Some upheld, recommendations

Summary

Mrs C's husband collapsed at home and an emergency ambulance was called. Although Mrs C lives near an ambulance station and a hospital, the ambulance sent was not the nearest one at the time, and there was a delay before it arrived. Mrs C's husband later died from a heart attack. The service explained to her that the nearest ambulance was already involved with a patient, and so the next available vehicle was despatched. Mrs C complained to us that the service had not conducted a thorough investigation into what had happened, and that, after she complained to them, it was five months before she received a final response.

Our investigation found that the service had completed a thorough investigation, so we did not uphold that complaint. We did, however, uphold her complaint about the complaints handling, as the board had not sent her regular updates on the progress of the investigation or told her that she could contact us, when the response to her complaint was delayed. We also established that they incorrectly told Mrs C that the investigation was nearing completion, when in fact it had been concluded.

Recommendations

We recommended that the service:

• conduct a review into the time taken to respond to formal complaints; and
• apologise to Mrs C for the time taken to respond to her complaint.

Summary

Mrs C complained that the board failed to provide her with appropriate care and treatment when she attended a hospital accident and emergency department (A&E). Mrs C said she had gone to hospital a number of weeks after injuring her ankle. She said she was told that she had a bad sprain, but that she did not need an x-ray as the pain would ease itself. A week later Mrs C went back to hospital in severe pain. A number of x-rays were taken and she was told that her foot was fractured. Mrs C complained that the staff nurse who dealt with her on her first visit to hospital did not check on her while she was waiting and treated her with contempt, as if she should not have been there.

During our investigation, we took independent advice from a medical adviser. He explained that the treatment Mrs C received when she first went to A&E was appropriate, and in accordance with internationally validated and recognised clinical guidelines. He said it was clearly recorded that there was no evidence of bone pain and that Mrs C was able to put weight on her foot. He explained that the absence of bone pain suggested that an x-ray was not required. We did not, therefore, uphold Mrs C's complaint about her care and treatment.

On the matter of the nurse’s conduct, although the board said they had discussed this with her during their investigation of the complaint, they had not recorded what was said, and had taken no statement from her. In response to our enquiries, they obtained an account from the nurse in which they said she accepted that her conduct towards Mrs C had been inappropriate. Although it would have been more appropriate for a statement to have been taken at the time rather than eleven months later, we upheld this element of Mrs C's complaint, as the evidence supported her view that the nurse did not deal with her appropriately.

Recommendations

We recommended that the board:

• apologise to Mrs C for the staff nurse’s conduct towards her; and
• provide the Ombudsman with a copy of the change to their procedure for investigation of complaints.

Summary

Mr C complained on behalf of Mr A about the care and treatment he received at a hospital. Mr A had attended the hospital's accident and emergency department (A&E), complaining of dehydration, frequent urination, vomiting and lack of energy. Mr A had also said that his eyesight was blurry and he had a dry mouth. After tests, Mr A was diagnosed with a virus and a low salt count, and discharged. Two days later, Mr A became ill during a journey and was taken to hospital where he was immediately diagnosed as having type 1 diabetes. He was in hospital for about a week. Mr C complained that Mr A was not properly diagnosed during his initial hospital visit.

Our investigation took account of all the available information, including the complaints correspondence and Mr A's medical records. We also obtained independent medical advice. We found that not all the tests that should have been carried out were carried out. This meant that Mr A's condition was not properly diagnosed and he was discharged from A&E too early. Our investigations also showed that the board had not addressed all the complaints Mr C put to them on behalf of Mr A.

Recommendations

We recommended that the board:

• apologise to Mr A for their failure to carry out appropriate diagnostic testing;
• apologise for failing to correctly diagnose Mr A and for discharging him prematurely;
• confirm that the GP specialist trainee raised this case as a significant event at her appraisal;
• confirm to the Ombudsman that they are satisfied that the systems failure that allowed a patient to be discharged from A&E before test results were reviewed has been remedied;
• apologise to Mr C and Mr A for failing to admit when responding to the complaint that there had been faults with regard to Mr A's care and treatment; and
• apologise for their failure to respond to the complaint about the way in which Mr A was spoken to.

Summary

When Mr and Ms C's young daughter became ill, they took her to their medical practice. She was examined by a GP, who said that she was suffering from a yeast infection and nappy rash. Later that day Mr and Ms C's daughter’s condition deteriorated and she was taken to hospital, where she was diagnosed with scarlet fever. Mr and Ms C complained to the practice that the GP did not diagnose their daughter correctly. The practice responded but Mr and Ms C felt that the response was inaccurate and did not deal with the complaint.

As part of our investigation, we took independent advice from a medical adviser. He explained that the diagnosis of scarlet fever is rare, and that there was evidence that the GP had taken appropriate steps to diagnose Mr and Mrs C's daughter's condition. Taking this into account we did not uphold the complaint.

When investigating the complaint about the practice's complaints handling, we looked at the practice's complaints procedure and response. We found that the practice had not followed their complaints process. We also found that the GP had not written detailed medical notes which meant that the practice's response was incomplete. We, therefore, upheld this complaint and made recommendations to address these failings.

Recommendations

We recommended that the practice:

• ensure that all relevant members of staff reacquaint themselves with the practice complaints procedure and ensure that they follow it; and
• ensure that the GP concerned is aware of the General Medical Council guidance on record-keeping.

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.