Some upheld, recommendations

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.

Summary

Mrs C complained that the medical practice did not provide reasonable care and treatment to her husband (Mr C). Mr C had gone to the practice complaining of back and neck pains; pins and needles in his fingers, and difficulty walking and working. After several appointments, he saw Doctor 1, who recorded that he told Mr C that the problem was probably related to his spine and nerve entrapment. Doctor 1 also recorded that he had referred Mr C to physiotherapy and neurology (which deals with problems of the nervous system). He later completed a referral to physiotherapy, but there is no evidence that he completed a referral to neurology at that time.

Mr C saw another GP, Doctor 2, several days later. Doctor 2 recorded that Mr C had worsening pain in his arms, spine and back and some muscle spasms in the lumbar region. He also recorded that Mr C had weakness and numbness in his hands and was awaiting a neurology appointment. Mr C then saw Doctor 1 again. This was nearly three weeks after Doctor 1 had agreed to refer him to physiotherapy and neurology. Doctor 1 recorded that the pain was increasing despite analgesia (pain relief). He also completed a letter for urgent referral to neurology, as there was no sign of a referral being completed after the earlier visit. Mr C went to the accident and emergency department of a hospital (A&E) two days later. He was transferred to another hospital and an MRI scan (a diagnostic procedure used to provide three-dimensional images of internal body structures) led to a diagnosis of a serious back condition. Mr and Mrs C considered that this condition could have been prevented had the practice acted sooner.

After taking independent advice from one of our medical advisers, we found that the practice's general care and treatment of Mr C was reasonable, apart from the delay in sending the neurology referral letter. That said, Doctor 1 referred him to neurology urgently when it became clear that the initial (non-urgent) referral had not been done. In addition, he was transferred to another hospital for urgent treatment after attending A&E. In view of this, it is unlikely that the failure to complete the initial neurology referral had any significant impact on Mr C’s subsequent care and treatment.

Mrs C also complained that the practice’s response to Mr C’s complaint unreasonably contained inaccuracies. However, we found that the comments in the practice’s response were confirmed by Mr C’s medical records.

Recommendations

We recommended that the practice:

• issue a written apology to Mr C for the failure to send the referral letter.

Summary

Mr C's garden was contaminated when a blocked sewer overflowed. In the process of clearing up other gardens, further contamination was washed into Mr C's garden. Mr C said he was not properly notified of the contamination or the risk to his health. He complained that the clean-up of his own garden, which involved an operative spraying disinfectant for less than five minutes, was completely inadequate. He said that, in contrast, other properties got new topsoil, turf and stone chippings. Lastly, Mr C was unhappy that an operative suggested that he dig raw sewage into the soil.

We upheld three of Mr C's five complaints. Scottish Water accepted that some contamination was washed into Mr C's garden during the clean-up operation. We concluded that this run-off had, inappropriately, gone unnoticed. We found evidence that Mr C had not been properly issued with written information and guidance about contamination early enough. We also found that the option of a further clean-up was not discussed with or offered to Mr C, as it should have been.

We did not uphold Mr C's complaint of unfair treatment, in that his garden was not re-turfed etc. We took the view it was appropriate for Scottish Water to act proportionately, and to allocate more resources to those who were worst affected. It was not possible for us to establish what Mr C had been told by the operative and, as there was no supportable evidence, we did not uphold the complaint that Mr C had been told to dig sewage into the soil.

Recommendations

We recommended that Scottish Water:

• apologise to Mr C for those aspects of his complaint that we upheld.

Summary

Mr C, who is a prisoner, complained that when he reported that he was unable to attend his prison's learning centre due to illness, the actions of a residential prison officer were unreasonable. We did not uphold this complaint. As there were no truly independent witnesses to what was said between Mr C and the residential officer, the conversation could not be proven either way. That is not to say, however, that we believed either party's version of events over the other. We noted, however, that Mr C did not have authorisation from prison health centre staff to be absent that day. It was, therefore, reasonable for an officer to have counselled Mr C about the consequences of not attending the learning centre without authorisation.

Mr C also complained that the prison governor unreasonably delayed in responding to his confidential complaint. We upheld this complaint. We accepted that in this specific case there were mitigating circumstances, which meant that it took the governor longer than the statutory seven days to respond. However, the governor did not inform Mr C of all the reasons for the delay and advise him of the timescale within which a decision would be given.

Recommendations

We recommended that Scottish Prison Service:

• ensure that Governors, or staff responding on their behalf, adhere to Rule 124(5) of the 2011 Prison Rules, and retain evidence that they have done so.

Summary

Ms C complained that Business Stream delayed in issuing her bill after Scottish Water told them that her business premises were receiving water and waste water services, for which she had not been charged. When Scottish Water identify a property like this, they notify a licensed provider such as Business Stream, who then start billing from the date they were notified. In Ms C's case, however, Business Stream took seven months to issue a bill. The bill was based on the rateable value of the property, as Ms C did not have a water meter installed at that time. During our investigation of the complaint, Business Stream told us that when they receive details of properties that are not being charged for water, they need to open a property account, discover if there is someone in the property and then confirm their details in order to begin charging. However, in Ms C's case, there was no evidence that they had taken any significant action until they issued the bill to her. This was seven months after they received the information from Scottish Water.

Ms C then applied for a water meter and her charges were reassessed from the date it was installed. However, this was four months after Business Stream sent out her bill and eleven months after Scottish Water contacted them about Ms C's premises. Ms C complained that Business Stream did not tell her how she could request a meter or apply to have her charges reassessed. Business Stream said that there were no notes on their computer system of any conversation with Ms C about reassessment, but there was information on their website about how to apply. We considered that Business Stream should send out information about reassessment when they initially contact customers who do not have a meter installed.

Ms C had benefited from free water and waste water services for six months before Scottish Water contacted Business Stream. We considered that she had some responsibility to ensure that she was paying for these services. During our investigation, Business Stream agreed to backdate Ms C's metered charges for a short period, because they had not responded to correspondence. However, in view of the fact that we upheld her complaints that Business Stream delayed in setting up her account and failed to provide her with adequate information about reassessment, we asked them to reconsider their decision about the date to which the metered charges should be backdated, taking all of the above information into account.

Ms C also complained that Business Stream had failed to respond to some of her emails. However, we did not find any evidence of this.

Recommendations

We recommended that Business Stream:

• issue a written apology for the failure to provide Ms C with adequate information about reassessment when they initially contacted her;
• consider how they can ensure that they provide adequate information about reassessment to new customers who do not have a meter installed;
• reconsider their decision regarding what date metered charges should be backdated to in Ms C's case; and
• issue a written apology to Ms C for the delay in issuing the initial bill.

Summary

Mr C complained that the health suite in a leisure centre was closed so often in 2011 that Glasgow Life were failing to provide him with an adequate membership service. He thought that he should have been compensated for this.

We investigated the complaint, and asked Glasgow Life for details of all the leisure centre's closures in 2011. We found that there was a planned closure for six weeks at the very beginning of the year for refurbishment, and several unforeseen closures in April/May due to technical problems. These closures led to a permanent repair being made, which took two weeks in October/November. Glasgow Life also provided details of how they had mitigated the effects of the repairs and the offers made to customers for alternative use in other facilities, or to put their membership on hold, where appropriate.

Taking these details into account, we were satisfied that Glasgow Life had acted appropriately and we did not uphold this complaint. However, Mr C also complained that Glasgow Life had delayed in dealing with his formal complaint. Available correspondence indicated that this had been the case, and we upheld this part of the complaint.

Recommendations

We recommended that Glasgow Life:

• apologise for failing to deal with the complaint in terms of their complaints procedure.

Summary

Mr C complained to the council about a social services investigation into child protection issues affecting his family. Mr C said that the council had not handled his first complaint appropriately and had refused to fully respond to two further complaints he raised.

Although we noted that there were significant delays in Mr C's first complaint progressing through the council's social work complaints procedure, we considered that the council had handled it appropriately and in line with their procedures. We found that the delay was due to exceptional weather conditions over the Christmas and New Year period, along with problems the council had in understanding the detailed letters of complaint that Mr C had submitted. We also found evidence showing that Mr C was given the opportunity to provide evidence to support all the elements of his first complaint and to provide his version of events at a complaints review committee hearing.

Mr C's second complaint was about a video recording he had made, which apparently showed that social workers had provided inaccurate information at a social work child protection case conference. After obtaining legal advice, the council refused to review the recording because they said they believed it was inadmissible as evidence. They later departed from this view, and said that they were unsure whether it was lawful to use a recording that had been made covertly (ie not made openly), without the consent of the staff involved.

We have previously obtained advice about covert recordings, which allows us to provide a clearer view that an authority, such as the council or our office, may consider evidence even if it was obtained through covert recording without the prior consent of all parties involved. Relevant material in respect of a case which has been obtained covertly, without the prior consent of all parties, is not as a rule inadmissible as evidence. So, when considering a case, both the Ombudsman and the council are obliged to take into account all relevant evidence in reaching their conclusions and are under a common law duty to give adequate reasons for these conclusions. However, it is then for the authority concerned to decide how much weight they should attach to such evidence when reaching their decision about the matter. We concluded that the council should have fully responded to Mr C's complaint about the case conference and reviewed his video evidence through the social work complaints procedure.

Mr C raised a third complaint about matters surrounding the birth of his youngest child. Although the complaint was related to social services' overall child protection investigation, we considered that the council acted unreasonably in not fully responding to the complaint through the social work complaints procedure.

Recommendations

We recommended that the council:

• ask the complaints review committee to consider reviewing Mr C's video recording of, and his concerns about inaccurate information being discussed at, the case conference on 25 November 2010; and
• ask the complaints review committee to consider reviewing Mr C's complaints about the pre-birth and post-birth conferences in relation to his youngest child.