Some upheld, recommendations

Summary

Mrs C complained that her late husband Mr A (who had terminal cancer), had suffered during his illness up to his death. Mrs C stated that in her view, she could not believe so many things had gone wrong with the care and treatment Mr A had received from the practice over 17 months. These issues were a failure to follow up Mr A’s admission to a hospital in the board’s area after the hospital had discharged him; that a practice GP had provided incorrect information about Mr A during a home visit and that the practice failed to follow the appropriate processes and procedures when completing the Do Not Resuscitate Form (the DNR).

Our adviser considered all aspects of Mrs C’s complaint and said that Mr A had lung cancer and that it was the responsibility of the hospital clinician that arranged Mr A’s investigation to follow up and act on the results, not the practice.

Our adviser stated that a practice doctor had provided incorrect information during a home visit; however, the practice doctor had speedily corrected this and apologised.

The adviser stated that the DNR Form (as part of end-of-life care), assists with the management of terminally ill people and compliments the expertise of those using it. We took account of the adviser’s advice and considered that the practice had followed the correct DNR procedures. Mrs C’s complaint was partially upheld.

Recommendations

We recommended that the practice:

• re-examine along with the District Nursing Team as a whole, their role in this case within the Liverpool Care Pathway continuous Quality Improvement Programme (to include the completion of the DNR form), to see (and reinforce) if there are lessons to be learned and how they can be applied to prevent such a scenario arising in the future (reference to both complaints 3 and 4).

Summary

Mr C complained that a medical practice would not issue prescriptions that he considered were appropriate to accommodate his individual circumstances. Mr C wished, as standard, to receive 56 day prescriptions (not the 28 day prescriptions the practice issued to him), for a long standing medical condition. Mr C had only recently moved to the practice. He also complained that the practice did not deal with his complaint appropriately.

We took independent advice from our medical adviser. After careful consideration of the advice and taking into account that the practice had made Mr C a reasonable offer to try to suit his personal circumstances, we did not uphold the complaint. We also considered that the practice had appropriately addressed Mr C’s complaint in good time. They had not, however, advised him of his right to bring his complaint to us if he wished to do so, which they are required to do. We upheld this aspect of his complaint.

Recommendations

We recommended that the practice:

• ensure that, in any complaint response, SPSO details are included to provide a complainant with the opportunity to contact us if they wish to do so.

Summary

Mr C complained that the board failed to provide him with reasonable care and treatment for his mental health problems. He detailed a number of areas about which he was concerned, and he was also unhappy about the way in which the board handled his complaint. He said that the consultant concerned had lied in his response.

During our investigation, we took independent advice from our medical adviser who is a consultant psychiatrist. We found that that the frequency of the board’s contact with Mr C was reasonable. We also found that the frequent use of hospital admissions and the fact that a large team were involved in his assessment and treatment were examples of good clinical practice. Although some of the clinics that Mr C was to attend were cancelled, we did not consider that this was excessive. We also found that it was reasonable to arrange clinics in locations that would benefit the greatest number of patients. However, we found that Mr C had been prescribed with large doses of medication that were not appropriate for the disorder he had been diagnosed with. This led to him being over-sedated. For this reason, we upheld his complaint about care and treatment, although we noted that the board had since carried out a review of his medication. We did not uphold the complaint about complaints handling, as we found that the board’s response was reasonable and we did not consider that the consultant had lied.

Recommendations

We recommended that the board:

• issue a written apology for their failings in relation to prescribing medication, which led to Mr C's over-sedation.

Summary

Mr C's home was flooded with sewage and his insurance company arranged for him to stay in a nearby hotel. That evening, his home was again flooded with sewage. He complained to us that Scottish Water delayed in responding effectively to the sewage flooding. Scottish Water's code of practice states that they will usually attend within four hours if internal sewage flooding is reported. We found that an officer had attended the flood within four hours. A clean-up squad attended on the following morning and Scottish Water's contractors attended on the next day to try to resolve the problem in the sewer. We did not, therefore, consider that Scottish Water delayed unreasonably in responding to the sewage flooding.

Mr C also complained that Scottish Water failed to routinely inspect the sewer as part of their maintenance programme. There is no requirement for Scottish Water to proactively monitor and inspect the whole of their sewage system and it is not within our power to recommend that they adopt such a policy.

Finally, Mr C complained that Scottish Water failed to deal with his claim for compensation appropriately. We upheld this complaint. We found that Scottish Water had referred Mr C's claim for compensation to their insurers. However, they failed to tell them that a half brick had been found in the sewage system. We considered that they should have done so in order that the insurers could reach a sound decision based on all of the relevant evidence.

Recommendations

We recommended that Scottish Water:

• issue a goodwill payment of £200 to Mr C to cover his insurance excess; and
• apologise to him for failing to initially inform their insurers that a half brick had been found in the sewage system when they referred his insurance claim to them.

Summary

Mr and Mrs C live in a house on a coastal strip below a site that contains two plots which received planning consent in 2005 (after a successful appeal to Scottish Ministers). A subsequent application was made in 2010 for full planning permission for an amended design on these plots. As part of the 2010 application the applicant provided an overlay comparing the earlier consent with the 2010 proposal.

Due to an error by the applicant's agent, first noted by a senior planning officer the day before a site visit, the case officer's report referred to the 2010 application as being at a lower height than the 2005 approval, although the finished floor levels were in fact about the same. The senior planning officer had requested an amended overlay from the developer, and this had been available to the planning committee the next day when they visited the site before deciding on the 2010 application. Mr and Mrs C made three complaints, two of which we upheld. We found that, had the error been uncovered earlier, then in the period leading up to the site visit an amended or supplementary report could have been provided (removing the references to the lower height of the 2010 proposals) and that a more appropriate methodology could have been used to demonstrate height levels at the site visit.

Recommendations

We recommended that the council:

• apologise to Mr and Mrs C for the defects identified in the way that they processed the 2010 application.

Summary

Mr C, an advocacy worker, complained to the council on behalf of a client (Mrs A).

The complaint was about the council complaints review committee (CRC)'s handling of her complaint about her husband's care package. Mrs A said that the CRC was unreasonably delayed; that it did not take all of her evidence into consideration concerning the care provider and the council's offer of a meeting to discuss the complaint; nor did it include important information in its report to the council's Health, Social Care and Housing Review Committee (HSCHRC).

We upheld Mrs C's first complaint, as our investigation found that the council had not arranged the CRC hearing within the statutory timescale nor within a reasonable length of time. We did not uphold the complaints that the CRC was not given sufficient evidence to show that the council had attempted to arrange a meeting between Mrs A and the care provider to try and address Mrs A's concerns; that Mrs A had not been given the opportunity to provide her evidence in writing to the CRC and to discuss this at the hearing; and that the CRC had not provided the HSCHRC with their decision and recommendations in line with their policy and procedures. We reached this conclusion as we found no evidence to show that the council had acted wrongly in these matters.

Recommendations

We recommended that the council:

• apologise for the delay in convening the CRC.

Summary

Ms C, a solicitor, complained on behalf of a tenant of the housing association (Mrs A). She said that the association had failed to take action to resolve problems with the sewerage and septic tank that Mrs A shared with three other properties, two of which were privately owned.

Our investigation found that the association had obtained professional advice on the matter. They considered that major renovation work was necessary to improve the sewerage system and septic tank, but this would require the consent of Mrs A's neighbours. The neighbours refused to agree and so the association were unable to arrange for the work to be carried out.

Ms C also complained that the association had blamed Mrs A for the problem by referring to the disposal of inappropriate items. We found that the association had evidence to show that some of the problems might have been caused by inappropriate use of the system. In response to this, they gave advice to all residents about how the system could be better used. We considered that it was appropriate for the association to tell residents about this. This position was supported by the council's area environmental health manager, who considered that the system could be managed by careful use and regular flushing.

Ms C's final complaint was about the association's failure to adequately respond to Mrs A's complaint. We found that the association's response did not confirm that it was a response to the complaint or how Mrs A could take the matter further. We also found that they had delayed in taking some of the action they said they would take, and had failed to keep Mrs A updated. Our investigation found that the association's letter was not an adequate response to Mrs A's complaint, therefore, we upheld this part of the complaint.

Recommendations

We recommended that the association:

• remind staff that responses to complaints should include information about how the complainant can pursue the matter should they remain dissatisfied; and where appropriate, complainants should be kept informed of the progress in relation to a matter; and
• issue an apology to Mrs A for their failure to adequately respond to her stage one complaint.

Summary

Mrs C suffered from lung cancer and chronic obstructive pulmonary disease (a disease of the lungs in which the airways become narrowed). She was receiving chemotherapy but after the second cycle her condition deteriorated and she was admitted to hospital, where she died a few days later.

Her daughter, Miss C, was concerned that while her mother was in hospital one of her medications, which was given by injection, was not always administered. She said that at times the injections were prepared and then left by her mother's bedside if they were not given. Miss C also complained that a pain relieving patch was not administered. The board said that the patch had been administered but was later removed. There was conflicting information from the board and Miss C about when this happened.

We investigated and took independent advice from one of our medical advisers, a senior and experienced nurse. She said that the Nursing and Midwifery Council (NMC) issue guidance on the preparation and administration of drugs and that the practices demonstrated in this case did not comply with that guidance. We upheld both complaints.

Miss C said that there were inaccuracies in the fluid monitoring charts, but we could not establish the accuracy of these, given the time that has passed since. The board did say that Mrs C, who was a retired nurse, liked to maintain her independence where possible and preferred to go to the bathroom when she was able. They said that this may have introduced some inaccuracy to the charts. Our investigation found that it was reasonable to allow Mrs C to maintain her independence where possible. The nursing adviser reviewed the charts and had no concerns, and we did not uphold this complaint.

Finally, we upheld Miss C's complaint about complaints handling. We found that there were unacceptable delays in responding to Miss C's complaints. The final response took four months rather than the 20 working days required by the NHS guidance on complaints handling. In addition, our investigation found that although it largely reflected the NHS guidance, the board's complaints procedure did not fully comply with it.

Recommendations

We recommended that the board:

• apologise for the deficiencies identified by our investigation;
• provide an update on the changes to the evening medication round;
• ensure all staff are aware of and comply with the NMC standards and board policy on administration of medication;
• report on the integration of the policy on the administration of medication to the board's staff induction programme;
• provide an update on the progress of changes to the complaints and advice team; and
• ensure that their complaints procedure fully reflects the NHS guidance on complaints handling.

Summary

Mr A had abdominal pain in the early hours one morning. The pain had been present the previous day, but had got much worse. Mr A's wife (Mrs C) contacted the ambulance service for assistance, but they did not send an ambulance so Mrs C took her husband to hospital. Mr A had acute appendicitis (sudden inflammation of the appendix). His appendix was removed that afternoon. He was discharged from hospital seven days later. Mrs C complained that the service failed to attend when she called them for Mr A, and did not deal with her complaints appropriately.

We did not uphold Mrs C's complaint that an ambulance was not sent. We took advice from one of our medical advisers, who said that Mr A's condition was not detrimentally affected by not being taken to hospital by ambulance, and that the decision not to send an ambulance was correct in terms of the service's protocol. We listened to the telephone call and reviewed the service's records and procedures together with information provided by Mrs C. We decided that although the emergency medical dispatcher's communication with Mrs C was not as helpful as it could have been, the decision not to send an ambulance was reasonable in the circumstances.

We upheld Mrs C's other complaint. We found that she received a response to her complaint after eight weeks, which was longer than the 20 working days the service aimed to work to, and she was not updated with an explanation of why there was a delay. We found evidence that service staff disagreed on who was responsible for sending the update. Our adviser thought that because the service's review of Mrs C's call focused on technical aspects, rather than taking a holistic view that included Mrs C's experience, it lacked any real empathy with her situation. Their investigation report recommended that Mrs C be given a more detailed explanation of the reasons for not sending an ambulance, but we noted that this was not provided.

Recommendations

We recommended that the service:

• review this call with the emergency medical despatcher involved, and ensure that they receive appropriate support for their customer care skills to achieve the standard aspired to in the service's 999 procedure;
• review how they respond to complaints relating to incidents where callers dispute the outcome, such as this case, to ensure that investigations and responses acknowledge and take into account the service user's experience, rather than being solely driven by compliance with protocol; and
• ensure all staff dealing with complaints know who is responsible for updating complainants at particular stages of the complaints process.

Summary

Mrs C complained about the care and treatment her father (Mr A) received while in hospital. Mrs C said that her family were asked to contact the ward on the day of Mr A's operation. She said that when they did this, they were made to feel over-anxious. Mrs C complained that after his operation, Mr A had been left alone without access to his buzzer, that staff failed to give Mr A prescribed laxatives, and that staff were generally rude and uncaring. However, Mrs C was mainly concerned that a nurse harshly treated Mr A.

We investigated the complaint and took advice from our nursing adviser. Our investigation found that because of Mrs C's allegation, action was taken under the health board's disciplinary policy and procedure. We also found that there was no evidence in the medical notes that Mrs C's family had been asked to contact the hospital. However, on the balance of probability, we upheld that Mr A had not had access to his buzzer and that staff failed to communicate adequately. We also upheld Mrs C's complaint that Mr A had not been given the laxatives as there was evidence of this in his medical records. We did not uphold the complaint alleging harsh treatment as there were conflicting statements about this, and there was no independent evidence to allow us to reach a decision.

Recommendations

We recommended that the board:

• remind staff to regularly ask patients about the accessibility of their buzzer on the ward and give consideration to completing a ward audit to establish that buzzers are accessible;
• make Mrs C and Mr A a formal apology for their failure in this matter; and
• provide evidence that remedial action has been taken to ensure a similar situation does not reoccur.