Some upheld, recommendations

Summary

Ms C complained about the length of time that the housing association took to complete repairs to her flat. She had moved into her property in December 2012 and had been in contact with the association from then on about repairs, before eventually making a formal complaint some three months later. At that point the association agreed to the works to be done and closed Ms C's complaint. However, Ms C then submitted a new complaint that her home had not met the standards that the association set for their properties. Because of this she said she wanted a refund of her rent up until that time.

The association upheld this complaint and acknowledged the delays in carrying out repairs. They offered Ms C a lesser amount of compensation but Ms C did not feel that this was appropriate. She told the association about the difficulties the delays had caused her in her particular circumstances and maintained that she should be entitled to a full rent rebate. Although the association's final response confirmed their earlier decision to uphold Ms C's complaint, confirmed that her home had not met their standards, and increased their offer, they did not agree to refund the rent in full.

We found evidence that the delays in having the repairs completed were unreasonable and so we upheld Ms C's complaint. However, we do not have the legal power to question the association's decision of how much compensation to award, unless there is some evidence of fault, omission or failure on their part in making that decision. We did not find this in Ms C's case, as the association had made their award based on the 'right to repair' regulations.

Recommendations

We recommended that the association:

• confirm to us that any repairs outstanding from Ms C's complaint have been completed.

Summary

Mrs C lives in a house that had electric night storage heaters, using an economy meter with a reduced tariff. Following public meetings with their tenants, the housing association decided to implement a programme of external wall insulation and replace night storage heating with an air source heat pump system. After the necessary consents were obtained, work started in November 2012, in phases of groups of houses. Tenants were advised of timescales and the start date, and were told that external works were weather dependent.

The internal work was completed in Mrs C's house the following February, during what turned out to be an extremely cold winter, but it was not until May that the external insulation was completed and scaffolding was removed. Mrs C complained that the information and advice she was given about the new heating system was inadequate, and that the association did not complete works within the specified timescales.

Our investigation found that the association had had a lot of contact with tenants to explain what would be involved. They had not, however, made it clear to Mrs C that she would lose her economy meter and would have to negotiate a new tariff for electricity with her energy supplier, and so we upheld her complaint about this. We did not uphold her other complaint as the association had made it clear in advance that external insulation works were weather dependent.

Recommendations

We recommended that the association:

• apologise for failing to advise Mrs C of the need to make early contact with her energy supplier;
• consider whether they should reimburse Mrs C for any unavoidable costs incurred between the removal of the economy meter and the application of the new tariff and confirm the outcome; and
• apologise for the confusion caused to Mrs C by a letter stating that the scaffolding had at that time been removed.

Summary

Mr C was undergoing treatment for leukaemia and had to have a 'Hickman Line' (a small tube to give long-term access to a vein to administer chemotherapy) inserted. Mr C complained that this procedure was not performed correctly as it had caused him a great deal of pain. He also complained that his complaint about it was not dealt with reasonably.

Our investigation, which included taking independent advice from one of our medical advisers, found no evidence that the procedure was not carried out properly. The adviser said that different patients experience differing levels of pain in such a procedure and there was no evidence that anything went wrong with the first insertion. However, no record of the problems Mr C experienced was made at the time. The radiologist who performed the procedure had, after speaking to Mr C after the procedure, agreed to make a record in the clinical notes and to put an alert on the electronic records saying that Mr C required sedation for any future insertion. This did not happen and, when Mr C had to be admitted for a further line to be inserted, he was distressed that the team were not aware of his experience. Because of this, although we did not uphold the complaint about the procedure, we made recommendations about record-keeping.

On the matter of the complaints handling, it was clear from our investigation that for a number of reasons, there were extended delays in the handling of Mr C's complaint. Some of these were outside the board's control but some were not, and so we upheld this complaint.

Recommendations

We recommended that the board:

• apologise to Mr C;
• conduct an audit of record-keeping in the department and use any learning points to formulate an action plan for improvement;
• ensure their patient information leaflet is provided to patients before consent is given and that this is documented; and
• provide evidence that the complaints handling team have learned from these events and that those learning points have been used to improve the service.

Summary

Ms C, who is an advocacy worker, complained on behalf of her client (Mrs A) about the care and treatment provided to Mrs A's late husband (Mr A) before he committed suicide. Mr A had a history of depressive illness. He was referred to a community psychiatric nurse (CPN). He saw both the CPN and the board's mental health assessment service before he was admitted to hospital after presenting with suicidal thoughts. He took his own life two days after being discharged from hospital.

In considering this complaint, we took independent advice from our psychiatric adviser, after which we upheld only one of Ms C's four complaints. Ms C had complained that the CPN delayed in referring Mr A to hospital. Our investigation found, however, that the CPN had not delayed in referring him to a consultant psychiatrist at the hospital. We were also satisfied that there were reasonable attempts to manage Mr A with other treatments, and noted that there was contact with other parts of psychiatric services at an early stage.

Ms C also complained that the board failed to make a reasonable diagnosis or offer reasonable treatment and medication to Mr A when he was admitted to hospital. Our investigation found that Mr A's case was complex and he had diagnoses of personality disorder and depression. The risks he presented were considered and assessed, but it was concluded that he did not meet the criteria for detention. We found that attempts had been made to manage his case with appropriate drug and psychological treatments and our adviser said that his treatment and medication were reasonable.

Ms C also complained that the board failed to carry out an appropriate risk assessment. She said that they failed to properly assess the risk of suicide and child protection issues. She also said that they had failed to involve Mrs A when deciding to discharge Mr A. We found that the hospital had carried out frequent risk assessments on Mr A in a satisfactory manner. He did not show impaired decision-making and so could not be detained in hospital. We also found that Mrs A was involved as far as possible in her husband's care, and that child protection issues were taken into account. However, we upheld the complaint about the assessment of risk, as we found that Mr A had been discharged to his brother's home. We considered that the hospital should have asked Mr A for consent to contact his brother in order to involve him in the discharge plan, and to check if there were children at his address. We noted that the standard documentation around discharge had not been completed and had this been done, it could have acted as a prompt to contact Mr A's brother.

Recommendations

We recommended that the board:

• make the staff involved in Mr A's care and treatment aware of our findings.

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.