Some upheld, recommendations

Summary

Mr C attended a community consultation session about a town centre regeneration plan. He later complained that a council officer did not include his comments in a summary document. Mr C also questioned the motives behind the officer's decision not to include his comments. After complaining to the council, he approached us with his concerns about the length of time they took to respond to his complaint, the fact that they referred to his role as a newly elected member of the council and because in their final response they did not give him details of his right to bring his complaint to us. The council had explained to Mr C that the officer felt that the comments did not contribute to the consultation, either in a positive or negative way, and that this was why they were not included. Mr C pointed out that the council had included other comments which could also not be considered to contribute in any way to the exercise.

Our investigation reviewed the supporting documentation, and found no evidence to suggest that the council's decision not to include the comments was unreasonable. However, we did agree with Mr C that other comments which were included in the summary document could not be said to have contributed to the consultation and we noted that this could lead to a perception of bias. However, Mr C did not suffer any injustice in terms of having his views heard as his comments, in full, were presented to the planning committee, and he had further opportunities to comment before the planning application was considered. We did not, therefore, uphold this aspect of the complaint.

We did uphold his complaint about the time the council took to respond to his complaint, and their failure to provide referral rights to us. We noted, however, that the council were correct to point out that a change of status to councillor would change the relationship with the council and its officers, and would have an impact on how they examine a complaint such as this.

Recommendations

We recommended that the council:

• write to Mr C to apologise for the delay in responding to his complaint.

Summary

Mr and Mrs C’s twin children attended a local primary school but were placed in separate classes. Mr and Mrs C considered that one of their children had been subjected to bullying by classmates over an extended period since late 2011. Unhappy about the way the head teacher of the school had handled the matter, they asked the council’s education service to intervene, and in early 2012 a council quality improvement officer chaired a meeting in the school. Subsequently, Mr and Mrs C reported various other incidents in the summer term and, dissatisfied with the education service’s handling of the matter, they complained to the service.

Mr and Mrs C made six complaints to us. We did not uphold two of these: that the education service unreasonably failed to follow disciplinary procedures to prevent the bullying of their child or that the education service unreasonably failed to implement agreed support measures to assist their child. We upheld the remaining four complaints, one of which was that the school unreasonably failed to return a phone call when Mr and Mrs C had taken the step of withdrawing their child from school. The other three complaints related to complaints handling and the sharing of information about the education service’s investigation and notes of two meetings Mr and Mrs C attended with officers during the investigation process.

Recommendations

We recommended that the council:

• apologise to Mr and Mrs C for the deficiencies in the handling of their complaints identified in our investigation.

Summary

Mrs C's elderly uncle (Mr A) had been a tenant of a housing association for many years. His home is factored by a subsidiary company (the company) of the association. When that association then transferred a large quantity of housing stock to another housing association (the new association) non-common repairs (ie most internal repairs) became the responsibility of the new association. However, common repairs to external stairs and paths remained the responsibility of the company.

Mrs C complained about the poor condition of the external stairs leading to the building where Mr A lives and that they were a safety hazard. Mrs C also complained that it took over a year for outdoor handrails to be fitted, and for Mr A’s kitchen drawers to be repaired. She was also unhappy that the new association did not clearly explain their repairs policy nor advise her for over a year that the factoring of Mr A’s home remained the responsibility of the company.

We upheld three of Mrs C's four complaints. Our investigation found that the new association had been planning a joint programme of improvement works with the company in relation to the stairs. We also found that the new association did not know, at the time of Mrs C’s complaint, that the company factored Mr A’s building and so were responsible for installing the handrails. As a result of this, there was a long delay in the matter being referred to the company. We found that the records of the internal repair were misleading in that they showed that it was complete when in actual fact it remained outstanding for over a year. In addition, although the new association had been undergoing a period of change in terms of their housing stock, they should have identified that the company were the factors for Mr A’s building. We made three recommendations because of these failings. However, we took the view that the new association had made reasonable attempts to respond to Mrs C’s questions about their repairs criteria and to explain that repairs to the stairs would form part of a wider plan involving those residents across the estate who owned their homes.

Recommendations

We recommended that the association:

• review how the initial repair request for the drawer was handled, with a view to ensuring clear records are made and outstanding repair work is not recorded as complete without good reason;
• make a time and trouble payment to Mr A; and
• apologise to Mrs C and Mr A for all the failings identified in our report.

Summary

Mr C’s son (Mr A) had died, leaving a widow and young family. Mr A and his widow were tenants of the housing association. After Mr A died, Mr C handled matters, including contacting the association within days of his son's death. Mr C complained that the rental direct debit was taken for the following two months, despite Mr C having been assured that it had been cancelled. In addition, representatives of the association visited the property with paperwork that was still in joint names, inappropriate rent reminder letters were sent and correspondence continued to be issued in joint names. This was already a very difficult time for Mr C and his family and he told us that this added unnecessarily to their upset and distress. Mr C complained that the association, on being told of his son’s death, did not internally communicate this appropriately to staff. He also felt that they should have had a specific policy in place to handle such matters.

We upheld Mr C’s complaint that the association's internal communication had failed. The association had explained that the local housing officer who would normally have handled such matters had left her post suddenly. We noted that Mr C had taken this into account and had contacted the housing association directly, rather than trying to do so through that officer. We noted that the association had apologised for and explained their mistakes, and had offered some redress to Mr A's widow. Having considered all the evidence and taken account of the fact that the retired officer was soon to be replaced, we did not uphold his complaint that they should have a specific policy in place.

Recommendations

We recommended that the association:

• confirm that a replacement housing officer is in place; and
• confirm that steps will be taken to ensure that bereavements are communicated more effectively.

Summary

Mr C complained about the care given to his wife (Mrs C) in an accident and emergency department on two occasions, and said that she was displaying clear symptoms of stroke on both. He also complained that Mrs C was discharged from hospital on her second visit, even though she was unable to speak without slurring. He told us he pointed this out to the doctors, but was ignored. Mrs C's GP referred her urgently to the hospital the following day, where she was found to have suffered a stroke.

We took independent advice on this case from one of our medical advisers. Our investigation found that on the first occasion Mrs C was diagnosed as suffering from migraine (an extreme type of headache which can cause disturbances to speech and vision). We found that it was reasonable to attribute Mrs C's symptoms on this occasion to migraine, but that her case should have been discussed with the on-call neurologist (a specialist in diseases of the nerves and the nervous system) and a management plan agreed. We, therefore, upheld the complaint that her treatment and diagnosis was not reasonable and made a recommendation referring to the relevant guidelines from the Scottish Intercollegiate Guidelines Network (SIGN).

We also found that on her second visit to hospital, it was unreasonable for Mrs C to have been diagnosed as suffering from migraine. There was no record of either a FAST (Face, Arm, Speech, Time of Event) assessment, or of a ROSIER (Record of Stroke in Emergency Room) review. Our adviser said that had either of these been carried out, then the result would have been positive. There was no record of discussion between emergency department doctors about Mrs C's unusual symptoms, and her case should have been discussed with a neurologist or stroke physician and a CT scan (a type of scan using x-rays to create a detailed picture of the inside of the human body), should have been requested. The board had not recognised this failing in their response to Mr C’s complaint.

We did not uphold Mr C's third complaint as our investigation did not find evidence that doctors had ignored reported symptoms of slurred speech. The notes provided clearly detailed the symptoms and signs that Mrs C had when she was assessed at the hospital.

Recommendations

We recommended that the board:

• apologise to Mr and Mrs C for the failings identified in Mrs C's care;
• review the processes governing referral to the on-call neurology team when a patient presents with symptoms consistent with hemiplegic migraine, to ensure an appropriate management plan is agreed and documented, with reference to the SIGN guidance; and
• provide evidence that they have reviewed the procedures within the accident and emergency department for the identification of stroke and the appropriate point for involving a stroke physician in light of the failings identified in this complaint.
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Summary

Miss C had a history of occasional minor back pain over a number of years, and was diagnosed with sciatica and a prolapsed disc. In November 2011, Miss C developed pain in her lower back and pelvis, which made walking very painful. The pain moved to her right hip, leg and buttock and she began to experience numbness and muscle weakness. In early January 2012, the pain moved again to her lower back and upper left leg. The pain was severe and affected her mobility. Miss C phoned NHS 24, having not been able to contact her own GP. Miss C's GP was asked to visit her at home. He prescribed pain medication and advised her to monitor her condition and to contact NHS 24 again should the pain worsen when the practice was closed. Miss C contacted NHS 24 again late that night. It was suggested that she attend an accident and emergency unit, but due to the pain she experienced when sitting, standing or walking, she did not feel able to do so. NHS 24 then arranged for an out-of-hours (OOH) GP to conduct a consultation by phone. The OOH GP concluded that Miss C's condition was improving and that she likely had a urinary infection. She was told that she should continue to self-monitor overnight. Miss C's condition deteriorated further the following day and, after another call to NHS 24, she was admitted to hospital where she underwent emergency surgery. She was diagnosed with cauda equina syndrome, where a lesion, or prolapsed disc, presses on the nerves at the base of the spinal cord, causing pain, numbness, weakness and/or urinary disturbance or faecal incontinence.

Miss C raised a number of concerns about the OOH GP's assessment of her condition and his failure to visit her at home or to arrange an ambulance to take her to hospital that night. She was left with persistent numbness after her surgery and felt that, had the OOH GP recognised the red-flag symptoms (symptoms that are especially likely to indicate a particular serious illness) of cauda equina, and arranged for her to be admitted to hospital earlier, this might have been prevented.

We found that Miss C had described recognised red-flag symptoms of cauda equina to NHS 24 and the OOH GP. These included numbness in the area between the legs and urinary problems. We accepted independent medical advice that these should have prompted a home visit from the OOH GP. Although we acknowledged that Miss C's symptoms and mobility appeared to be improving between the time of her discussions with NHS 24 and the OOH GP, this is not uncommon for patients with cauda equina and the fact that red-flag symptoms had been described should have been the primary consideration. We considered that, by failing to carry out a home visit, the OOH GP did not put himself in a position to properly diagnose or rule out cauda equina syndrome.

Recommendations

We recommended that the board:

• share our findings with the OOH GP and consider whether additional training should be provided to him on the identification of, and response to, red flag symptoms; and
• apologise to Miss C for failing to provide a home visit.

Summary

Mr C complained on behalf of his late wife (Mrs C) who developed severe abdominal (stomach) pain in November 2011. After initial tests, hospital doctors at first thought Mrs C had a urinary tract infection, then appendicitis. These diagnoses were ruled out after she was transferred to another hospital, where a CT scan (a special scan using a computer to produce an image of the body) showed that Mrs C had a shrunken right kidney. This had been identified the year before in an MRI scan (a scan used to diagnose health conditions that affect organs, tissue and bone), when Mrs C was told that the shrunken kidney was likely congenital (present from birth). The CT scan also showed that bile ducts within her liver were enlarged, but that her liver was functioning normally. Further tests led to a suspected diagnosis of primary sclerosing cholangitis (a disease causing inflammation and obstruction of the bile ducts). Mrs C was later referred to a consultant urologist (a clinician who treats disorders of the urinary tract) who reviewed her CT scan and identified that the abnormalities in her kidneys had in fact progressed since the previous year's scan, and that the shrunken right kidney contained a solid cancerous mass. The cancer later spread into Mrs C's lungs and stomach.

Mr C complained that Mrs C's shrunken kidney had been observed as early as June 2010, but she had repeatedly been assured that this was congenital. He thought that the board's failure to investigate the cause of this had contributed to a delay to the diagnosis of her cancer.

After taking independent advice from a medical adviser, who is a consultant surgeon, we considered the initial investigations into Ms C's abdominal pain, and the working diagnoses, to have been reasonable. Early ultrasound and CT scans highlighted abnormalities in Mrs C's biliary tree (the structures responsible for transporting bile) and it was appropriate for these to be investigated. That said, we were concerned by the apparent lack of consideration of Mrs C's shrunken kidney, and upheld Mr C's complaint that this was not investigated quickly enough. Investigations concentrated on the biliary tree but found no significant abnormalities other than gallstones. Mrs C's pain was located in the area of her shrunken kidney, which was highlighted in June 2010 and showed again in the November 2011 CT scan. It was established in December 2011 that the biliary tree abnormalities were not the source of the pain. We concluded that there was sufficient cause to refer Mrs C to a urologist at an early stage, rather than to concentrate investigations on the biliary tree abnormalities. We did not uphold Mr C's complaints about how details of his wife's condition were explained in a letter to her and about medication prescribed.

Recommendations

We recommended that the board:

• share our findings with the clinical team so that they may consider reviewing how referrals are managed for patients requiring multi-disciplinary investigations.

Summary

Ms C and Mr C are sister and brother. Their elderly father (Mr A) was admitted to a hospital as an emergency with a suspected urinary tract infection, and was discharged home five days later. Ms C was unhappy that although she held a power of attorney for her father, no senior member of staff contacted her to discuss Mr A's care, in particular the changes that were made to his heart medication. The hospital clinician's view was that Mr A suffered from several illnesses and his admission was precipitated by increasing confusion and reduced mobility. The clinician said that the medicine changes made in hospital took account of Mr A's condition at the time of his first admission. Mr A was readmitted to the hospital about four weeks later and tests confirmed he had suffered a heart attack. He died there three days later. Both Ms C and Mr C said that the hospital withdrew Mr A's life supporting medication during his first admission and they made several complaints linked to this.

We took independent advice from one of our medical advisers, who considered all the clinical aspects of the case. We took account of his advice along with the documentation provided by Ms C and Mr C and the board. The adviser said that life supporting medication was not withdrawn, and that Mr A's age, frailty and his other illnesses had to be taken into account. However, the adviser also said that consideration should have been given to Mr A's future symptom control when he was discharged home after his first admission, so we made recommendations to the board about this. The adviser also said that there was no evidence that a review by a doctor was not independent. Although, therefore, we did not uphold the complaints about Mr A's clinical treatment, we considered that the board had offered unsatisfactory explanations to Ms C and Mr C when they complained and we upheld this aspect of the complaint.

Recommendations

We recommended that the board:

• feedback the learning from this complaint to all staff;
• ensure that when changes in medicine(s) are made to patients with diminished capacity, such changes are discussed with their carers;
• ensure that, when medicines are changed prior to a patient's discharge home, consideration is given for appropriate follow-up or monitoring of the patient;
• ensure that information entered in case records is an accurate reflection of events;
• apologise to Ms C and Mr C for the failures identified in this case; and
• ensure that the rationale for changes in medication is clearly documented.

Summary

Mr C's brother (Mr A) was in hospital for two months before being discharged to a care home. Mr C's other brother (Mr B) had welfare and continuing power of attorney for Mr A. Mr C complained that staff failed to take into account Mr A's communication problems related to his cognitive impairment (a condition that affects the ability to think, concentrate, formulate ideas, reason and remember) and his rapid deterioration while he was in hospital. Staff also failed to notice his legs were swollen or that he had injured his eye. Mr C asked to see a doctor who knew Mr A but as that person was unavailable, the family had to speak with another doctor who was not familiar with him. The doctor suggested an assessment. Mr C said that when this was carried out, Mr A's dementia and inability to recognise threats and dangers to his own safety were obvious. Mr C was also unhappy that nursing staff put items of lightly and heavily soiled clothing in the same bags for taking home to launder.

As part of the arrangements to discharge Mr A from hospital, an occupational therapist and social worker visited his home. Mr C did not agree with their findings, or that the proposed adjustments to the house would enable his brother to live there. The family were, therefore, concerned about Mr A's planned discharge home. The hospital consultant phoned Mr C at home to explain why Mr A was being discharged, but the family were not told exactly when this would happen. On arriving at visiting time one day, Mr B found an ambulance crew taking Mr A to be discharged home. The family said this was not acceptable, and Mr A was returned to the ward. He was eventually transferred to a care home. Again, Mr C said that the family and Mr A's social worker were not told about this in advance and only learned of it in a phone message left on an answering machine. Mr C complained about Mr A’s care and treatment at the hospital. In particular, he complained about the lack of clinical treatment which was provided; a lack of co-ordination by health and social work staff; a failure to properly assess Mr A's needs and a failure to communicate with Mr C and his other brother about Mr A’s welfare and eventual discharge.

After taking independent advice from one of our medical advisers, we upheld Mr C's complaints about care and treatment and about communication with Mr A's family. We found that while the care and treatment provided in relation to Mr A’s physical health, including medication, was reasonable, there were failures in relation to his mental health care needs. These included fully assessing his capacity for decision-making, which was of considerable concern to us. While we found evidence in the medical records of communication by nursing staff with Mr A's family about his discharge planning, the medical consultant's communication with them was limited to one phone call. This was below a reasonable standard, as the communication failed to meet the needs of Mr A or his family in relation to Mr A’s welfare given the complexity of his condition. We found, however, that the assessment and planning for discharge was reasonable. We found evidence that Mr A's family were involved and we were satisfied that the arrangements themselves were reasonable.

Recommendations

We recommended that the board:

• ensure that failings identified in relation to communication and documentation are brought to the consultant's attention and reviewed as part of the consultant's annual appraisal;
• apologise to Mr C for the failures identified;
• bring our adviser's comments about the review of Mr A’s prostate medication to the attention of relevant staff;
• provide evidence of how they are implementing Scotland's National Dementia Strategy with particular reference to communication with the families and carers of patients with cognitive impairment; and
• introduce a policy to ensure that the cognitive function of elderly patients is assessed and, if this is impaired, that capacity for decision-making is also assessed.

Summary

Mr C was under the care of a specialist pain physiotherapist in the board's pain clinic service. He was also referred to, and awaiting treatment from, a specialist pain psychologist there. However, the physiotherapist left her post and later, after two periods of sickness absence, the psychologist did likewise. Mr C complained about the delay in filling these posts and the resultant gap in service provision. During our investigation, we took independent advice from one of our medical advisers, who said that the board took reasonable steps to explain the position to Mr C, to make alternative treatment options available to him, and continue to provide a service in the face of challenging circumstances. We also saw evidence that Mr C had not always fully engaged with his treatment plan, and in the circumstances we did not uphold the complaint. However, although we acknowledged the difficulties the board faced in filling these specialist positions, we considered that they could have acted more promptly in advertising the physiotherapist post.

Mr C also complained about the way in which the board handled his complaint. In particular, he was unhappy that he was told that the psychologist would be returning to work, only to later find that she had resigned. We found that the information shared with Mr C was accurate when it was provided and we did not consider that the board could reasonably have foreseen that the post would later be vacated. We saw no evidence of a deliberate attempt to mislead Mr C, as he alleged. Mr C also complained that the board failed to respond to an email he sent them and to address all the complaint points he raised. The board accepted that an administrative error had led to a response not being sent and apologised for this. We also noted that the board had agreed four points of complaint for investigation with Mr C, but did not appear to have responded to all of them so, in the circumstances, we upheld Mr C's complaint about their complaints handling.

Recommendations

We recommended that the board:

• highlight to relevant staff the importance of timely recruitment to specialist posts in order to minimise disruption to patients’ therapeutic programmes; and
• remind complaints handling staff to ensure they respond to all complaint points that have been agreed with the complainant.