Some upheld, recommendations

Summary

Mrs C's two children were educated at home. During the academic year 2011/2012, they both attended a course at a local community high school. However, with little notice, the course was withdrawn and there was no alternative provision. Mrs C was later told that community courses were only available to adults and young people over the age of 16. She said this was contrary to her experience as one of her children was aged 14 when attending the course. Mrs C complained that the council unreasonably denied her home educated children access to community courses and caused unnecessary confusion to her and her family, as their communication with her about community courses was unclear and inconsistent.

Our investigation took into account all the relevant information, including the complaints correspondence and complaints file, the council's policies on education complaints and home education, and relevant sections of the Scottish Government's home education guidance. We found that while the council applied a standard policy with regard to community education, they did not have any documentation about this. It was their intention to develop guidelines to avoid confusion to staff and customers. The council also acknowledged that one of Mrs C's children had previously been allowed to attend a community course in error. The investigation further confirmed that the information given to Mrs C was unclear and confusing, particularly in the absence of a formal written policy.

Recommendations

We recommended that the council:

• apologise for the confusion caused by their correspondence;
• apologise to Mrs C's daughter for her disappointment in being allowed to successfully audition when she did not meet the qualifying criteria; and
• develop a set of written guidelines regarding access to community schools.

Summary

Ms C was unhappy with the heating system in the property she rented from a housing association. She complained that it was ineffective, unreliable and expensive to run. She also complained that the association had failed to carry out repairs or to deal with her complaint appropriately.

Our investigation found that the heating system was chosen by the previous tenant, and there had been difficulties with it that had taken months to resolve. We were concerned that the association had not assessed Ms C's medical information before offering her the property. We also found that although she had been told the location of the property's Energy Performance Certificate (EPC), which had indicated that the efficiency of the main heating was very poor, the EPC and the potential running costs of the heating system had not been explained to her. We found no evidence that general repairs had not been carried out, or that the association had failed to investigate Ms C's concerns about dampness but we were concerned that it took some months before the heating system was repaired, especially as the problems had occurred during the winter.

We, therefore, upheld Ms C's complaints that the system was inappropriate and that the association did not carry out repairs appropriately. We found no evidence, however, that they failed to deal with Ms C's complaints.

Recommendations

We recommended that the association:

• issue Ms C with an apology for the failings identified in the complaint;
• ensure that both a copy and a full explanation of the EPC is provided to prospective tenants before a tenancy agreement is signed; and
• ensure that when they receive a completed Health and Housing Need form from a prospective tenant that this is assessed and taken into account before a tenancy agreement is signed.

Summary

One of Mr C's children is severely disabled, and the family home was not suitable for his family's needs. He had for several years been awaiting the offer of a suitable house. When local builders submitted planning applications for part of a new housing association development, Mr C's child was twice assessed by a council occupational therapist for the adaptations that would be needed for one of the new houses to meet their specific needs. These adaptations were to be funded by the council and would be communicated in a particular design brief to the builders. Mr C was provided with a copy of the then current plans, which showed the proposed house to be detached. Mr C attended a meeting with the association in the late summer of 2010, and in response to queries he raised in email correspondence was informed that several of the points could be postponed to a subsequent detailed design stage. After planning consent was given for the development, the plans were amended without further consultation with Mr C or the council's occupational therapist. When Mr C saw the amended plans, he said that these showed a semi-detached house and that there were other significant differences in the proposals.

Mr C made two complaints - firstly that the association unreasonably altered the plans, and that this meant that the house would not meet his child's needs; and secondly that the association failed to inform him or consult with him about the amended plans. We did not uphold Mr C's first complaint as there was no unequivocal evidence that the association had instructed the amendments. When they learned that changes had been made, they had rectified matters by instructing further changes to ensure that the house, when completed, would meet Mr C's child's needs. The association agreed, however, that there had been a breakdown of communication with Mr C and so we upheld that complaint and made a recommendation.

Recommendations

We recommended that the association:

• liaise with relevant senior officers in the health partnership now responsible for Occupational Therapy input, to look into the issues of communication in this case to better identify the specification of needs in new build projects and to manage family expectations.

Summary

Mr C complained about the care and treatment the board provided after he went to their accident and emergency department (A&E). He said that they failed to appropriately examine and assess his symptoms of severe abdominal pain with urinary and bowel problems. He also said that they inappropriately discharged him at 05:30 in the morning without considering whether he had the means or ability to return safely home. Mr C said that after seeking further medical assistance elsewhere, he was admitted to hospital the next day with an obstructed bowel and was kept in for assessment and treatment.

We took independent advice on this case from one of our medical advisers. The adviser said that the assessment and examination in A&E were of a reasonable standard and that the treatment Mr C received elsewhere the next day did not indicate otherwise, so we did not uphold his complaint about care and treatment. However, the adviser was critical of the board for failing to have adequate discussions with Mr C about treatment for constipation and failing to give him laxatives to take home with him. The adviser also said that they failed to discuss practical arrangements for Mr C's discharge to ensure that he could return home safely. We upheld the complaint about discharge and made recommendations accordingly.

Recommendations

We recommended that the board:

• provide Mr C with a written apology for the failings identified;
• feed back our adviser's comments on the treatment of Mr C's constipation to the staff who examined him in A&E; and
• remind relevant nursing staff of the need to discuss and make appropriate discharge arrangements for patients in A&E and record this information in the clinical notes.
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Summary

Mrs C complained that a hospital made mistakes in the reporting of an x-ray that her late mother (Mrs A) had taken on 10 April 2012 after falling in her care home and injuring her left knee. Mrs A was discharged from hospital that day but was admitted to a second hospital three days later because she was in severe pain and unable to put weight on her left leg. She was eventually found to have fractured her knee. When the second hospital asked the first hospital to carry out another x-ray seven days after the first, the first hospital found that there had been an error in the reporting of the original x-ray.

Mrs C felt that the board had delayed in taking action to investigate whether there was a problem with the x-ray or arrange a follow-up, when Mrs A's symptoms did not resolve. Mrs C was also concerned that there was a failure to establish the reasons why the x-ray was wrongly interpreted. The board had explained that the likely cause of the error was a problem with their software system for viewing x-rays, which meant that a much older image of Mrs A's knee was superimposed on the new image. They advised that the error was a rare and unusual incident but that they had made relevant staff aware of the matter to ensure it did not happen again. However, our investigation identified that there was also an error with the reporting of the x-ray that was requested seven days after Mrs A fell, as it too was initially noted as showing no fracture. The board said of this that the x-ray image on 10 April 2012 had been displayed when trying to view the image taken seven days later.

We could not say for certain whether the errors in reporting the x-rays were as a result of a failure in the software system, or the wrong x-ray being opened, or if the correct x-ray images were viewed and the fracture was simply not identified. We concluded, however, that the board had not provided sufficient evidence that they had carried out a thorough investigation into both x-ray incidents. However, we noted that the first hospital had promptly arranged for Mrs A to return the following day for a second x-ray after the fracture was identified. We upheld Mrs C's complaints about interpretation of the x-rays, but not about their follow-up action.

Recommendations

We recommended that the board:

• undertake a significant event analysis into the reporting of the x-rays taken after Mrs A's fall, to establish clearly where the fault lay in order to reduce the likelihood of this happening again; and
• apologise to Mrs C for the failings identified.

Summary

Mr C's young daughter (Miss C) suffers from a number of medical conditions and has serious mobility problems. She uses either a wheelchair or a gait trainer, both of which need a lot of space for turning. After a number of years during which the family waited for a suitable house, a housing association, in conjunction with the local council, agreed to provide a new house. In relation to this, an occupational therapist from the health board assessed Miss C's housing needs and liaised with the housing association. Mr C complained that the occupational therapist did not properly assess Miss C and ensure that the house being built met her needs. He alleged that when he complained to the board about the situation, they did not properly investigate it.

Our investigation found that the procurement process for the house being built to meet Miss C's needs was not straightforward. There were a number of agencies and organisations involved and the role of the occupational therapist was to assess Miss C's needs in order to properly facilitate them in the development of the properly. The occupational therapist provided her professional opinion of what these needs were. However, during the complicated construction and development, the housing association contacted the occupational therapist about a number of design changes, which she agreed without speaking to Mr C. If followed through, one of these changes would have had serious repercussions for Miss C's mobility. We also found that Mr C had first complained to the council, who passed him on to the health board, but then the board took too long to reply to him. We, therefore, upheld his complaints about these matters, but not about the assessment of his daughter's needs, in which nothing had gone wrong.

Recommendations

We recommended that the board:

• apologise to Mr C for the errors identified, and for the delay in responding to his complaint.

Summary

Mr C had a history of heart problems and was previously a patient of the practice. He said that, while he was their patient, they twice lost blood samples although the explanation given was that they were lost by the hospital. Mr C also complained that on one occasion when he attended the practice while experiencing heart symptoms, he was seen by a nurse and then sent home after discussing his condition with a doctor, having been told he might have shingles. He said that when he returned home, he was so ill that he required an emergency ambulance to take him to hospital.

To investigate the complaint, we obtained independent advice from one of our medical advisers, and took this into account with all the available information, including the complaint correspondence and relevant clinical records. We upheld the complaint, as our adviser identified a number of problems in handling Mr C's blood samples. They also said that when Mr C went to the practice he appeared to be suffering from a number of symptoms indicating the likelihood of a heart attack, which should have been addressed differently. In accordance with relevant guidance he should have received a detailed assessment by a doctor and been treated with glyceryl trinitrate spray to relieve pain.

Recommendations

We recommended that the practice:

• review their transport procedures after blood samples are taken from patients;
• carry out a review of their system and submit the results to their Community Health and Care Partnership lead for an external review;
• review their management and procedures of 'walk in patients' and clarify and review their Practice Nurse/Advanced Practice Nurse competencies/ autonomy;
• discuss Mr C's case as part of the GP appraisal process;
• carry out a significant event analysis; and
• note the 'identification and management of acute myocardial infarction' within their appraisal learning needs and review SIGN Guidance 93 (guidance for dealing with such matters).

Summary

Mr C complained about the care and treatment of his late mother (Mrs A) when she was admitted to hospital. Mrs A suffered from cognitive impairment (a condition that affects the ability to think, concentrate, formulate ideas, reason and remember) and had difficulty settling. Although Mr C's sister offered to come in to help her go to sleep, staff refused the offer. Mr C said that, when he visited on the evening of her admission, he found his mother 'trapped' in a chair behind a desk at the nursing station. She was cold, with no blanket, socks or slippers. Mr C said that throughout her stay in hospital his mother received only basic care and, although she was diagnosed as having gastric cancer at the end of her stay, she was discharged the next day without a care plan in place and with only a box of paracetamol.

Mr C said that the board did not deal with his family reasonably on the day his mother was admitted to hospital, nor did they make reasonable arrangements for Mrs A's discharge. Mr C was also unhappy with the way in which the board responded to his subsequent complaint.

Our investigation took all the relevant information into account, including the complaints correspondence and Mrs A's clinical notes. We also obtained independent nursing advice. The adviser said that while it was not clear why Mrs A was in the chair on the evening of her admission, she had been there too long. The adviser also said that the offer of assistance should perhaps have been accepted, and that communication with Mr C and his family that day was poor. Because of this, on balance we upheld the complaints about communication and Mrs A's overall care and treatment, although we found that her medical care was reasonable. We found that a discharge plan was available for Mrs A, but there was no evidence that it had been communicated adequately to her family or her GP and so, although we did not uphold this complaint, we made a recommendation. Our investigation found that the board had reasonably dealt with Mr C's complaint.

Recommendations

We recommended that the board:

• formally remind staff on the ward of the professionalism required of them;
• remind appropriate staff of the necessity of completing patients' records properly and fully; and
• advise the Ombudsman of the action since taken to prevent such a situation recurring, and if no action has been taken, advise what is proposed.

Summary

Mr C complained about issues arising when his late wife (Mrs C) was admitted to hospital. He said that at first it was believed that Mrs C was suffering from pneumonia and had suffered a slight heart attack. This was confirmed by a heart scan. However, during her stay in hospital, Mrs C began to show symptoms of confusion. A psychiatric opinion was obtained which confirmed that she was suffering from fluctuating delirium (confusion). Despite Mr C's concerns about his wife's mental health, he said he was told that she was not detainable in hospital and was subsequently discharged. Mr C said that at this time she was in a very confused state.

A few days later, Mrs C was readmitted to hospital as an emergency. Mr C said he was advised that his wife had not suffered another heart attack and that no procedures would be carried out. He was told that he could go home, which he did. However, after short time, Mrs C died without her family beside her.

Mr C complained that his wife was discharged from hospital despite being in a very confused state. He also alleged that the board failed to explain the seriousness of Mrs C's condition to him and said that she had not suffered a heart attack.

As part of our investigation we obtained independent clinical opinions from two of our medical advisers, who are consultants in geriatric medicine and forensic psychiatry. Having considered her medical records, they confirmed that Mrs C's state of mental health was not such that the board could detain her, and concluded that she was not unreasonably discharged from hospital. We did not uphold this complaint. However, we found that the notes taken at the time of Mrs C's final admission were insufficiently clear to confirm what Mr C was told about her condition. It was clear, though, that his wife had in fact suffered a very serious heart attack from which she was unlikely to recover. It was, therefore, arguable whether Mr C was given appropriate information from which he could make an informed decision about whether to leave the hospital. We upheld Mr C's complaint about the information provided.

Recommendations

We recommended that the board:

• make a formal apology for the circumstances on the night of Mrs C's death; and
• remind staff in Accident and Emergency and the Coronary Care Unit of their obligation to properly record the information given to families about the condition of their relatives who have suffered a heart attack.

Summary

Mr C, who is a MSP, complained on behalf of Mrs A's family. Mrs A, who was 94, was admitted to hospital with shortness of breath, and chest and back pain. Her family were told that she would be examined for a possible chest infection or a clot on her lung. Mrs A was found to have a chest infection and pneumonia. The family were reassured that she would be discharged home within a few days. During her admission, however, Mrs A had a fall and a number of seizures. She also developed confusion. Her breathing difficulties persisted and she died nine days after admission.

Mr C raised a number of concerns about the treatment and nursing care provided during Mrs A's admission. He also complained about the level of communication with the family.

We took independent advice from two of our advisers, one a specialist in the care of older people, and the other an experienced nurse. Our investigation found that, although Mrs A was initially assessed as being at a low risk of falling, she was not reassessed in line with the board's policy after she fell, and so we upheld the complaint about this. That said, we were satisfied with the level and type of investigations that the board carried out to assess whether she had incurred any injuries or whether her condition had changed. We did not uphold the other complaints, as generally we found the nursing care to be adequate, although we highlighted some issues that could have made Mrs A's stay in hospital more comfortable. Mrs A's family had found the communication from staff to be poor and the information contradictory on some occasions. Based on the clinical records, however, we were satisfied that the family were given full details of the nature and severity of Mrs A's condition. We recognised that there may have been additional conversations not documented in the notes, but felt that, overall, the communication was sufficiently frequent and detailed.

Recommendations

We recommended that the board:

• remind staff of the post-fall protocol outlined in the in-patient falls resource pack and the need to properly record all action taken; and
• provide the Ombudsman with evidence of the additional training provided to nursing staff.