Some upheld, recommendations

Summary

When Ms C moved to a new house she experienced problems of noise, harassment and intimidation and reported to the association matters that she considered contravened the secure tenancy agreement. She reported matters to the police as well and over a two-year period instructed solicitors, contacted elected representatives and the council, and latterly had help from an advocate in making a formal complaint to the housing association. She complained that the association failed to take appropriate action in response to her complaints of antisocial behaviour; took an unreasonably long time to deal with her formal complaints and did not provide an adequate response; and failed to respond appropriately to correspondence from her GP and to advise on the medical assessment reached.

Our investigation found that there was a lot of documentation, but only two specific antisocial incident files that were opened as a result of contact from Ms C. It was clear that the housing association had not met Ms C's expectations that they would strictly enforce tenancy conditions, but we did not find evidence to uphold her complaint that they had failed to take appropriate action, although we did make a recommendation about letting Ms C know what they would do in future. Our investigation also found that the responses to the complaint were timely and adequate. We did uphold her third complaint, as we found that they had not taken appropriate action in respect of a particular GP letter, and again made a recommendation.

Recommendations

We recommended that the association:

• confirm to Ms C that they will continue to investigate her complaints of antisocial behaviour on their merits, and provide her with written reasons of action taken or why they do not intend to act further; and
• apologise to Ms C for not seeking earlier a copy of a letter from a GP, and for inaccuracies in their stage two complaint response to her advocate.

Summary

Mrs C complained about the children's waiting arrangements in a hospital accident and emergency department (A&E). She said that when she had to go there with her grandson she was appalled that children waited together with adults and were, therefore, exposed to bad language and inappropriate behaviour. She said that despite complaining to the board's chief executive little action was taken and the board failed properly to deal with her complaint.

We carefully considered all the available information, including all the complaints correspondence, and the response to our formal enquiries to the board. Our investigation confirmed that at the time Mrs C made her complaint, the board were simply required to provide emergency care 'within a safe environment' which could have been provided in a variety of ways. Since then, new standards have been introduced which are more than mere recommendations. The board are currently exploring the feasibility of creating a children's waiting area in A&E and reviewing how this could be achieved. However, it would seem that progress is slow. Although we did not uphold this complaint, we made a recommendation in order to monitor this.

The investigation also showed that the board took too long to respond to Mrs C's complaint, so we upheld her complaint about this. We noted that the board have introduced new ways of working to avoid this in the future, and made relevant recommendations.

Recommendations

We recommended that the board:

• update the Ombudsman on the outcome of the feasibility study;
• formally apologise to Mrs C for their failure to deal with her complaint in a timely manner; and
• confirm to the Ombudsman that they are satisfied that their complaints process is robust and the resources to support it are sufficient to allow them to deal properly and efficiently with complaints made to them in accordance with the terms of the Patients Rights (Scotland) Act 2011.

Summary

Mrs C had a long history of chronic obstructive pulmonary disease (a disease of the lungs in which the airways become narrowed) and as her condition worsened, she was admitted to hospital. After initial treatment, because of a shortage of appropriate bed spaces, she was transferred to a surgical rather than a respiratory ward through a process known as boarding. Mrs C complained that, once there, she began to react badly to the medication she was prescribed but staff on the surgical ward were unable to deal with her concerns. She maintained that she was given too high a dose and that she may have been suffering from side effects. She said no one explained this to her or addressed her concerns.

We took independent advice from one of our medical advisers, and carefully considered all the relevant information, including Mrs C's clinical records. We upheld Mrs C's complaints about the ward transfer and about staff not responding to her concerns. Our investigation found that although Mrs C was transferred to a surgical ward, throughout her stay there she was under the supervision of a specialist respiratory doctor; the nursing care she received was the same as that provided on any other ward with the exception of an intensive care ward; and her care had been reasonable. However, the board had not followed their own policy to facilitate such a change of ward. The investigation also showed that despite Mrs C's concerns that she was given an unusually high drug dosage, she had not, although she may have reacted badly to the dosage she received. However, we did find that staff failed to respond to Mrs C's concerns despite her long experience of taking this drug, nor did they address mental health concerns that had arisen.

Recommendations

We recommended that the board:

• review the decision to board Mrs C to a surgical ward in circumstances that were not in line with their own policy;
• assure Mrs C that she will not be boarded during future admissions unless this is in line with their policy, and her care needs, including potential side effects from treatment, can be met on the ward she is transferred to;
• formally apologise to Mrs C for their shortcomings in this matter; and
• review Mrs C's case notes and consider providing her with a letter so that if she is admitted as an emergency in future, clinicians are aware of the circumstances surrounding the prescription of salbutamol and her assessment of how the increased dose affected her.

Summary

Miss C complained about the care and treatment that her late mother (Mrs A) received in two hospitals. She said the board failed to appropriately manage her mother's intake of food and fluids; failed to adequately communicate with her mother and her family; handled her mother's transfer to the second hospital inappropriately; and unreasonably refused to discharge her mother from that hospital despite her wish to go home and her family's willingness to care for her.

We took independent advice from one of our medical advisers, a consultant geriatrician, and upheld most of Miss C's complaints. The adviser explained that in many respects the board managed Mrs A's intake of food and fluids appropriately. However, he was critical of the first hospital's failure to assess Mrs A's nutritional needs using a malnutrition universal screening tool, a universally recognised nursing standard used to identify adults who are at risk of malnutrition.

The adviser said that overall the level of communication by staff in this case was relatively good. However, he was critical of the board's timing of a 'do not resuscitate' decision (a decision that a doctor is not required to resuscitate the patient if their heart stops) and their failure to speak to Miss C face-to-face about that decision, once it had been made, or to discuss the issue of Mrs A not returning home. We also noted that the tone of one of the consultant's comments was rather insensitive.

Our investigation found significant failings by the board in their handling of Mrs A's transfer to the second hospital. These included the assessment for transfer, the transfer decision, the documentation transferred, speech and language therapy assessments before and after transfer, and engagement with Mrs A's family. We were also critical of the board for failing to advise Miss C, in their response to her complaint, about failings in her mother's transfer that were identified in the internal correspondence between the consultants at the time of the transfer.

We did not uphold the complaint about Mrs A's discharge from the second hospital, as we took the view that the board's actions were reasonable in the circumstances.

Recommendations

We recommended that the board:

• apologise to Miss C for each of the failings identified;
• feed back our decisions on these complaints to the staff involved to try to ensure that similar situations do not happen again; and
• review their transfer arrangements, including assessment for transfer, to try to ensure that such failings do not occur in future.

Summary

Mr C complained about the care and treatment provided to his late mother (Mrs A) by her medical practice. He also complained that they failed to refer her to hospital for definitive diagnosis. Mrs A had been living in a care home. She was examined by a doctor from the out-of-hours service in the early hours of the morning. He recorded that there were signs that she had vomited blood and that her abdomen was soft and 'non-tender'. He recorded that his diagnosis was gastritis and that the care home should observe Mrs A. Mrs A was seen by a GP from the practice later that day. The GP considered that she had melaena (passing blood in the stool), haematemesis (vomiting blood) and an upper digestive tract bleed. He did blood tests and stopped some of her medication. He also prescribed omeprazole (medication used to reduce the amount of acid produced in the stomach). Mrs A was examined by the practice on a number of occasions over the next few weeks and was admitted to hospital three weeks after the first GP had examined her. Mrs A died of a small bowel obstruction in the hospital nine days later.

The practice GP who examined Mrs A decided to keep her at the care home and carry out non-invasive investigations, and to adapt her medication. After taking independent advice from one of our medical advisers, we considered that this was reasonable. Mrs A was bleeding from the digestive tract, and there was no evidence to suggest that she had a small bowel obstruction at that time. Our adviser said that even if she had been admitted to hospital earlier, the decision not to carry out invasive procedures would still likely have been made, given her overall frailty and general poor health. There would also have been no benefit in admitting Mrs A to hospital as an emergency, when there were nursing staff in the care home who could monitor her condition. We found that the practice's management of Mrs A's care and treatment was reasonable and there were no failings in the clinical treatment provided.

That said, Mr C was welfare power of attorney for his mother, and so her care should have been discussed with him. There was no evidence that the practice consulted him about the treatment provided to Mrs A and about her future care plans. We found that the practice had incorrectly assumed that the care home staff would have told Mr C about this. However, there was no evidence that the practice checked that this had happened or that they spoke directly to Mr C to discuss his mother's condition. In their response to Mr C's complaint, they had apologised and said that they would review their communication processes to improve on this.

Recommendations

We recommended that the practice:

• provide evidence that they have taken action to review their processes for communicating with relatives in light of Mr C's complaint.

Summary

Mrs C was unhappy with the medical treatment and nursing care that her late mother (Mrs A) received in hospital over a two-month period. Mrs A was admitted to hospital with a fractured leg and suspected heart attack after a fall at home. Mrs A had an operation shortly after her admission. Unfortunately, her condition continued to deteriorate and she died several weeks later. Mrs A had previously had two liver transplants because of liver disease, and Mrs C said that there was an unreasonable delay by the hospital clinicians in contacting the transplant unit at another hospital for advice. She also questioned whether appropriate medication was provided and whether Mrs A's increasing confusion was addressed properly. In relation to nursing care, Mrs C said there was a failure to prevent Mrs A falling from her bed and in seeking medical attention when her condition deteriorated. Mrs C and her family were also distressed by the manner in which staff treated them about obtaining Mrs A's death certificate.

The advice we accepted was that despite appropriate surgical and medical management, Mrs A's liver started to fail following surgery. As she was not suitable for a further liver transplant, unfortunately her death was unavoidable. Furthermore, although the medical adviser considered that the transplant unit should have been contacted earlier this did not have any bearing on the eventual outcome. Having said that, we also found that there were failings by clinical staff in relation to record-keeping and in their communications with Mrs C and her family which, understandably at such a difficult time for them, caused distress. The medical adviser said, however, that these did not have any adverse effect on Mrs A's clinical treatment or outcome. Nonetheless, we were concerned about the failures given the seriousness of Mrs A's condition, in particular the failure relating to record-keeping which does not show that appropriate medical assessments were carried out over four days following her admission and operation. Therefore, we found that staff at the hospital failed to provide Mrs A with an appropriate level of clinical treatment.

Having carefully reviewed all of the evidence and the advice received from the nursing adviser, we were unable to establish exactly what happened in relation to nursing care and attitude, due both to a lack of evidence and the differing accounts of those involved. The board apologised for specific issues raised about staff attitude, and accepted there was a failure to provide Mrs C with the appropriate information booklet following Mrs A's death. In relation to Mrs A's fall, the nursing adviser said that the care plan and assessment that did not put Mrs A at high risk of falls was appropriate. Taking account of all of the evidence, we did not find that nursing staff failed to provide Mrs A with an appropriate standard of nursing care and treatment.

Recommendations

We recommended that the board:

• ensure timely referrals to all appropriate specialists where a patient has complex medical conditions (transplant patients in particular) so the specialists are involved early in the patient's treatment;
• review how clinical staff communicate with a patient's family and share our medical adviser's comments with them;
• act on the comments of our medical adviser in relation to poor record-keeping and share those comments with the appropriate staff;
• ensure that appropriate medical assessments are carried out on the ward and are documented; and
• apologise to Mrs C and her family for the failings identified in our investigation in relation to poor communication and record-keeping.

Summary

Ms C, who is a claims assessor for an insurance company, contacted us on behalf of her client (Mr A). Mr A was concerned that an operation to fix a fracture to his upper leg had failed and he was left with a shortened leg as a result. He thought that this was because a junior doctor was allowed to complete the operation unsupervised, and said that follow-up physiotherapy had only caused him additional concerns when the fracture re-opened. Mr A also believed he suffered a morphine overdose at the time of surgery which left his health additionally compromised and contributed to a post-operative problem with blood clots.

We took independent advice on this complaint from three of our medical advisers – specialists in orthopaedics, anaesthetics and physiotherapy. The orthopaedic adviser said that the surgery was not performed to an adequate standard, although not because of a lack of supervision. The adviser noted that during the operation there had been difficulty inserting screws to fix the fracture, and ultimately these had not been placed correctly. This was a recognised complication, but one he felt should have been identified at the time. He was concerned that there was no record showing that the possibility of the leg being left shortened was discussed with Mr C beforehand. The dosage of morphine was not considered to be unreasonable in the circumstances of the trauma Mr C had suffered, although it was clear that he had suffered a recognised side-effect from it. The physiotherapy problems were considered to be an inevitable consequence of the failed surgery, but not unreasonable in all the circumstances. We upheld the complaint about the standard of surgery but not those about supervision or physiotherapy.

Recommendations

We recommended that the board:

• provide evidence that their new consent form is now routinely used and includes space for noting all risks discussed; and
• remind surgical staff of the need to make a comprehensive note of operations, particularly where adverse technical problems have arisen, so that subsequent review is possible.

Summary

Miss C complained that the college had unfairly withdrawn her from her course and had failed to address her concerns about her placement. She had reported these, and when she felt they were not being addressed, tried to find an alternative placement herself. She said that the college did not allow her to take up the alternative and instead told her that she was being withdrawn from the course.

Our investigation found that the college had not allowed enough time to investigate Miss C's concerns before withdrawing her. Although some of the information Miss C gave us could not be verified, we took the view that the college should have arranged to slow things down by allowing time for proper discussion with Miss C to explore her concerns. We also saw no evidence that the college asked the placement for their views on what had happened, and we found they did not properly follow their procedures when withdrawing Miss C.

Recommendations

We recommended that the college:

• apologise for not addressing and investigating Miss C's concerns about her placement;
• apologise for not following reasonable procedures when they withdrew Miss C; and
• share our findings with relevant staff.

Summary

Mr C, who is a prisoner, had special security measures imposed upon him by the prison. These were put in place to ensure that Mr C could be managed safely. Mr C complained to us because the paperwork completed by the prison in deciding to put those measures in place was missing. Mr C also complained because the measures were applied even when the relevant paperwork was missing.

The prison agreed that the paperwork was missing and because of that, we upheld the complaint. However, we did not make any recommendations because once the prison became aware that the paperwork was missing, they took steps to replace it by completing it again. We did not uphold Mr C's complaint that the measures were applied although the relevant paperwork was not available. The prison had the authority to impose the measures, and the evidence they provided confirmed they had concerns about Mr C's safety.

Mr C also complained because the governor told him that she would respond to his complaint once her investigation was complete. The prison could not provide any evidence to show us that the governor had responded, and because of that, we upheld that complaint.

Recommendations

We recommended that Scottish Prison Service:

• apologise to Mr C for failing to respond appropriately to his complaint.

Summary

In January 2009, an inquiry reporter decided to uphold a council decision to refuse planning permission to build houses in a long established area of open space behind the homes of Mr and Mrs C and their neighbours. When, in March 2012, the council granted planning consent for residential development of the same site, Mr and Mrs C and their neighbours were unhappy and made nine detailed complaints to the council and then to us. Seven of these related to the report of handling of the later application that council officers presented to members of the council committee.

We upheld three of the seven complaints about the report of handling - in relation to failure to refer to a planning advice note and to fully address and consider the implications of the reporter’s dismissal of the appeal on the first application. The other two complaints, which we also upheld, related to a lack of proper evaluation of the loss of open space that implementation of the proposals would entail and unreasonable delay by the council in investigating the complaints.

Recommendations

We recommended that the council:

• consider and set out a timetable for the preparation of an open space audit and strategy to comply with Scottish Planning Policy on Open Space and Physical Activity; and
• consider the preparation of internal guidance that reports of handling should assess all relevant aspects of planning history, particularly where a previous decision might be seen to be contradicted by the proposed recommendation; and clearly distinguish between the analysis of the provisions of the development plan in force and those of any emerging plans as material considerations.