Some upheld, recommendations

Summary

Mr C complained about the way in which the Office of the Scottish Charity Regulator (OSCR) dealt with his complaint about a charity. His concerns related to both the quality of the OSCR investigations and their communication with Mr C during and following their investigations.

Our investigation found no administrative failure in terms of the content of the investigation, but we did note that it had taken far too long to complete. In addition we noted that OSCR had failed to keep Mr C fully informed of the progress of the case and had not dealt appropriately with his subsequent complaint. We upheld these aspects of his complaint.

Recommendations

We recommended that the Office of the Scottish Charity Regulator:

• provide an apology to Mr C for the injustice identified in our decision notice;
• introduce some limited form of routine updating to complainants and alter their inquiry and investigation policy accordingly; and
• review their complaints policy and consult with the Ombudsman before introducing a revised version.

Summary

Ms C had to move out of her home temporarily while the council carried out repair work because woodworm had affected most of her property. Ms C said that the council assured her that the work would be carried out with the minimum of fuss and that her home would be returned in the same condition. She said that, during this time, on several occasions she and her partner were contacted by workmen to gain access to her home, although she had provided a spare set of keys before the work started. On one occasion, while on holiday, the council had called to advise her that they would have to force entry to the property if they could not get a set of keys, due to an emergency that had arisen involving her neighbour. On another occasion, Ms C said that she was asked to take keys to her home and lock up at the end of the day but on returning later, found the workers had left her home insecure. Ms C was also unhappy that the council had not got her to sign off individual work carried out at the property and that a housing officer told her that no cleaning or redecoration would be provided after the repair work. She also said that the council had not responded reasonably to two letters of complaint she sent.

We upheld most of Ms C's complaints. Our investigation established that the council met with Ms C before the work was carried out to discuss the significant amount of work to be done. As Ms C had highlighted that she had health problems, arrangements were made for a spare set of keys to be given to the tradesmen, and her partner was to be contacted in the event that the council needed to discuss any matter related to the work. During the time of the repair work we found evidence to support that there were problems with the different trades accessing the property. Whilst the council took steps a couple of weeks later to fit a key safe outside Ms C’s home, we considered that this could have been implemented sooner as the council would have been aware that the various trades would need access to the property at different times. We also identified that the council had tried to obtain feedback from Ms C after the work had been completed, but that it was not compulsory for the council to 'sign off' individual pieces of work, so we did not uphold that complaint.

Whilst Ms C gained access to her home in order to begin cleaning it prior to the work being finished, we did not find evidence to support that she was advised no cleaning would be carried out. On the contrary, there were records to show that cleaning was to be done after the work had been completed. However, we upheld her complaint that the property was not left in the state that she understood it would be. Finally, we upheld Ms C's concerns about the handling of her complaint, as we identified that the council had not compensated her for a missed appointment nor had they repainted her bedroom as stated in their complaint responses to her.

Recommendations

We recommended that the council:

• apologise to Ms C for the problems with accessing her property;
• fulfill its agreement and ensure Ms C's bedroom is repainted; and
• that the council provide the Ombudsman with a copy of their apology letter and evidence to confirm that Ms C has been reimbursed for the missed appointments in August and September 2011.
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Summary

Mr C runs a business situated on a road that the council intended to close temporarily for a week to allow for resurfacing. The normal practice was that the council prepared a letter for a representative of the contractor to hand-deliver to businesses at least a week before work started and, at the same time, to discuss specific access requirements. Mr C complained that the council did not reasonably undertake their responsibilities under the Construction (Design and Management) Regulations 2007 about access and egress (entry and exit) to the works area; did not follow their own health and safety procedures in relation to the road works; and did not investigate his complaints about these matters within a reasonable time scale.

Our investigation confirmed that the council’s contractor had not notified and discussed specific access and egress requirements with Mr C (and a number of other businesses) until four calendar days before the work started. Mr C also had photographic evidence showing that health and safety procedures were on at least one occasion not followed when a vehicle reversed without a banksman (reversing assistant) in attendance. We, therefore, upheld the first two elements of Mr C’s complaint. We did not uphold the complaint about complaints handling, as although the complaint took slightly longer to deal with than indicated by the council’s published timelines, we found there had been mitigating circumstances.

Recommendations

We recommended that the council:

• copy this decision notice to the contractor and remind them of their responsibilities under the Construction (Design and Management) Regulations 2007 and related health and safety measures.

Summary

Mr and Mrs C live in a ground floor four-in-a-block flat and are the sole council tenants in the block. The flat directly upstairs has a private tenant. Mr and Mrs C complained about unreasonable delay by the council in repairing the roof and rhones, which they felt resulted in dampness in their flat; the council’s failure to deal with problems of antisocial behaviour from the upstairs tenant, and the council’s failure to take action in relation to five incidents of flooding from the upstairs property.

We upheld one of the three complaints, as our investigation found that there was an unreasonable delay of eleven months between the council obtaining a quote for the roof and rhone repairs and the repairs being done. This was initially because they sent a copy of the quote to the occupant rather than the owner of the upstairs flat and did not follow up the lack of a reply. We made recommendations to address these failings. We did not uphold the complaint about antisocial behaviour because Mrs C had not provided the necessary information to take the matter forward and there was no corroboration from others. The council had no record of three of the five incidents of flooding, and had taken action on one some three years earlier. The fifth incident had only occurred on the eve of Mr and Mrs C’s final stage complaint to the council.

Recommendations

We recommended that the council:

• explain to Mr and Mrs C what the installation of a chemical damp proof course and kitchen upgrading would entail and, if that work would be unduly disruptive to Mrs C because of her medical condition, make appropriate arrangements for short term temporary accommodation; and
• investigate any request that Mr and Mrs C make about repairs to the fabric of their flat as a result of the internal flooding incident on a date in March and take the remedial action necessary.

Summary

Mr C's elderly mother is cared for in hospital. He told us that one day when he was visiting her, the nurse in charge spoke to him in an inappropriate way. He was unhappy because when he complained to the board about the incident, he said they did not investigate or handle his complaint properly. He said that the board did not ask a witness for information and that there was an unexplained delay in passing his complaint to the board's complaints team.

We upheld his complaint about the investigation. We found that the board did the correct thing by interviewing the nurse involved, and we were satisfied that they did so as soon as they could after the complaint reached the complaints team. We could reach no conclusion about whether all the correct witnesses were interviewed, as accounts of who was there were different. We were, however, concerned that two witness statements appeared to have been taken after the date on which the board responded to Mr C's complaint, and made recommendations to address this.

We did not uphold his concerns about the complaints handling. Our investigation found that Mr C initially asked for his complaint to be handled on the ward, but later decided that he did not want to meet the member of staff who was handling it. Although there were typing errors in the board's letters and we identified a minor issue about the time it took to provide a final reply to his complaint, we noted the board's policy that staff made aware of a complaint should handle the matter locally as far as possible. We, therefore, found that the reasons for the delay in passing the complaint from the ward to the complaints team were understandable. We also noted that, as Mr C and his family had repeatedly expressed concerns about his mother's care, the board had appropriately arranged for reviews of her nursing and medical care.

Recommendations

We recommended that the board:

• remind staff to ensure that, in future, relevant witnesses to events are interviewed or asked to provide a statement as soon as possible after the event, and in any case, during the investigation of the complaint;
• provide specific guidance on obtaining witness information (in their advice to staff about operating the complaints policy); and
• review their practice for checking draft letters to be issued by the complaints team, with the aim of minimising the chance of typing errors. The board should let the Ombudsman know the steps that they put in place as a result.

Summary

Mr C complained about the care and treatment that his father (Mr A) received when the board referred him to a private hospital as an NHS patient for an operation. Mr C said that his father's discharge from the hospital was unreasonable, as he had not passed urine. He also complained that his father was discharged in severe pain with pain relieving drugs co-codamol and paracetamol, despite the fact that he had told the hospital he could not take co-codamol as it contained codeine. A nurse had recorded in Mr A's notes that he had passed urine before being discharged. In response to the complaint, the nurse said that although she could not remember Mr A, she had noted this in the records, and he would not have been allowed to leave the hospital had he not done so. We found that there was no evidence to support Mr C's complaint that the record had been falsified. However, we found that Mr A was prescribed co-codamol in error, as the hospital had previously recorded that he was not to be given codeine. We upheld this complaint and made recommendations to address this. Mr C also complained that the hospital's response was unreasonable when his mother contacted them about his father's pain after his discharge. We found no evidence to support this aspect of Mr C's complaint.

Recommendations

We recommended that the board:

• issue a written apology to Mr A for administering co-codamol in error; and
• review this matter in order to identify how they can prevent such errors.

Summary

Miss C's father (Mr A) was admitted to hospital via the accident and emergency department after a fall. Mr A had suffered two previous falls and had become increasingly forgetful over a period of seven to ten days. Mr A's level of consciousness was recorded as being normal upon admission, but dropped shortly afterward. A scan showed that he had had a cerebral bleed (bleeding on the brain). Although he made a slight improvement while in hospital, he developed pneumonia and died the next month.

Miss C raised a number of concerns about the treatment that Mr A received from the hospital's staff and the level of attention paid to his needs whilst he was an in-patient. She also complained about the board's communication and handling of her complaint.

We took independent advice from two of our medical advisers, and upheld almost all of Miss C's complaints. We found that the overall level of care and treatment provided to Mr A was reasonable, but there were some specific issues that concerned us and we considered these to be serious failings. Specifically, we found that insufficient nursing care was provided throughout one day, when Mr A was in a single room. A lack of written notes cast doubt as to whether certain tasks had been performed and, in particular, whether a swallow screen test (a test to check the patient’s ability to swallow) was carried out by a suitably qualified member of staff.

We were concerned to note that Mr A's family were not told that a decision had been made not to attempt resuscitation (ie that a doctor was not required to resuscitate Mr A if his heart stopped). We also found that this decision was taken without the input of a senior clinician as is required. Generally, we did not consider that the lead clinician caring for Mr A was sufficiently involved in his care. We were satisfied that the information contained in Mr A's clinical records was reasonable, but were critical of the board for the number of omissions in the records. We made a number of recommendations to address the failings we found.

We did not uphold the complaint about complaints handling, as we found the board's handling of Miss C's complaint to be reasonable.

Recommendations

We recommended that the board:

• draw our adviser's comments on the use of anti-sickness medication in syringe drivers to the attention of clinical staff;
• provide the Ombudsman with details of the outcome of their 'care round' document trial and any changes to their patient monitoring procedures that result from this trial;
• review the level of involvement of senior clinical staff in patients' treatment;
• remind their staff of the need to discuss 'do not resuscitate' decisions with patients and their families;
• remind nursing staff of the need to maintain full and accurate nursing records in line with Nursing and Midwifery Council guidance; and
• apologise to Mr A's family for the issues highlighted in our investigation.

Summary

Mr C complained that he was prescribed the wrong dosage of his medication and that clear instructions were not given as to how many tablets he could take at a time. The practice provided us with copies of their records, clearly showing the appropriate dosage and instructions attaching to Mr C's prescription. We found no documentary evidence to support Mr C's account of events and we did not uphold the complaint. Mr C also said that he mistakenly received a letter from the practice about test results and complained that the practice had not explained why this had been sent. The practice confirmed that the letter was not intended for Mr C but, for data protection reasons, they could not offer an explanation to him. However, they provided us with sufficient information to satisfy us that there had been no administrative error and we did not uphold the complaint.

Mr C also complained that a meeting was set up for him to discuss his complaint with the practice manager and one of the doctors. He said that when he turned up the doctor did not know why he was there and the practice manager was not in attendance. Upon reviewing the records, we noted that the practice manager had documented that she set up this consultation for Mr C to discuss his medication with the doctor. It, therefore, appeared that both parties had differing recollections of the purpose of the meeting. We had no way of reconciling these different interpretations and we did not uphold the complaint. Finally, Mr C complained about the practice's handling of his complaint. We found that they failed to respond to him within the timeframe set out in their complaints procedure. We acknowledged that this may not always be possible but considered that Mr C should have been kept up to date. This did not happen and we, therefore, upheld the complaint.

Recommendations

We recommended that the practice:

• review their complaints procedure in order to ensure that, where complaint investigations are likely to take longer than their published timescales, they notify complainants of this and provide a revised target response date.

Summary

Mrs C complained about the care and treatment her late husband (Mr C) received in hospital. Mrs C said that a locum (temporary) assistant had not carried out the correct procedure for referring Mr C to a specialist chest consultant at the hospital; that records from another patient were found in Mr C’s notes and that an occupational therapist (OT) had conducted an assessment on Mr C using water from a tap with a blocked sink.

We took independent advice from a medical adviser, who considered all aspects of Mrs C’s complaint and Mr C’s care at the hospital. He said that the board had failed to ensure that an abnormality on Mr C’s chest x-ray was appropriately investigated after it was noted by the radiologist (a medical specialist that uses imaging to diagnose and treat disease). The board had acknowledged and addressed this, and apologised to Mrs C before the complaint was brought to us. We, therefore, upheld this complaint. Mr C subsequently died of cancer, but our adviser said that it was not possible to say whether the outcome for Mr C would have been different had a diagnosis been made earlier.

Although our investigation found no evidence that another patient’s records were included in Mr C’s notes, we acknowledged that such an event can occasionally occur and noted that the board had expressed regret about this. We upheld the complaint.

We found no evidence that water from a blocked sink had been used in the OT assessment and so we did not uphold this complaint.

Recommendations

We recommended that the board:

• provide an update on the implementation of their protocol, with specific reference to how results of investigations undertaken whilst a patient is an in-patient are reconciled with their case notes after discharge.

Summary

Mrs C complained that delays in the investigation and treatment of her late husband's cancer hastened his death. She also complained about a lack of nursing and personal care provided to him, including pain relief; inappropriate discussions about resuscitation; a shortage of beds in the specialist respiratory ward and the hospice; delays in giving her access to her late husband's medical records; and that the board delayed in dealing with her complaints.

Our investigation found that Mr C had been investigated for pain, stiffness and swelling in his legs and ankles, which was attributed to a rheumatic condition. However, as this condition can also affect the lungs, a chest x-ray was taken in January 2011. The x-ray was reported to be normal and Mr C's treatment and monitoring of the rheumatic condition continued. In February 2011 Mr C's condition had deteriorated, and he had lost weight. He returned to the rheumatology clinic for further investigations. Various investigations including computer tomography (CT – a special investigative scan) and positron emission tomography (PET – a special investigative scan) were undertaken and Mr C was diagnosed with lung cancer in March 2011. The cancer was an aggressive one and by the time of diagnosis it had already spread and was considered to be inoperable. Despite treatment, including chemotherapy, Mr C died in June 2011.

We took independent advice from three of our medical advisers - a respiratory physician (lung specialist), an oncologist (cancer specialist) and a senior nurse. The respiratory physician was critical that the January x-ray was reported as normal as there was what he felt to be 'unequivocal', if fairly subtle, indications of abnormality on the x-ray. However, he and the oncologist agreed that even had this x-ray been correctly reported and a referral to the chest clinic made in January 2011 the outcome and duration of Mr C's life would have been the same. They also agreed that Mr C’s management was otherwise appropriate and timely. The nursing adviser was, however, critical of the lack of assessment, monitoring and review of Mr C’s pain; the standard of the notes; and the lack of personal care, including washing, provided to him.

Our investigation identified several areas of concern and we upheld five of the six complaints. The only complaint we did not uphold was that about the lack of beds in the respiratory ward and hospice. We found that the only reason Mr C was not transferred was because there was a particularly high demand for beds at that time. Mr C was transferred to the respiratory ward as soon as a bed was available, but died before a bed was available in the hospice.

Recommendations

We recommended that the board:

• issue a written apology;
• review a sample of x-ray reports to ensure that no others have been mis-reported;
• review the process of reporting on x-rays to ensure timely reporting;
• ensures that all relevant information is recorded on the multi-disciplinary team meeting forms;
• reviews the policy on ordering PET scans in line with SIGN (Scottish Intercollegiate Guidelines Network);
• review training on the discussion, decision making, review and recording of 'do not resuscitate' decisions;
• ensure that all nursing staff are aware of and implement national and local guidance on assessment, management and review of patients' pain;
• ensure that all nurses are aware of the need to provide regular and appropriate personal care where patients require assistance;
• ensure that all nurses are aware of and implement national guidance on record-keeping issued by the Royal College of Nursing; and
• report on the remedial action taken to prevent a recurrence of delays on access to copy medical notes.