Some upheld, recommendations

Summary

Mr C complained that when he went to the practice for root canal treatment, the dentist fractured a crown and broke a portion of a front tooth. The dentist put in the existing crown, which lasted for two days. Mr C returned to the practice, but a further repair only lasted a day. Mr C obtained an emergency appointment with another dentist who inserted a temporary crown. On returning to the first dentist for further treatment Mr C explained he had been in a lot of pain and was unhappy that he had to pay for a new crown.

The practice said that Mr C had agreed to save the tooth and in order to carry out root treatment it was necessary to drill through the inner surface of the tooth/crown. At that point it was not possible to ascertain how much tooth structure was present below the crown. The practice said that the first dentist explained this to Mr C and that a fractured crown is a recognised problem which occurs fairly commonly after root treatments. The practice went on to say that it was also relatively common for temporary crowns to fall out, as normally they are only used for two weeks until permanent restoration can take place.

Mr C complained to us that the treatment options were not explained to him and he was not told the crown could be damaged. After taking independent advice from a dental adviser, we found that clinically the treatment which had been provided was appropriate. However, we upheld part of Mr C's complaint as we found no recorded evidence that the dentist had communicated the risks to him.

Recommendations

We recommended that the dentist:

• reflects on the importance of completing detailed records regarding communication with patients.

Summary

In 2007, Miss C was diagnosed with ulcerative colitis, a form of inflammatory bowel disease (IBD) causing ulcers or open sores to form on the colon. She suffered severe flare-ups in 2008 and 2010, and had to be admitted to hospital. Miss C explained that she was very aware of her own body and recognised the pattern of symptoms that would lead to flare-ups. She developed bleeding in 2011 and was referred to a gastroenterologist (a clinician specialising in the treatment of conditions affecting the liver, intestine and pancreas). Miss C complained that, although she was sure that she was heading towards another flare-up, the gastroenterologist did not take her concerns seriously and provided investigations and medications that did not help her. Ultimately, she developed a severe flare-up, and needed surgery.

We did not uphold most of Miss C's complaints. It was not possible to determine from the records what conversations had taken place between her and the gastroenterologist, or how seriously her concerns about her condition were taken. However, we found clear evidence that medication decisions were affected by what she had said. We also accepted independent medical advice that the treatment plan put in place for Miss C was appropriate for her symptoms and in line with national guidance. Our adviser said that Miss C's treatment did not deviate from the British Society of Gastroenterology’s Guidelines for the management of inflammatory bowel disease in adults (the BSG Guidelines).

Miss C also complained that the board did not obtain her medical records from another health board that had treated her previously. We were satisfied that procedures were in place to obtain records where necessary. However, on this occasion, the gastroenterologist had decided to conduct a fresh review of Miss C's symptoms, which we considered reasonable.

Although we found the treatment decisions to have been appropriate and made with reference to information from Miss C, we were critical of the standard of communication with her, and upheld her complaint about this. We found that staff could have done more to empathise with Miss C during her admission, and to explain the reasoning behind treatment decisions that she did not agree with.

Recommendations

We recommended that the board:

• provide details to the Ombudsman of the facilities they have in place to meet the BSG Guidelines' requirement to provide patients with access to an IBD helpline;
• consider asking their clinical team to review how they communicate with patients in terms of explaining decisions made about their treatment; and
• ask the clinical team to consider how they can ensure patients' comments, concerns and treatment options are discussed empathetically.

Summary

Mr C complained on behalf of a neighbour (Ms A) that Scottish Water’'s actions in respect of flooding were unreasonable. He said that Scottish Water had accepted that there was water coming in under Ms A's property, but had said that there was no evidence this was caused by their sewerage network. Ms A lived beside a beach and Scottish Water said that the flooding could have been caused by seawater.

We noted that Scottish Water only have funding to deal with capacity issues (where their sewers overflow) that cause internal flooding to a property. If the cause of external flooding is a simple blockage that can be easily fixed, they will do so, but if it is a structural problem, this may be more difficult to deal with. Our investigation found that there had been external sewage flooding around Ms A's home. We took the view that if the flooding was considered to be external, and Ms A had agreed that it was, then Scottish Water's actions would have been reasonable. However, we found evidence indicating that there was enough water under the floor of Ms A's bedroom to cause damage to skirting boards and internal plasterwork. There was also a report of odour, and damp meter readings were very high. We, therefore, upheld this complaint, as we considered that Scottish Water should have looked further into the reports of internal flooding at Ms A's property. Had they then identified internal flooding, they should have taken further action.

Mr C also complained that Scottish Water's communication with him and Ms A had been unreasonable. We did not uphold this complaint, as we did not find any evidence of this.

Recommendations

We recommended that Scottish Water:

• issue a written apology to Ms A for the failure to carry out further investigation into the reports of internal flooding at her home; and
• carry out further investigations to try to identify if the internal flooding was caused by their sewerage system. They should assess both the cause of the flooding and the risk of this occurring again in the future.

Summary

Ms C runs a dog grooming business from home. She complained that Business Stream phoned her and asked for details of her business without giving reasons for the call, then emailed her saying that they were the licensed provider for the water and waste water services for the business element of her property. She then received demands for payment for 2011 to 2013. Ms C complained of delay in notifying her that she was liable for these services, and that the charges were inaccurate and Business Stream would not engage reasonably with her to resolve the matter. Ms C complained also about the handling of her complaint.

Our investigation found that, although there was a gap between the date the account was opened and their first contact with Ms C, there was no delay on Business Stream’s part in processing and issuing their invoices. While the unexpected bill clearly caused Ms C concern, there was nothing to suggest that the charges were incorrect, and we did not uphold her complaints about this. We did find that there were instances where Business Stream failed to handle Ms C’s complaint in accordance with their service standards, and so we upheld this aspect of her complaint.

Recommendations

We recommended that Business Stream:

• apologise for the failure to respond to Ms C in accordance with their service standards; and
• reduce Ms C's account as compensation for these shortcomings.

Summary

Mr C, who is a prisoner, complained that his personal officer had failed to engage with him appropriately. He was also unhappy with the prison governor's response to his complaint. We were unable to comment on whether the personal officer had encouraged or motivated Mr C in line with the relevant guidance or on whether he had had a positive relationship with her. However, there was no evidence that she had attended or completed the required reports for his integrated case management conferences or that she had sent anyone to attend in her place. In addition, most of the entries that the personal officer completed on the prisoner record system were made after Mr C referred his complaint to us.

There was little documentary evidence that the personal officer had engaged with Mr C before he complained, although we noted that she had been absent from work for part of this time. We found that Mr C had not received the service and support from the personal officer scheme to which he was entitled, and in view of this, upheld this aspect of his complaint. That said, our investigation found that the prison governor had responded promptly to Mr C's complaint, and that her comments about trying to resolve the matter were reasonable in the circumstances. We did not uphold his complaint about this, as we found that the governor had dealt with Mr C's complaint appropriately.

Recommendations

We recommended that the Scottish Prison Service:

• issue a written apology to Mr C for the failure to provide him with the service and support he was entitled to receive from the personal officer scheme;
• consider whether it would be appropriate to change Mr C's personal officer in light of our findings; and
• consider if a review of the personal officer scheme should be carried out.

Summary

Mr C complained that, following the completion of a new school behind his property, his garden was experiencing flooding during heavy rain. Mr C was unhappy with the council's handling of his complaints about this and said that they had unreasonably failed to resolve the problem. He was also unhappy with the council's handling of his representations.

During our investigation we were satisfied that the council had provided evidence that they had taken action in an effort to resolve the problems. While Mr C remained dissatisfied, they were satisfied there was no other work they could reasonably carry out. They had said that maintenance work would be carried out to ensure the drainage system continued to function as designed. We, therefore, did not uphold this complaint. We did uphold his complaint about how they had handled his representations, as we found evidence that the council had failed to deal with Mr C's complaint in line with their complaints procedure.

Recommendations

We recommended that the council:

• apologise for their overall handling of the complaint.

Summary

Mrs C raised her concern about the council's handling of a planning application submitted by her neighbour to extend his property. In particular, she was unhappy that, following the submission of amended plans that included an area of decking, Mrs C was not renotified of these. She also complained about the handling of her representations.

After taking independent advice from one of our planning advisers we upheld the complaint that the council had failed to renotify Mrs C following the submission of the amended plans. As a result she was prevented from submitting her concerns about the amendments. We also found no evidence that the council had assessed the area of decking while processing the application. The council accepted that by mistake they had failed to notify Mrs C of the amended plans and that there was no evidence that the decking had been assessed. We did not uphold the complaint about her representations, as we found no evidence of fault in the council's handling of Mrs C's correspondence.

Recommendations

We recommended that the council:

• ensure that there are clear guidelines for the acceptance of amended plans to ensure that reiteration of neighbour notification, press advertising or other consultation or publicity is not overlooked;
• review their procedures on householder and delegated applications to ensure all material elements of a development are not overlooked during the processing of an application and are properly assessed before making any determination; and
• take steps to identify what action they can take using any available statutory powers or by negotiation to improve the current situation, and report back to the Ombudsman on the action they propose to take.

Summary

Miss C complained about aspects of the care she received during the birth of her son. She was unhappy with the time taken to allocate her a midwife on admission and to give her pain relief. She was also concerned about the attitude of staff in the labour ward, which she felt was dismissive and unprofessional at times. Miss C had a forceps delivery (where the baby is delivered using a surgical instrument resembling a pair of tongs). She complained that the care provided by the labour ward doctor and the surgeon in the theatre during the procedure was abrupt and overly forceful. In particular she was concerned about the physical damage that she and her son sustained during the birth.

We took independent advice on Ms C's complaint from two medical advisers. We upheld her complaints about delays and about unprofessional behaviour on the ward, noting that the board had already apologised for these, although we concluded that her overall treatment was reasonable in the circumstances. We did not uphold the complaint about the staff in the operating theatre, as we found no evidence of failures there, although in relation to this complaint we identified a concern with the quality and accuracy of the board's investigation it, and made recommendations accordingly.

Recommendations

We recommended that the board:

• review the consent form for operative vaginal delivery, to consider including all the common risks given in the Royal College of Gynaecologists Consent Advice No 11 (Operative Vaginal Delivery) July 2010;
• apologise to Miss C for the failure to adequately investigate her concerns and provide her with an accurate response to her complaint; and
• provide the Ombudsman with the outcome and details of any actions arising from their investigation into the failures of their original investigation into this complaint.

Summary

Mrs C's late father (Mr A) was admitted to hospital in late 2011 with recurrent abscesses. In October 2011, he was transferred to another hospital for audiology (hearing) tests. He was transferred without an escort and wearing only pyjamas and a cardigan. Mr A was doubly incontinent during the journey and also suffered a fall.

In November 2011, Mr A was referred to a specialist colorectal (bowel) surgeon and a loop colostomy (a procedure whereby the loop of the bowel is pulled through the thickness of the abdomen wall) was planned. Mr A had bowel surgery several days later. During the operation, Mr A’s bowel suffered a trauma, which the board said the surgical team did not know about at the time. He returned to the ward with a temperature which was treated by antibiotics (drugs to treat bacterial infection). His condition deteriorated and he started to show signs of sepsis (blood infection). Further investigations (chest x-ray, ECG, blood tests and blood cultures) were carried out and he was prescribed a strong antibiotic intravenously. Just over an hour later, staff noted that Mr A might be showing signs of sepsis, and an abdominal examination showed tenderness. An anaesthetic review noted that surgical emphysema (formation of bubbles of air in the soft tissues) was present. He was taken back to the operating theatre, where the surgeon discovered that Mr A’s bowel had been perforated and this had caused peritonitis (inflammation of the tissue lining the abdomen). Mr A needed further operations, and was transferred to intensive care, but his condition deteriorated and he passed away several weeks later. The cause of his death was recorded as acute peritonitis and perforation of colon (bowel) during colostomy operation.

Mrs C complained about Mr A’s care and treatment at the hospital including aspects of his transfer to the other hospital. In particular, she complained about the surgeon's failure to detect that Mr A’s bowel had perforated during the original operation and that the post-operative complications were not recognised and treated within a reasonable time. Mrs C also complained that the board failed to handle her complaint within a reasonable time and failed to respond to her questions reasonably. After taking independent advice from two of our advisers - a surgeon and a nurse, we upheld two of Mrs C's complaints. Our investigation found that the board failed to provide adequate nursing care for Mr A during his transfer and that he should have had an escort and a blanket or outdoor clothes on. We also found that there was a significant delay of five months by the board in responding fully to Mrs C's complaints. As, however, the board had taken steps to address most of the shortcomings identified in these complaints we made only one recommendation. We did not uphold Mrs C's complaint about the operation and after-care, as we found no evidence that the surgical team failed to perform the operation in a reasonable way and we were satisfied that the post-operative complications were identified and dealt with appropriately within a reasonable time.

Recommendations

We recommended that the board:

• bring the shortcomings in record-keeping to the attention of staff concerned.

Summary

Ms C, who is an advocacy worker, complained on behalf of her client (Mrs A) about the care and treatment that Mrs A’s husband (Mr A) received from the medical practice. Ms C said the practice failed to take appropriate steps to lead to an earlier diagnosis of Mr A’s cancer and assured the couple that Mr A's 'bloods' had been checked when they had not. She also said that one GP unreasonably failed to follow up on blood tests and a second GP failed to deal with Mrs A in an appropriate manner when she went to the practice for support.

We took independent advice from one of our medical advisers on this case. Our adviser said that the practice had tried to care for Mr A in this very difficult situation. He said that the care and treatment they provided was appropriate and there was no evidence to suggest that they should have referred Mr A to hospital earlier or made a diagnosis of cancer themselves. The adviser said the evidence in the records did not suggest that the practice failed to take appropriate steps to lead to an earlier diagnosis.

We upheld the complaint about the assurance given to Mrs A about 'bloods'. We found that both parties agreed that the first GP at the practice indicated that she had ‘checked Mr A’s bloods'. However, we took the view that when the GP spoke to Mrs A, a layperson, it was reasonable for Mrs A to interpret this as meaning that the GP had checked Mr A’s blood test results and not simply that she had taken blood samples for testing, which is what the GP suggested she meant. Given the language used, we considered that, on balance, the centre did tell Mrs A that Mr A’s bloods had been checked when they had not.

On the matter of follow-up, the first GP had said that she went online to see where Mr A’s blood test results were. She found that the results were not there and Mr A had been admitted to hospital. Our adviser indicated that this seemed reasonable, as from the point at which the first GP discovered that Mr A was in hospital, there would no longer have been any need for her to follow up on blood test results. We accepted the adviser’s views and did not find that the practice unreasonably failed to follow up the blood tests.

On Mrs A’s appointment with the second GP, the notes the GP made at the time did not contain any information that supported Mrs A’s account of what had happened, and we could not uphold this complaint. It was Mrs A’s word against the GP’s and there were no independent witnesses or other means for us to verify whose version of events was correct.

Recommendations

We recommended that the practice:

• provide Mrs A with a written apology for not explaining clearly what had happened to Mr A's blood samples;
• feed back our views on the communication and record-keeping to the staff involved in this case;
• take steps to ensure that in future, clear language is used when communicating with patients and summaries of phone calls are recorded in patients’ medical records;
• feed back our adviser’s comments on significant event analysis/audit to the staff involved in this case; and
• amend their procedures to include a requirement for significant event analysis/audit in future instances of this type.