Some upheld, recommendations

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.

Summary

Mrs C complained about the care given to her late husband (Mr C) while he was in hospital. She said that he was moved three times but only on the last occasion was it suitable for his condition. She alleged that he was not comfortable or properly looked after and that his clinical care was poor. In particular, she said that he endured terrible pain when his chest drains were being replaced. Overall, Mrs C believed that the lack of proper care hastened Mr C's death. She further complained that she was not kept informed by staff about his condition.

In investigating this complaint, we obtained independent advice from medical and nursing advisers. We also took into account all the information provided by Mrs C and by the board (including the relevant correspondence and clinical records). The board had said that the clinical care and treatment given to Mr C were appropriate. However, our medical adviser said that Mr C should have been referred earlier to a thoracic surgeon and should not have undergone four attempts to insert chest drains, particularly without appropriate sedation. There were also failings in Mr C's nursing care, in that his dignity and privacy were not always protected. We, therefore, upheld Mrs C's complaints about her husband's care and treatment, although we did not uphold the complaint that she was not kept informed, as the evidence showed that good attempts were made to let her know what was happening.

Recommendations

We recommended that the board:

• make a formal apology to Mrs C for the shortcomings in the clinical care given to her husband;
• train doctors, as insertion care appears to be less than adequate, to ensure that drains are properly inserted and secured properly;
• review their protocol for Intercostal Chest Drain to ensure that it is sufficiently comprehensive and includes how to deal with recurrent pneumothoraces;
• make a formal apology to Mrs C for failings in the nursing care given to her husband; and
• provide the Ombudsman with evidence confirming that systems are in place (and regularly monitored) to address the failures identified.

Summary

Mrs C complained about an examination she was given by a doctor before undergoing an emergency caesarean section (c-section - an operation to deliver a baby). She felt the examination was unnecessary, that she was not given information on what it entailed and that the doctor had not obtained her consent for it. Mrs C was also unhappy with the length of time it took the board to reply to her complaint and said that some of the information in their letter was inconsistent with previous information she had been given.

The hospital had identified two days before the c-section was carried out that Mrs C's baby was in the breech position (ie in a bottom down position instead of the more common head down position). We established that on the day of the c-section, it was necessary for the doctor to examine Mrs C to confirm whether her waters had broken and that she was in labour. After taking independent advice from one of our medial advisers, we found that the examination was carried out in accordance with both the board's local policy and guidance issued by the Royal College of Obstetricians and Gynaecologists. Without further independent evidence, we could not say for certain what the doctor discussed with Mrs C about the examination, as her recollection of events differed to those of the doctor. Our medical adviser said that it is good practice for oral consent to be documented, and that the General Medical Council recently issued guidance that a patient's consent to an intimate examination should be obtained and recorded. We noted that this guidance was not in place at the time of Mrs C's examination, however, so although we made a recommendation we did not uphold that complaint.

Whilst we found that the board regularly updated Mrs C on the progress of her complaint, we found that there was a significant delay of three months in providing a full response and we upheld that element of her complaint. We concluded, however, that the response was not contradictory, but provided more detailed information than a previous letter to Mrs C about her complaints.

Recommendations

We recommended that the board:

• ensure that verbal consent for intimate examinations on the labour ward is recorded in a patient's medical records; and
• ensure that complaints are responded to in a timely manner, by carrying out a review of how Mrs C's complaint was handled to identify potential improvements.

Summary

Mr C's business experienced a significant increase in water consumption in December 2011. However, it was not until a further bill arrived in May 2012 that he became aware of an underground leak on the pipework. Mr C noted that Business Stream state on their website that they will notify customers when they identify abnormally high water usage at properties. He complained that Business Stream failed to live up to that commitment, causing his business to incur unnecessarily high bills. Mr C also complained about Business Stream's communication when dealing with his concerns.

Our investigation found that Business Stream's policy is to notify customers if they identify an increase of more than two and a half times the normal level of water usage. We were satisfied that Mr C's water meter was read twice per year in line with normal practice and that, while his water usage increased before May 2012, the increase was less than the two and a half times threshold. As such, we would not have expected Business Stream to contact him before the May 2012 meter reading. After this reading, Business Stream took immediate action to check that it was correct and to phone Mr C. In line with their procedure, when he could not be contacted, they wrote to him to advise him of the high water consumption. We were generally satisfied that Business Stream took reasonable steps to identify the leak and bring it to Mr C's attention.

We found that Business Stream had followed the relevant policy or procedure with regard to each of Mr C's concerns. However, in every case we found their communication with him to be poor. We also found that a policy referred to by their staff was misleading and had likely added to the confusion when explaining Business Stream's position.

Recommendations

We recommended that Business Stream:

• apologise to Mr C for the confusion caused when dealing with his enquiries; and
• consider clarifying the wording of their Burst Allowance Policy to make consistent reference to the 'supply boundary' throughout.

Summary

Miss C's mother had received care services through her local council for a number of years, but these were suddenly withdrawn. Miss C complained to the council and also asked the Care Inspectorate to investigate. The Care Inspectorate investigated four complaints about the council's termination of Miss C's mother's care arrangements and upheld two of those complaints. Miss C was, however, concerned about the way this was investigated, and how the available evidence was used. She asked that they review their decision on two of her complaints. She then complained to us about delays in the Care Inspectorate's handling of her review request and about the lack of any action being required of the council when her complaints were eventually upheld.

We found that, although there were certainly delays in reinvestigating Miss C's complaints, the investigation generally progressed reasonably and communication with her about the cause of the delays was good. The delays were caused by matters that were largely beyond the Care Inspectorate's control. That said, we were critical of the length of time that they took to decide that the two complaints should be reinvestigated. We upheld the complaint about the delay in investigating, but were otherwise satisfied with the Care Inspectorate's actions in terms of notifying the council of their revised decision and following up on the action they asked the local authority to take on the issues highlighted by their investigation.

Recommendations

We recommended that the Care Inspectorate:

• apologise to Miss C for the delay in coming to a decision to reinvestigate her complaint and to conduct the investigation; and
• consider incorporating into the 2012 complaints procedure a specific timescale for the initial assessment of whether a decision should be reviewed.

Summary

Mr C complained on behalf of himself and his neighbours about the council’s handling of a planning application for the erection of a telecommunications mast near his home. Mr C said that he and his neighbours only became aware of this some seven months after it was approved, when work started at the site. He complained that the council failed to carry out the necessary public notifications on the planning application, failed to process the application correctly, and that their report on the planning application was misleading.

In response to our enquiries, the council said that they sent a neighbour notification letter to Mr C in the same way as to other notifiable residents. Although the letter did not appear to have reached Mr C, the evidence suggested that the council did send it, in accordance with normal procedure.

We took independent advice on the other matters from one of our planning advisers who said that the council acted appropriately and advertised the application in accordance with the regulations. The council had, however, acknowledged there were failings in notifying objectors of the outcome of the application and apologised for this. Our adviser said that their remedial action was not sufficient and that further steps should be taken, so we made recommendations that reflect this. We also noted that in the planning report the council incorrectly named the newspaper in which the application was advertised, but considered it unlikely that consideration of the application was prejudiced by this.

In terms of processing the application, our adviser explained that it would be normal practice for there to be some consultation between the council's planning and roads departments. It was clear that there was no record of consultation in this case although the council repeatedly said that it had happened. Based on the evidence on file, it was not possible for us to determine whether or not it did happen, and we were critical of the council for failing to keep a record of the consultation. However, the adviser said that as road safety was not an issue in planning terms, the outcome of the consideration of the application would not have been adversely affected if there had been no consultation. Our adviser also explained that the council were required to consider the application against their development plan; a plan which he said was well in line with good practice on such policies. There was no requirement for the council to have a spatial strategy for telecommunications equipment or to suggest alternative sites for masts. On land ownership, our adviser said it would be reasonable for the council’s planning department to take the information in the signed ownership certificate from the applicant at face value and that there was no requirement for anyone to obtain the owner’s agreement to the submission of an application.

On the accuracy of the report, our adviser said that the 30 metre distance referred to in the site section of the planning report would not have misled the planning committee. He explained that the determining issues in this case were consistent with policy and that the omission of consideration of the tree preservation order and information on the deciduous nature of the trees was not prejudicial.

Recommendations

We recommended that the council:

• make staff aware that the planning report incorrectly stated the newspaper in which the application was advertised and take steps to try to ensure that such errors do not happen in future;
• feed back to the staff involved our adviser’s views on the importance of objector notification and the potential environmental justice implications;
• amend their procedure to reflect our adviser’s views on objector notification; and
• adopt a more rigorous mode of recording significant information, such as the outcome of informal consultation with Roads, for the purposes of subsequent audit.