Some upheld, recommendations

Summary

Mr and Mrs C's son was admitted to hospital for surgery to correct a squint. He was discharged the same day but had to be re-admitted three days later as his eye had become infected. Mr and Mrs C were unhappy that their son has since had to endure the pain and trauma of five further operations, and that despite these, the prognosis for his eye remains poor.

Mr and Mrs C were critical of the care and treatment given to their son both during and after the operation. They said that his eye should have been patched immediately afterwards, which would have prevented infection. They also maintained that as the infection was so rare, medical staff involved were uncertain about treatment and had been unable to predict any degree of success for any of the procedures undertaken.

Our investigation took into account all the relevant information, including complaints correspondence and the relevant clinical records. We also took independent advice from a medical specialist in paediatric ophthalmology (the anatomy, physiology and diseases of the eye in children).

Our adviser said that the decision to operate was correct, that all the procedures undertaken were reasonable and appropriate, and that the care and treatment provided were satisfactory. He did not consider that the lack of an eye patch had had any effect. However, he said that Mr and Mrs C could have been given a more detailed explanation about how the infection had occurred. He said it was unclear from the records what had or had not been discussed with them, and that the consent forms used did not provide space to record the aims or possible risks or complications of an operation. We did not, therefore, uphold Mr and Mrs C's concerns about their son's treatment, although we did uphold their complaint that the explanation given was not reasonable.

Recommendations

We recommended that the board:

• apologise to Mr and Mrs C for failing to provide a full explanation; and
• satisfy themselves that their consent forms are adequately formatted to allow the recording of information about the aims and risks of surgery.

Summary

Mrs C, an advocacy worker, complained on behalf of Ms A about the care and treatment she received at the dental practice when her upper right second molar was extracted. After the extraction, Ms A experienced extreme pain. Her face started to swell and she felt physically sick. She contacted NHS 24 and attended the dental hospital for treatment. Ms A said that the dentist had failed to explain the risk associated with the removal of the tooth and made an error when extracting the tooth. She also felt the dentist had not provided an adequate response to her complaint.

We upheld two of Ms C's three complaints. Our investigation found that the dentist had failed to explain the risks involved, and we noted that x-rays were not taken, after difficulties with the extraction were recognised. We also found that there was not enough detail in the dental records and that, while the dentist provided accurate information in responding to Ms A, the response was incomplete because of the inadequate level of detail. However, we found no evidence that an error was made when extracting the tooth, and noted that the complications that occurred were a well recognised complication of the extraction of upper molars.

Recommendations

We recommended that the dentist:

• apologises to Ms A for the issues highlighted in our investigation;
• reviews her clinical dental practice in relation to this complaint, taking into account our adviser's comments, and provides the Ombudsman with confirmation that she has done so; and
• ensures that dental records are in accordance with General Dental Council standards including obtaining informed consent.

Summary

Mrs C, an advocacy worker, complained on behalf of Mrs A. Mrs A had given birth to her third child twelve days after the date on which the baby was expected. The board said that before the birth, Mrs A had only minor problems and so she was on a low risk pathway. The plan was for the baby to be born with the use of an epidural (spinal pain relief) but as labour progressed, the baby began to show significant distress and so was delivered by caesarean section under general anaesthetic. Within a few minutes, Mrs A began to suffer heavy bleeding, and needed a hysterectomy (surgery to remove the womb) to control this. Unfortunately, during this procedure Mrs A suffered damage to her urinary system, which needed further surgery. She had a slow recovery and was not discharged home for several weeks. Mrs C said that Mrs A suffered psychologically because of these events and that not enough was done to prevent them from happening.

Our investigation took into account all the available information, including the complaints correspondence and the relevant clinical and nursing records. We obtained independent advice from relevant consultants in all the areas relating to Mrs A's concerns, and from a senior matron in a maternity unit.

The board had sympathised with the difficult time Mrs A experienced and had apologised that aspects of her care had caused her concern. They acknowledged that the events of the delivery and what had happened after it had been difficult for Mrs A, but said they were of the view that everything that had been done had been in the best interests of her and her baby.

We did not uphold Mrs A's complaints about her care and treatment before and during the birth. We found that the clinicians involved in Mrs A's case had done nothing that contributed to her serious and life threatening condition. Our advisers said that all the procedures carried out were reasonable and had been appropriately administered. Although Mrs A felt that her husband had not been properly updated about her condition we concluded that this was reasonable, as the clinician's first responsibility had been to save Mrs A's life.

Overall, we found that Mrs A's care was generally reasonable. However, one of our advisers said that, once Mrs A was returned to a ward, it would have been appropriate to reassess her situation with regard to transferring her to a single room, particularly in view of her prolonged stay in hospital. The adviser also noted that an error was made with an injection and that Mrs A had been discussed publicly. These things should not have happened. We, therefore, upheld her complaint about the care she later received in the maternity ward and made recommendations to address this.

Recommendations

We recommended that the board:

• apologise to Mrs A for their shortcomings in this matter;
• emphasise to staff the importance of ensuring that discussions between professionals about an individual's care needs are kept private; and
• remind nursing staff to take account of individual patients' needs when allocating single rooms.

Summary

Mrs C said that her husband (Mr C) was involved in an accident in which he fell from height, and was airlifted to hospital. She said that following various CT scans (special scans that use a computer to produce an image of the inside of the body), Mr C was diagnosed with a spinal fracture. He was transferred to another hospital nearer to where they lived, but suffered a major stroke that resulted in him having severe communication difficulties. After Mr C had the stroke, it was diagnosed that Mr C's carotid artery was dissected (the layers of the artery wall supplying oxygen-bearing blood to the head and brain became separated). Mrs C complained that the hospital did not provide clarity about the treatment Mr C had received from them and that her complaint about this was not adequately addressed.

Two of our independent medical advisers considered all aspects of this case. We took account of their advice along with all the documentation provided by Mrs C and the board. We did not uphold Mrs C's complaints about treatment and complaints handling. The advisers said that Mr C had been correctly assessed and investigated at the hospital, in accordance with standard UK practice, and that appropriate diagnostic imaging techniques were used. They also said that clinicians diagnosed Mr C correctly and he had received a reasonable level of care. Our investigation found that the board had appropriately investigated and responded to Mrs C's complaint. However, we considered that they had failed to respond as agreed to Mrs C's enquiry about the board's protocol for image scanning, and we upheld that aspect of Mrs C's complaint.

Recommendations

We recommended that the board:

• feed back the learning from this complaint to all staff to ensure such an evolving communication failure will not recur; and
• apologise to Mrs C for this failure and the upset it has caused.

Summary

Mr C complained that the university unreasonably withdrew his right to study. He said he had not received communications that they sent whilst he was overseas because his university email account had been disabled, and that he had told his supervisor about his intended period of study off-campus. He also complained that the university unreasonably refused to hear his appeal against the decision to withdraw his right to study.

The university said they withdrew Mr C from his studies because he had not complied with their monitoring procedures for overseas students, as required by the UK Border Agency. In particular, he had not signed in weekly at the university office while on-campus, and had not completed the required form to obtain permission to study off-campus. Mr C had also consistently failed to respond to correspondence.

We did not uphold his complaint about withdrawal of the right to study. Although our investigation found evidence that Mr C had told administrative staff about the difficulty he had experienced in accessing emails, he had not reported it to the university IT help desk as he had been advised to do. Nor had he made any attempt to contact the university to arrange an alternative form of contact while any IT issues were being resolved. There was no evidence to suggest that Mr C's email account had been disabled or blocked by the university.

We did, however, uphold his complaint about the appeal. The university had rejected Mr C's appeal because it was made after a five working day appeal deadline had elapsed. We found, however, that they had not properly applied their policy on complaints and appeals and should have offered Mr C a ten working day period in which to appeal. We considered whether the university should now offer Mr C an appeal hearing but concluded that, as the decision to withdraw Mr C from his studies had been a reasonable one, this would not serve any practical purpose.

Recommendations

We recommended that the university:

• amend their existing policy to identify the circumstances in which the Informal Resolution Stage may not be appropriate, and could, legitimately, be bypassed.

Summary

Ms C complained that the university did not follow their regulations in the way they handled her PhD programme. She also complained that when she appealed against being de-registered from the programme, the university failed to respond reasonably to her appeals.

The particular issues which Ms C complained about related to the way in which the university supported her with difficulties she encountered with her research, including the loss of samples and a change in blood sampling techniques. She also complained that they had not provided her with sufficient written feedback on assessments she completed for the course. When she declined to meet with staff on several occasions until they provided her with information in writing, the university started to invoke procedures for de-regulation. Ms C was unsuccessful in her appeals against her de-registration.

We upheld the complaint about the way the university handled the PhD programme. Our investigation identified failings with the way in which the university provided feedback to Ms C following her assessments. Feedback was delayed, insufficient in detail, and not always in writing. We also identified issues with the sharing of other information about the conduct of research. In relation to the de-registration, our investigation found that the regulations had not been followed; insufficient notice was given of the situation, and this was followed by delays in providing responses to Ms C's appeals. However, we found that the content of the responses provided by the university was reasonable.

Recommendations

We recommended that the university:

• remind all staff of the obligation to follow through procedures in relation to any future cases of de-registration;
• review the way in which they communicate with students to ensure they provide consistent written feedback and communications, particularly where there are concerns over research methodology; and
• apologise to Ms C for any confusion caused by the irregularities in how the early stages of the de-registration process was handled.

Summary

Mr C complained to the college on behalf of his daughter (Miss A), after the Student Awards Agency for Scotland took recovery action against her. This highlighted a disagreement about the date on which Miss A's studies had ended, as Mr C said that Miss A was still attending college after the date on which the college said they had withdrawn her from her studies. This affected the amount of student award she was due to repay.

The college had investigated this and decided that the evidence supported their recorded withdrawal date. As part of our investigation, we reviewed the evidence that they provided, along with Mr C's evidence. Having done so, we considered the college's position on the matter to be reasonable and we did not uphold the complaint. However, we noted that it was not the college's practice to issue withdrawal letters and that Miss A, therefore, received no formal notification at the time of her withdrawal. We took the view that this might have avoided the subsequent disagreement and complaint, and made a recommendation to address this.

Mr C also complained about the college's complaints handling, as he was unhappy with the the time it had taken for him to complete their complaints process. We found that stage one of the college's process was informal and that three separate members of staff had dealt with Mr C during this stage before his complaint was formalised and escalated to stage two. We considered that this informal stage was unnecessarily protracted. Once the complaint was formalised, we found it was handled reasonably. However, we noted that throughout the process the college failed to proactively signpost Mr C to the next stage. In the circumstances, we upheld his complaint about complaints handling. However, we considered that the imminent introduction of a standardised complaints handling procedure for the further education sector will address this and so we made no further recommendations.

Recommendations

We recommended that the college:

• revise their policy to ensure that students who are withdrawn from courses are notified of this in writing.

Summary

Mr C complained that the college failed to respond to his complaints about the teaching staff on his course. We found that there were a number of shortcomings in the college's handling of Mr C's complaints. It took them too long to respond, not all issues he had raised were properly considered, and there was a lack of robust follow-up action to improve Mr C's learning experience. The college apologised unreservedly and reimbursed Mr C's fees.

Recommendations

We recommended that the college:

• provide update training to all staff involved in Stage 1 complaints handling.

Summary

Ms C received an unusually high water bill. She checked the pipework for leaks and confirmed there had been no changes to her business practice to explain the increased use of water. Business Stream said that as the bill had returned to normal, it could not have been a problem with the meter. They also checked the meter as Ms C was having trouble gaining access to the meter.

Ms C was unhappy that she still had not been told how to access the meter and that Business Stream could not explain why the usage had gone up for a short period. Our investigation found that Business Stream had undertaken most of the checks they should have done to reassure themselves the problem was not on the public network. However, they had not confirmed with Scottish Water whether there was any work being carried out on the network at the time. We found that they should have done so, and we upheld this complaint, as well as that about access, as we also found that they should have done more to help Ms C access the meter. However, we did not uphold her complaint that they should have explained why the increase had occurred, as there were matters outwith their control on the private side of the supply, about which they had no knowledge. Business Stream was only required to explain why they were satisfied that the additional usage was not caused by problems on the public side of the meter.

Recommendations

We recommended that Business Stream:

• confirm with Scottish Water whether there were any issues with the network during the relevant period that could have caused the meter to register increased usage prior to pursuing the bill; and
• arrange a visit by their meter reader to ensure that Ms C can access the correct meter.

Summary

After an incident, Mr C, who is a prisoner, was placed on closed visits (where a prisoner and their visitor cannot make physical contact) for a month. Mr C complained to us that the prison did not review his closed visit status appropriately. He said the review board did not consider his closed visit status within a reasonable time and the results of the review board were not communicated to him properly.

Our investigation found that a prisoner can be placed on closed visits if they behave inappropriately. The prison's guidance says that a prisoner's closed visit status will be reviewed monthly by a review board and the prisoner will be advised of the outcome. In Mr C's case, his closed visit status was reviewed by the prison a little under seven weeks after he was placed on closed visits. In addition, the prison told us that the results were fed back to him and he received a paper copy of the decision. Mr C's evidence to us conflicted with the information provided by the prison. Because of that, we were unable to determine with certainty whether the decision had been clearly communicated to Mr C, so we upheld his complaint made recommendations to address this.

Mr C also complained to us about the internal complaints committee (ICC). He said the officer who responded to the earlier stage of his complaint was also a member of the ICC and he felt that was inappropriate. We did not uphold this complaint. We noted that the ICC is responsible for considering a prisoner's complaint at the later stage. The prison rules and complaints handling guidance state that the ICC must be made up of at least three members, two of whom must be officers or employees from the prison. There is nothing to suggest that an officer who responded to the earlier stage of the prisoner's complaint cannot also be involved in the ICC stage. The prison told us that they were satisfied there was no conflict of interest in having the same officer sit as a member of the ICC. We were satisfied that the prison appropriately exercised discretion in deciding that the officer could also sit as a member of the ICC and that they did so in line with the prison rules and guidance.

Recommendations

We recommended that the Scottish Prison Service:

• ensure the prison reviews the wording of the closed visit protocol to ensure that the timescale for review is clear; and
• take steps to ensure that a prisoner confirms he has received a copy of the written decision of the review board by signing for receipt of the document.