ability to start a family, and we made a recommendation about this. We upheld the complaint about complaints handling, although the board had already acknowledged that their complaints handling procedure was inadequate and had taken steps to rectify this, including restructuring the complaints team and reviewing the procedure itself. Although we found that the delay in responding was unreasonable, we considered that the board had already taken enough action to prevent this happening again.

Recommendations

We recommended that the board:

• apologise in writing for the delay in providing a full response to the complaint; and
• review their procedures to ensure that for complex gynaecology patients, sufficient time is allowed for discussion of the full potential complications and implications with the patient, during the consent process, should the planned operation change.

Summary

Mr C was admitted to a hospital accident and emergency (A&E) department after falling down stairs. On arrival his neck was immobilised in a collar, and it was noted that he had movement in his arms and legs with sensation in all his limbs. However, it was also noted that there were problems with his cooperation during this examination. A scan showed no acute fracture or bleeding and Mr C's neck collar was removed. The next morning, Mr C was found to have lost the power in his legs and he was transferred urgently to another hospital for treatment. His wife (Mrs C) complained that, given his accident, Mr C should have been kept immobile and given a full spinal scan. She also believed that proper tests were not carried out to determine the extent of his injuries and that he should have been transferred immediately to a specialist unit.

To investigate the complaint, we carefully considered all the relevant information, including all the complaints correspondence and Mr C's medical records. We also obtained independent advice from a consultant in emergency medicine and took this into account. Our investigation found that although Mr C was immediately immobilised on his admission to A&E, his neck collar was removed despite recorded difficulties in completing an assessment. Relevant advanced trauma life support (ATLS) guidelines suggested that Mr C should have remained in the collar until he was determined to be neurologically normal and could have been properly assessed. We upheld the complaint that Mr C should have been kept immobile, but did not uphold the others as our investigation found that all appropriate tests were carried out to establish the extent of his injuries and that the proper protocol was followed in transferring him to another hospital, rather than to a specialist unit.

Recommendations

We recommended that the board:

• apologise to Mr C for removing the hard collar before he was confirmed to be neurologically normal; and
• take appropriate steps to satisfy themselves that, with regard to evaluation, ATLS guidelines are fully complied with.

Summary

Ms C complained that the board had failed to take action to prevent her father (Mr A) from falling while he was in hospital. The hospital had completed a nursing assessment when Mr A was admitted. It was recorded that he was able to walk independently with a stick, but that he needed bed rails. Mr A got up to go to the toilet during the night. The nightshift staff in the hospital found him standing next to the toilet, holding onto the handrail. The next day, staff found that Mr A's mobility had deteriorated. He told them that he had fallen in the toilet during the night. Staff arranged an x-ray and it was found that Mr A had fractured his pelvis.

After taking independent advice from one of our medical advisers, we found that it was appropriate to promote Mr A's independence and that it was reasonable that he was able to go to the toilet alone. Although it was decided that Mr A needed bed rails, the board's guideline for falls management stated that bed rails would not prevent a patient leaving their bed and falling elsewhere, and should not be used for this purpose. Ms C said that her father had told her that the bed rails were not up when he went to the toilet. However, the member of staff who had assisted Mr A when she found him in the toilet recorded that the bed rails were up when she took him back to the bed. Although we recognised that the fall had a significant impact on both Mr A and Ms C, we found that there was no evidence to suggest that it could have been prevented.

Ms C also complained about the board's handling of her complaint. We found that they had delayed in responding, although they had apologised to Ms C for this. They had also failed to provide a full and detailed response to the complaint. We found that they should have tried to address the points Ms C made about whether or not the bed rails were up when Mr A got out of bed. In addition, the response had incorrectly referred to her late mother instead of her father. In view of all of this, we upheld this aspect of her complaint.

Recommendations

We recommended that the board:

• issue a written apology to Ms C for incorrectly referring to her mother instead of her father in their response to her complaint and for failing to provide a full and detailed response to the complaint.

Summary

In 2007, Scottish Water carried out significant work on the infrastructure around a village. As well as replacing mains pipes, they also replaced some private supply pipework. They did this as a good will gesture. (Private pipework is in fact the responsibility of the owner of the property.) In the cold winter of 2010, many pipes around the village froze. It was discovered that some of the pipes laid by Scottish Water's contractors were laid at the wrong depth and Scottish Water undertook a further program of work to replace these.

A local club did not have a water supply for some time. On investigation, they found damage to some of the pipework and repaired this in early 2011. They also contacted Business Stream. It became clear that Business Stream had not been billing the club, as they had the property listed as vacant. A bill was sent in February 2011 for the period April 2009 to October 2010. This showed unusually high usage which indicated there had been a leak, until the repair by the club had fixed the problem. The club complained about having to pay for the water that had leaked, as they felt that the cause of the leak was Scottish Water's negligence in laying the pipe at the wrong level. They also complained about the delay in getting the bill.

We found that communication on the club's concerns about the alleged negligence had been inappropriate, and the issues had not been addressed clearly. Standard replies were provided to something that was not a standard situation. The club had been told that there was a policy, but this did not explain the position clearly or why this had not been dealt with as a claim for compensation. It had also not been made clear to the club that Business Stream figures showed the higher consumption was over a longer and slightly different period to the position as understood by the club. We took the view that it would be helpful for a meeting be held between the club, Business Stream and Scottish Water to properly assess the position and to confirm this in writing. This subsequently led to a significant reduction of the bill.

We did not uphold the complaint that there had been a delay in opening the account. We noted that the club also had a responsibility to ensure it was properly paying for utilities and we did not uphold a complaint of delay in setting up the account. However, there was also no information available about what initial checks were made about occupation of the property, but it was clear that the club had been there for some time. We, therefore, recommended an apology be made for this.

Recommendations

We recommended that Business Stream:

• apologise for failing to identify that the property was not vacant in 2009;
• arrange a visit to the club by themselves and Scottish Water to discuss the position in detail, and that Business Stream writes to the club explaining the position and any further steps the club can take; and
• apologise to the club for failing to ensure they received an appropriate response to their concerns.

Summary

Mr C was unhappy with the council's handling of his planning application to convert a disused farm steading to provide five houses. He said they pursued two separate breach of condition notices in respect of land contamination without seeking the agreement of their planning panel, contrary to both the published enforcement charter and planning advice on enforcement. He also said that they did not respond adequately to requests for meetings and discussions, that council correspondence was misleading and misrepresentative and that he had to make an unnecessary waiver application. Mr C also said the council unreasonably issued letters of comfort (a document provided to satisfy a buyer that the local authority will not take action to have work remedied) to two property owners whilst at the same time pursuing him for a breach of condition notice for the entire site, and failed to deal with his complaint in accordance with their complaints procedure.

We took independent advice on this case from one of our planning advisers. We did not uphold most of Mr C's complaints, as the adviser took the view that, in general, the council dealt with the planning matters appropriately. He did point out some areas where the council's actions had been less appropriate, for example where, although it was clearly Mr C's responsibility to comply with contaminated land conditions, the council did not take appropriate action to ensure compliance with the conditions before the houses were sold on. The adviser also said that the chief planning officer's failure to refer (in a letter to Mr C) to a letter of comfort for the fourth house was a significant oversight and meant that the letter misrepresented the situation. Although critical of the omission in the council's letter we were not, however, satisfied that this in itself required Mr C to submit a waiver application at that time.

We did uphold Mr C's complaint about the complaints handling, as we found that it would have been reasonable for the chief executive's office to have passed Mr C's complaint to the head of service in order to help move things on rather than telling Mr C to send a further letter himself. It was also clear that the chief executive's reply was sent to Mr C well outwith the timescale in the council's complaints procedure.

Recommendations

We recommended that the council:

• review their procedures to ensure that, in future, owners of properties subject to a breach of condition notice are properly informed as provided for in Circular 10/2009;
• review their communications between the departments involved to ensure adequate follow-up of planning conditions in future;
• provide Mr C with a written apology for the omission in the chief planning officer's letter; and
• provide Mr C with a written apology for failing to pass his letter of complaint to the head of service and for failing to acknowledge receipt of his letter within the timescale set out in their complaints procedure.

Summary

Mr C and his wife owned a flat in a tenement block. The owners of the block next door knew that a chimney-head on their building was deteriorating, but had done nothing about it. When three years later lumps of masonry fell on to the pavement, the council acted immediately under section 29(3) of the Building (Scotland) Act 2003 to make the chimney-head safe and prevent further danger to the public. The chimney-head next door had to be taken down. When this happened, it turned out that it was in fact connected to the chimney-head on Mr C's block, and it also had dangerous defects. The council got a quote to take down the chimney-head on Mr C's block and rebuild both. Arrangements were also made for another contractor nominated by the co-owners in Mr C's block to access scaffolding to let the owners there instruct works separately. The contractor, however, did not turn up and the council then instructed the works on the basis of the quotation they had obtained. The chimney-heads were rebuilt from the same bases, but contained inside a single casing.

When the apportioned bills for the work were issued, Mr C and other owners in his block disputed them and he eventually complained to the council. When he was unhappy with their response, Mr C brought his complaints to us. We did not uphold three of these - that the council failed to explain to Mr C his legal rights, failed to consult with him over the emergency repair, and unreasonably combined the two chimney-heads into one structure. However, we upheld his complaint that the council did not provide him with estimates for the repair, and we made recommendations aimed at improving communication.

Recommendations

We recommended that the council:

• review their procedures to ensure that in similar situations in the future they provide owners with information on the legislation under which they are acting and refer them to the relevant section of their website; and
• ensure that, in similar future situations, decisions taken orally on re-instatement work are confirmed in writing to interested parties.

Summary

Mr and Mrs C had had a number of problems with their neighbours, which they believed stemmed from their objections to planning applications made made several years before. The council had investigated other concerns about anti-social behaviour some time before, but this time Mr and Mrs C raised further issues. These were investigated by a council officer, who consulted with the police and interviewed Mr C and Mrs C separately. The officer said he would provide a dossier and seek legal advice within the council. He sought the advice some three months later, and it was provided nine weeks after that. The advice was that the information held did not meet the statutory test for the council to pursue formal action.

Mr and Mrs C then wrote to the council's chief executive, complaining about the five month delay in clarifying the council's position. The response (from the deputy chief executive), however, referred back to the original complaints, and ignored two requests for information. Our investigation upheld most of Mr and Mrs C's complaints as we found that the council's response took too long, and was inadequate. We did not uphold their complaint that the council team failed to deal with antisocial behaviour in accordance with council policies and procedures.

Recommendations

We recommended that the council:

• apologise to Mr and Mrs C for the delay in providing them with clarification on whether it was open to the Safer Communities Team to pursue formal action and for the failure to respond to their requests for information raised in their complaints.