Some upheld, recommendations

Summary

Miss C's mother (Mrs A) was admitted to hospital. She was very frail and had significant leg ulcers, and needed more care than could be provided at home. After a couple of weeks, Miss C had spoken with a healthcare professional about her mother's planned return home. However, Mrs A was then diagnosed with aspirational pneumonia (inflammation of the lungs and airways from breathing in foreign material). She was reviewed by a speech and language therapist, who considered that Mrs A's swallowing was unsafe and so she was given a modified diet. A doctor then reviewed Mrs A, and said that she had further deteriorated. She reassessed Mrs A's medication and decided that she should not be given normal quantities of food or drink by mouth ('nil by mouth') because of her difficulty in swallowing. Mrs A died of pneumonia a few days later.

Miss C complained to us that communication from staff was poor; that Mrs A went on to develop a urine and chest infection and that the doctor had, unreasonably, given instructions that should her intravenous antibiotic drip become detached, it was not to be re-fixed. Miss C said that when the drip became dislodged, despite repeated requests, it was not reinserted and Mrs A's medication was withheld. Miss C also said that, while her mother was in hospital, she had emphasised to staff that they needed to ensure that her mother received enough to drink as she knew it was critical that Mrs A did not develop an infection. Miss C said that her mother had been in great discomfort before her death, as she had not been receiving medication and had in fact developed a urine infection that had served to weaken her condition further.

After taking independent advice from a medical adviser, however, we did not uphold Miss C's complaints about her mother's care and treatment. Our investigation found that the care and treatment provided was reasonable, as was staff communication with Miss C, although they could have explained the meaning of 'nil by mouth' better. Our adviser said the records showed that Mrs A's leg wounds were appropriately treated, and her pain managed, and that there had been care from a multi-disciplinary team including physiotherapy, occupational therapy, dieticians, medical and nursing staff. The records were of a good standard and contained daily entries of the care and treatment given. We did, however, identify some shortcomings in the way the board dealt with Miss C's complaint in that there were a number of inaccuracies in their response.

Recommendations

We recommended that the board:

• satisfy themselves that when a patient is to be 'nil by mouth', the situation is clearly explained to, and understood by, those concerned; and
• emphasise to all their staff the importance of responding to complaints in accordance with their stated policy.

Summary

Mrs C's elderly mother (Mrs A) suffered from angina (heart pain) and high blood pressure. She fell at home and was taken to hospital. Although doctors found no bony injuries from her fall, they decided to keep Mrs A in hospital until her mobility improved. When visiting their mother a few days later, Mrs C and her brother found her in a deep sleep and unresponsive. It was suggested that Mrs A had had a stroke. However, when a consultant reviewed her, he suggested she might be having an adverse reaction to pain medication (tramadol - an opiate drug) that she had been prescribed. Mrs A was given another drug to reverse the effects of the tramadol. Although Mrs A's condition initially improved, she developed heart arrhythmia (abnormal heart rhythm) and collapsed and died thirteen days after being admitted to hospital. Mrs C complained that it was inappropriate for her mother to be prescribed tramadol and that the board's staff failed to take timely action when it was evident that she was sensitive to this medication.

During our investigation we took independent advice from a medical adviser. We did not uphold the complaint that the medication prescribed was inappropriate. The adviser explained that elderly, frail, patients can be at risk of chest infections, and opiates such as tramadol relieve rib pain and allow patients to cough properly, decreasing the risk of infection. However, they can also increase sedation and depress breathing. The risks are lower with tramadol than with other such drugs, however, and we found that it was appropriate for this to be prescribed, particularly as Mrs A was not known to have a sensitivity to the drug. Our investigation found, however, that Mrs A's deterioration was caused by a reaction to the tramadol, which could have been identified earlier. We were not critical of a junior on-call doctor who had investigated the cause of Mrs A's symptoms and had sought advice from two senior colleagues. However, we considered that the initial presumption that Mrs A had had a stroke may have led to some lack of consideration of other causes, such as tramadol sensitivity, and we upheld Mrs C's complaint that the board did not act quickly enough in this respect. We found that the subsequent twelve-hour delay before diagnosis would not have had any long-term impact on Mrs A's health, and that there was no link between the prescription of tramadol and her death. However, we recognised that the delay in identifying this issue caused additional distress to Mrs A and her family.

Recommendations

We recommended that the board:

• ask the clinical team to review Mrs A's case and our comments with a view to identifying any points of learning.

Summary

Miss C was detained in hospital under mental health legislation for nine days, and was assessed by a mental health team in the community after she was discharged. Miss C complained that while in the hospital, she was very bored, and had nothing to do. She said that she started to smoke just to pass the time. She also complained that the board failed to offer or provide the help that she needed after she was discharged, including accommodation away from her family home.

We upheld Miss C's complaint about her stay in hospital. Our investigation found that, while there was evidence that the hospital provided a programme of ward activities for patients, there was no evidence that Miss C was invited to participate, or that she was invited but declined to participate. Nor was there evidence that she had any planned one-to-one sessions with staff as she should have. In relation to the help provided after her discharge, we found that medical staff acted reasonably and in accordance with her wishes. We did not uphold this complaint, as we were not persuaded that there was an unreasonable lack of help.

Recommendations

We recommended that the board:

• ensure that staff encourage patients to participate in available ward activities, to record in a patient's records when this has occurred and whether the patient accepted or declined the invitation to participate; and
• ensure that staff are made aware of the need to provide patients with access to planned one-to-one sessions with staff, for the frequency and duration of these sessions to be negotiated and agreed and for this information to be clearly recorded in the patient’s careplan.

Summary

Mrs C complained that the GPs treating her late mother (Mrs A) failed to fully investigate her symptoms and take timely and appropriate action. She also complained that one of the GPs refused to refer Mrs A to the gastroenterology clinic (a clinic specialising in medicine of the digestive system) for further investigation.

Mrs A was a long-term sufferer of coeliac disease (a condition in which the small intestine fails to absorb and digest food) and was reviewed on an annual basis at a gastroenterology clinic. She also had a skin condition which was linked to the disease, and suffered long-standing back pain. Although Mrs A was prone to constipation because of the medication she took for her conditions, from mid-2010 she had told the practice that she had increasingly severe constipation, sometimes for four to five days. The advice she received from the practice was to increase her laxatives (medication taken to cause or encourage bowel movements). Blood tests taken in early April 2011 returned abnormal results, which the practice attributed to the infective skin condition Mrs A had at the time. They referred Mrs A urgently to the dermatology department (the department dealing with skin conditions). In early May, the department told the GPs that they should seek a further opinion on Mrs A's condition. Mrs A was referred to the gastroenterology clinic that month, where tests revealed that she had inoperable bowel cancer. Mrs A died the following month.

We upheld two out of three of Mrs C's complaints. Our investigation, which included taking independent advice from one of our medical advisers, found that there were delays in fully investigating Mrs A's symptoms and making timely and appropriate referrals for specialist advice. Mrs A had a long-term medical condition, and was taking medication that affected her bowels. Our adviser said that her initial symptoms in 2010 should not, therefore, have triggered a specialist referral. However, when these symptoms continued, and increased in severity despite a significant increase in her laxative medication, this should have triggered action from the GPs. The adviser was of the view that while it was reasonable for the GPs to address the issue of the infective skin condition, they appeared to do so to the exclusion of any other possible underlying condition and did not take a proactive and holistic approach. Although the adviser noted that, even if they had acted more urgently, the outcome for Mrs A was likely to have been the same, we upheld this complaint as we found that there was unreasonable delay in referring Mrs A to a specialist.

One of the complaints referred specifically to how quickly the GPs dealt with blood test results. The adviser was of the view that the results were dealt with in a timely manner, although the referral which followed was to the wrong specialism. Therefore, on balance we did not uphold that complaint. Another complaint was that one of the GPs refused to refer Mrs A to the gastroenterology specialist. Our investigation found no evidence that the GP actually refused to refer Mrs A to this specialist. However, we found that the fact that all the GPs focussed their attention on the skin condition had the same effect, and so we also, on balance, upheld this complaint.

Recommendations

We recommended that the practice:

• issue a written apology for the failings identified;
• conduct a significant event audit of this case, with any findings and recommendations to be discussed at the GPs' next annual appraisals; and
• undertake a review of a sample of patient records to ensure that clinical note taking complies with the standards set by the General Medical Council's 'Good Medical Practice: Providing good clinical care'.

Summary

Mr and Mrs C complained about care that the board provided to their son (Mr A). Mr A was placed in foster care in an area away from the family home. The doctor who had been treating Mr A at home referred him to the new area's child and adolescent mental health services team (CAMHS). Mrs C complained that she and Mr C were not involved in the subsequent process.

We upheld this complaint. Our investigation found that there was no opportunity for Mr and Mrs C to express their views to the team despite the fact they maintained parental rights. We also found that CAMHS did not communicate with Mr and Mrs C until a third party prompted them to do so. We also upheld a complaint that mental health care arrangements for Mr A were not reasonable. We found that, although the board had attempted initial unsuccessful engagement with Mr A, his views had not been clearly sought at any stage. We noted that, during a meeting, those involved considered that Mr A was 'reluctant' to engage with CAMHS, but did not initiate a follow-up plan (which should have included obtaining Mr A's views clearly). Five months passed before Mr A was contacted again with the offer of an appointment, which he accepted.

We did not uphold a complaint that staff unreasonably failed to contact Mr and Mrs C when Mr A was admitted to hospital, as we found that they had acted reasonably by accepting that Mr A's foster parents, who had attended hospital with him, were acting as the responsible adults. Mrs C said that Mr A had been asking for her and Mr C, but we found no evidence that staff at the hospital were aware of this, as this information came from Mr A's foster carers rather than the medical records.

Recommendations

We recommended that the board:

• apologise to Mr and Mrs C for not involving them in Mr A's transfer to CAMHS;
• review the procedures within CAMHS following referrals, to ensure parents have the opportunity to exercise their parental rights, where appropriate, and that parents are advised of outcomes and communicated with appropriately;
• ensure all the staff concerned, and the CAMHS team as a whole, are reminded of the need to maintain detailed minutes during professionals' meetings and to ensure the terms of a referral are considered fully; and
• review CAMHS processes to ensure that the views of the child or young person concerned are taken into account in a timely way.

Summary

Mr C was an advocate representing eight former students at the college. Mr C complained that the college unreasonably failed to deliver timetabled teaching hours or provide necessary additional support, given the students' circumstances and needs. Mr C also complained that the college unreasonably failed to address or listen to the students' informal complaints, and did not reasonably handle two formal complaints and an appeal. We found that there were no college records of the teaching or support provided, so we could not uphold the complaints. There was also no evidence available to prove that the students had made informal complaints, or that they submitted the first formal complaint. We found that the college handled the second formal complaint reasonably. However, we upheld the complaint that the appeal was not reasonably handled. The senior college staff member responsible for the appeal should not have been involved, as they had previously been responsible for dealing with the students' second complaint. To avoid either a real or a perceived conflict of interest, it would have been good practice for another member of staff to have handled the appeal from the outset. In addition, there was no minute or note of the appeal hearing and its outcomes.

Although there was insufficient evidence for us to be able to uphold most of Mr C's complaints, we were concerned that the college had destroyed records before the students had an opportunity to complain to us. We had accepted the students' complaints as being in time in terms of the law that set up our office, which says they can do so within a year of the date of whatever they are complaining about. While we would always encourage people to approach us soon after they have completed the complaints process of an organisation, it does not matter whether they approach us in the first month or the twelfth month – they have a right to complain during that time. We would, therefore, have expected the college to have kept important records relating to these students and their complaint for this period of time. As the college no longer had the records, and given the apparent discrepancies in some of the destroyed and the remaining records, we were concerned that natural justice may not have been served in this matter. In our view, the college gave weight and credibility to the anecdotal evidence of staff, while dismissing and discrediting the anecdotal evidence of the students without having retained evidence of the records considered during the complaint. We, therefore, made a number of recommendations to address this.

Recommendations

We recommended that the college:

• include a statement in the complaints procedure that where a senior member of college staff responsible for dealing with a complaint has already been involved (in either the substance of the complaint or in considering the complaint at an earlier stage) they should immediately stand aside and allow another senior member of staff to deal with the complaint;
• ensure that complaint meetings and appeal hearings are minuted, and the outcome of the meeting or hearing is communicated in writing to the complainant(s);
• contact the eight students to offer a further date for the appeal hearing originally set for 20 September 2010; and
• provide the Ombudsman with evidence that they now maintain complete student records, including all relevant correspondence, records of contact, communications and complaints documentation, and have a policy that ensures records will be maintained for an appropriate period and in particular when complaints are extant.

Summary

Mr C complained on behalf of an association that in October 2011, without warning, they received a water bill for over £19,000. He complained to Business Stream that, given the association's past history, the bill must be incorrect. Further bills followed despite Mr C's contention that the bill was incorrect but that it was not until five months later that he was told that his account had been reassessed and recalculated. While Mr C wrote and said that he wanted a more detailed explanation, he heard nothing more until July 2012 and this merely enclosed a copy of the March 2012 letter. Mr C continued to complain but a detailed reply was not sent until August 2012. Mr C was aggrieved that Business Stream had not read the association's water meter correctly between August 2008 and October 2011. He further complained that they did not adequately investigate the disputed high consumption since the association's meter was installed in August 2008.

Our investigation took the complaints correspondence, statements of account and invoices, and Business Stream's internal computerised records into account. We also made further enquiries of Business Stream. The investigation confirmed that there had been difficulty in finding the meter and that it had not been read until January 2011. It was read again in October 2011 and confirmed to be correct. A 'high consumption' letter was sent to Mr C on the day that the bill was issued. As a consequence of Mr C's insistence that his bill was incorrect, Business Stream established that the opening figure for his account was incorrect and they reassessed his bill accordingly. As there had been a problem with the initial meter reading, we upheld this complaint.

By January 2012, Business Stream had confirmed the problem with the reading and they started to implement required changes a few days later. What they did not do was to explain this clearly, in a timely manner. They did not tell Mr C this until March 2012 nor did they explain the situation clearly. They then failed to address his further letters properly until August 2012. Although we did not uphold this complaint, we made a recommendation to address this.

Recommendations

We recommended that Business Stream:

• formally apologise to Mr C for their error;
• reduce Mr C's bill by a further five percent; and
• apologise to Mr C for the way in which they handled his continued representations.

Summary

Mr C complained that Business Stream did not tell him when his water meter was replaced. He said that after this the water meter was not read in accordance with the relevant service standards and for an extended period, unnoticed by him, all his water bills were estimated. Mr C said he only discovered that the meter had been replaced and that his bills had been estimated when he received a large catch up bill. Mr C told us he believed that the new meter might have been faulty for a period as his metered water usage was higher than he had expected. He said that his bill could have been updated earlier when actual meter readings were first taken, which would have alerted him to the problem earlier. Mr C was also dissatisfied with the handling of his complaint. He felt that it had taken Business Stream too long to respond and he was not offered compensatory payments in line with stated service standards.

We found that the meter was the property of Scottish Water and had been replaced as part of their rolling replacement programme. We did not uphold Mr C's complaint about this as our investigation found that there was no obligation on Business Stream to tell Mr C about the exchange. They had also offered to carry out a meter accuracy test when Mr C queried the accuracy of his catch up bill. Mr C had declined this because he said he believed the meter was now recording water usage accurately and because Business Stream would levy a charge if the meter was tested and found to be accurate.

We did, however, uphold Mr C's other complaints. We agreed that under the terms of their licence Business Stream should have ensured that two actual meter readings were taken each year, one of which could have been provided by Mr C. However, they failed to do so for a period of around two years. We noted that they had already offered Mr C an apology and a compensatory payment of £100 in recognition of this failing.

Our investigation also found that it took around fifteen months from the date of the first reading for Mr C to receive a bill which reflected his metered usage. Business Stream told us that they had difficulties entering the actual reading because the computer system of the Central Market Agency, which it was beyond their control to update, did not accurately record Mr C's meter details and supply identification. However, they provided no evidence to suggest that on discovering this they pursued the matter with the Central Market Agency at the earliest opportunity, as they should have done. Nor did they alert Mr C to the difficulties they were having.

We found that there was an unreasonable delay in handling Mr C's complaint. Business Stream failed to acknowledge or apologise for the delay when it was brought to their attention and they took too long to apply the £20 credit that was due to Mr C in recognition of the delay (in line with their service standards). We also identified that Mr C was owed a further £20 credit.

Recommendations

We recommended that Business Stream:

• investigate the sequence of events that led to the errors identified in relation to the meter exchange and supply identification number, and identify any opportunities for improvements to business processes;
• make a further payment of £20 in acknowledgement of the delay in making the original £20 credit in line with Service Standards as is the complainants entitlement. Business Stream should consider in the circumstances whether the credit applied to the account should exceed their standard £20 payment; and
• apologise for delays in handling the complaint and for failing to award compensatory payments in line with service standards.

Summary

In 2007, Mr and Mrs C bought some old buildings and adjacent land. They intended to convert the buildings to properties for sale. When they bought the land there was a trough and a tap on it, although the meter for this supply was on land owned by a neighbour (Mr D). Mr and Mrs C believed this was Mr D's supply. Mrs C told us that they agreed with Scottish Water and Mr D that they would use this supply for water needed in their building project. They understood that at the conclusion of the project the supply would revert to Mr D.

When the project was completed in 2010 Mr and Mrs C sought to have the supply disconnected. They were told this would involve a cost. They explained that the supply belonged to Mr D and that they thought he was still using water from the original supply and that the meter was his. Business Stream undertook some investigation and established that Mr D was not using the supply. After ten months of correspondence Business Stream confirmed that Mr and Mrs C were responsible, as the owners of the address supplied. Correspondence continued for almost another year when Business Stream sent a detailed, written response. This, however, contained an error which Business Stream then clarified. Throughout this period Mr and Mrs C were paying fixed charges for the supply, which would end when the supply was disconnected.

Our investigation found that the location of the taps and trough was key. The owner or occupier of the land where the taps are is responsible for the supply. This meant that when the land was sold in 2007 Mr and Mrs C became responsible. We accepted they had not appreciated this at the time, but we could not uphold their complaint that they were charged for a supply that was not their responsibility. However, we found that there had been serious failings in Business Stream's response to their concerns. Mr and Mrs C raised these in July 2010 but did not receive a response until April 2011. We found that by October 2010 Business Stream should have had all the information needed to respond. Their eventual response in April 2011 was correct but was not sufficiently clear, and had not resolved the underlying confusion. However, it had also said that Mr and Mrs C could call to discuss this. When they did so, Business Stream simply noted that there had been a phone conversation and considered that Mrs C understood the position. It appears that, despite a number of attempts by Mrs C to make contact, it was not until March 2012 that they realised a further clearer response was needed. In the circumstances, we found that Business Stream's actions had delayed Mr and Mrs C's ability to organise a disconnection, and that their response to the concerns expressed about this had been inadequate.

Recommendations

We recommended that Business Stream:

• reduce the fixed charges liability for this supply by 50 percent for a certain period, if they receive a disconnection request within six weeks of the date of this decision; and
• apologise to Mrs C for the failings in communication about her concerns.

Summary

Mr C complained that the council delayed carrying out an emergency repair on the window of the communal hallway at his home. He also complained that they failed to compensate him under the terms of the Right to Repair scheme for the delay in repairing the window and to comply with their responsibilities to regularly paint the communal stairway.

Our investigation found that the repair did not qualify for compensation under the Right to Repair scheme as it was a repair to a communal area. We also found that although the original tenancy agreement indicated that the council would paint the stairway every five years, they had since signed the Scottish Secure Tenancy agreement, and that stair painting could now only be carried out when agreement was reached with all owners. The council demonstrated to us that they had tried to get other residents to agree to this work. However, we did find that, as the council accepted that the broken window had affected their tenant and carried out the repair, they should have done so when it was first brought to their attention. For this reason, and because their joiner failed to properly board up the window, we upheld this aspect of Mr C's complaint.

Recommendations

We recommended that the council:

• write to Mr C to apologise for the delay in repairing the window.