Some upheld, recommendations

Summary
Mrs C had surgery in hospital to remove a soft tissue lump from her right thigh. She said that a few days later the wound had become red and infected. She contacted NHS 24 who referred her to an out-of-hours (OOH) GP service where a nurse prescribed antibiotics. Mrs C returned home, but her condition worsened and later that day NHS 24 arranged for an ambulance to transfer her to hospital where she was diagnosed with a skin infection and an infection of the thigh wound. Mrs C had a further surgical excision and drainage, and the wound was left open to heal from the inside. She received antibiotics intravenously (directly into a vein) and was discharged on oral antibiotics.

Mrs C complained that the hospital failed to prescribe her with antibiotics after the initial surgery, which she believed might have prevented the infection she later contracted. She also said that the OOH service failed to take her seriously and recognise the seriousness of her condition. Mrs C said that as a result of the failure to provide antibiotics and the failures in the care and treatment she received from the OOH service, she has struggled to recover from her operation and continues to have difficulty in walking.

After taking advice from our medical adviser, we found that the hospital's decision not to prescribe Mrs C antibiotics after her initial surgery was reasonable. However, we also found that the OOH nurse failed to recognise the significance of Mrs C's symptoms and admit her to hospital, although our medical adviser said that this would not have affected the outcome.

Recommendations
We recommended that the board:

• have the relevant staff review the management of this case in light of the findings; and
• apologise to Mrs C. 

Summary

Mr C is a patient in a mental health facility. He complained that in documentation the board stated as fact information which had not been investigated or confirmed. He also said they had not sent reasonable responses to his letters of complaint.

Our investigation found that information had been incorrectly presented as fact, although it had not been clearly established what happened. A police investigation into the matter could not be progressed as a key witness refused to cooperate. We upheld this complaint and made a recommendation to address this.

Mr C was also unhappy with the response that the board gave to his complaint. However, we found that it was clear that the responses had fully explained the reasoning and the fact that the police investigation had stalled. We did not uphold this complaint.

Recommendations

We recommended that the board:

• apologise to Mr C for their actions in this matter and update, correctly, the information held on their care plan.

Summary

Mrs C's husband (Mr C) was ill and she called NHS 24. However, she complained that the board failed to respond to her call and that the out-of-hours (OOH) doctor who came did not treat her husband appropriately. She also doubted that the doctor properly recalled the visit.

We considered all the relevant information and obtained advice from our medical adviser. We found the information about the telephone calls inconclusive. Mrs C said that the board had not called, however, the board's records said that attempts to call Mrs C were made, but were unsuccessful. We did not see any records of these specific calls, and in the absence of evidence, could not uphold this complaint.

We agreed that the OOH doctor had not properly treated Mr C in accordance with his symptoms and had kept poor records of the visit. This meant that the information that the board gave Mrs C when she complained was confusing. We made recommendations to address the failures identified.

Recommendations

We recommended that the board:

• apologise to Mr and Mrs C for their oversights in this matter; and
• emphasise to the OOH doctor the importance of taking a full record and, if it has not already occurred, the OOH doctor should prepare a significant event audit on this case and discuss it at their next appraisal.

Summary

Mr C and Mrs D complained about the care and treatment provided to their late mother (Mrs A) by her medical practice. Mrs A attended the practice in May 2011 complaining of pain over the previous four months. Her GP arranged a number of tests including a pelvic ultrasound scan, which was inconclusive.

In June and July, Mrs A continued to attend the practice complaining of pain. Her GP prescribed antidepressants, and medication for her spasms and pain. After further visits, the GP referred Mrs A for a routine surgical out-patient consultation in August. This referral was upgraded to an urgent priority following another GP consultation in September. Before she could attend her out-patient appointment, she was admitted to hospital by emergency services. She was diagnosed with pancreatic cancer after a scan, and died at the end of October.

Mr C and Mrs D complained that no follow-up action was taken following the inconclusive results of the pelvic scan and they believed that, given the severity of their mother's pain and the number of times she attended the practice, she should have been referred urgently to hospital for further investigation. They also said that the practice failed to prescribe pain relief within a reasonable time and they raised concerns that their mother was diagnosed with anxiety and depression. They said that anybody suffering pain of this severity would understandably be anxious and depressed and felt that this distracted the practice from properly investigating the causes of her pain.

We found that although the practice could have been more proactive in searching for the cause for Mrs A's pain, the time taken to refer her was, on balance, reasonable particularly as there was no evidence of abnormalities available to the GP in August. We also found that although there may have been an over-emphasis on the psychological aspects of Mrs A's condition, the suggestion that she was suffering from anxiety and depression was not in itself inappropriate. We did not uphold either of these complaints. However, we found that while the practice attempted to manage Mrs A's pain, pain relief was prescribed relatively late and we upheld the complaint about this.

Recommendations

We recommended that the practice:

• review the management of this case in light of our findings; and
• apologise to Mrs A's family.

Summary

Mr C was unhappy about the suspension of his psychological therapy. He complained that the suspension took place on the basis of a tentative change of diagnosis which was later discounted. The advice from our medical adviser suggested that the suspension of treatment was premature, and we upheld the complaint.

Mr C also complained of a delay in his referral for alternative psychological therapy. He was referred in 2010 despite his psychiatrist having first considered a referral in 2009. We acknowledged the psychiatrist's concerns that Mr C may not have been ready for the treatment, but noted that a referral would only have been to assess whether he was a suitable candidate. We, therefore, concluded that the delay was unreasonable and upheld the complaint.

Mr C was prescribed anti-depressant medication, which had potentially serious side effects when mixed with alcohol. His psychiatrist informed him of the risks and referred him to a pharmacist for specialist advice. The pharmacist also provided Mr C with guidance from the drug manufacturer which said that alcohol presented a moderate risk. Mr C complained that this advice was inconsistent with the other advice offered. He felt that it had not been made sufficiently clear that alcohol should be avoided. We were satisfied that Mr C was appropriately told about the risks, so we did not uphold this complaint. However, we found that the pharmacist had not recorded details of her contact with Mr C or the advice given, and we made a recommendation to address this.

Finally, Mr C complained about the board's handling of his complaint. He felt that his complaint had a negative impact on his treatment but we found no evidence to support this. However, we found an unexplained delay in responding to his initial complaint and also that his last letter of complaint did not receive a response at all. In addition, complaints handling staff tasked Mr C's psychiatrist with gathering information on his complaint during a clinical appointment, which we considered to be inappropriate use of a therapeutic consultation. In these circumstances, we upheld this complaint.

Recommendations

We recommended that the board:

• apologise to Mr C for prematurely suspending his treatment;
• remind clinicians to ensure that, when writing to a patient's GP, they copy in other relevant professionals involved in the patient's care, especially when the content of the letter suggests a change of diagnosis and/or treatment direction;
• remind clinicians that, where there is a clear diagnosis, patients need to know what that is, and where there is uncertainty, they need to know why;
• apologise to Mr C for the delay in referring him for an assessment for further psychological therapy;
• remind pharmacists who have therapeutic contact with patients of the importance of recording their interactions and, in particular, any medication advice provided;
• ensure that, where they are unable to respond to complaints within their target timeframe, they explain the reason for this to complainants and advise of when they expect to be able to respond;
• ensure that they respond to all correspondence from complainants and provide clear guidance on what steps they should take if they remain unhappy;
• highlight to complaints handling staff that it is not appropriate to use therapeutic consultations for complaint information gathering purposes; and
• apologise to Mr C for the inappropriate handling of his complaint, as identified in our investigation.

Summary

Mrs A, who was elderly and disabled, was admitted to hospital. While in hospital she fell. Mrs A was seen by a doctor, who did not suspect any broken bones. Later, it was determined that she had broken her hip. Her solicitor (Mr C) complained that although her mobility problems were recorded, she was not given enough assistance. He said that as the fracture was not diagnosed at the time, Mrs A was caused additional pain.

We carefully considered all the available information provided by Mr C, Mrs A's son and the board. Our investigation found that the board failed to carry out an adequate mobility assessment when Mrs A was admitted to hospital. However, we found no evidence that she was not offered appropriate assistance. We also found that the board's care and treatment of Mrs A was satisfactory.

We upheld Mr C's complaint that the board unreasonably failed to respond when he questioned the outcome of their investigation.

Recommendations

We recommended that the board:

• offer a sincere apology for the failing identified; and
• emphasise to staff concerned the importance of following and acting upon guidance available to them concerning the prevention of falls.

Summary

Ms C complained about the care and treatment of her late mother (Mrs A). In 2009, Mrs A received treatment for leg ulcers and various symptoms relating to her underlying vascular condition (condition of the blood vessels). She was admitted to hospital in July 2009 for emergency treatment, including an operation, and discharged in September. After-care services were provided by the board's rapid response team for 11 days after discharge. Mrs A continued to receive treatment in the community for her condition. She was readmitted to hospital that November where she remained until her death in January 2010.

Ms C said that the initial discharge arrangements were inadequate because the after-care services had not been planned in advance. She said that after-care services were essential given the nature of her mother's condition and the length of stay in hospital. She said that the board only arranged services from the rapid response team because she asked about this when she collected Mrs A from hospital. Ms C also complained that the after-care services were inadequate, saying that Mrs A did not receive assistance with personal care, cooking, feeding, medication, getting to the bathroom or physiotherapy.

We found, given the importance in involving family in the process, that the planning and implementation of Mrs A's discharge was deficient because Ms C had not been involved. In all other respects, it was reasonable. We concluded that overall, the board's planning was unreasonable due to the lack of involvement of Mrs A's daughter. However, we found that the records showed that the after-care was comprehensive, individualised and reasonable.

Recommendations

We recommended that the board:

• bring our letter to the attention of relevant staff to ensure lessons are learned; and
• apologise to Ms C for the failures identified.

Summary
Mr C complained that the council had changed the process for issuing Blue European Parking Badges. He said that he had twice before used documentation from 1999 relating to his Disability Living Allowance to renew his blue badge. Because this was no longer accepted he felt this demonstrated that there had been a change about which he had not been advised. He also said that the council had stopped issuing reminders for renewals. We did not uphold the complaint as the council provided evidence showing that their policy had always been that documents in support of an application should have been issued within the previous 12 months. We also found that governmental policy suggested councils could issue reminders but were not required to do so.

Mr C also complained that his complaint about his treatment, when attending council offices, was not investigated properly. We upheld this complaint as we found that the investigation conducted was not sufficiently impartial, and did not consider Mr C’s version of events nor address the allegations made by him.

Recommendation
We recommended that the council:
• apologise to Mr C for the failings identified with the manner in which they dealt with his complaint.

Summary
Mrs C complained on behalf of her daughter that there had been an error in how an examination had been marked. Despite consistently telling the Scottish Qualifications Authority (SQA) that a mistake had been made, Mrs C was unhappy that her representations were treated as an appeal. She complained that the SQA failed to acknowledge that an administrative error in dealing with her daughter's results led to an incorrect result being recorded for her and that the SQA were rude and unhelpful in dealing with her complaint. She also said that they failed to properly investigate the circumstances.

When we investigated, we found that although the SQA made a full clerical check of the circumstances they did not explore the possibility that a error could have been made when originally transcribing Mrs C's daughter's mark. In the circumstances, we could not determine whether or not an error had actually been made. We could not, therefore, uphold this part of the complaint. However, it was clear that the SQA had not made appropriate and full enquiries about the matter. We upheld Mrs C's complaints about this and made recommendations to address the failings identified.

Recommendations
We recommended that the SQA:
• apologise to Mrs C and her daughter for the failures in the handling of the complaint;
• ensure staff receive training to allow them to differentiate between appeals and complaints and that their advice to the public should similarly differentiate; and
• emphasise to staff the importance of fully responding to correspondence from the public.

Summary
Mr C, who is a prisoner, received a visit from his wife and son. Following the visit, Mr C complained to the prison that he was reprimanded for his son's behaviour, while an another prisoner was not spoken to about a similar matter. He also complained that he was asked to clean up the visit area during the visit and that his son was refused access to the toilet. He sought assurances that the conduct of staff was not discriminatory.

In bringing his complaint to us, Mr C said that the prison had not responded to his complaint about toilet access and had not addressed the allegation of discrimination. He also complained that the prison had not carried out an appropriate fact-finding exercise as they had not viewed any available CCTV footage.

In responding to our enquiries, the prison said that the behaviour of the other prisoner's child did not warrant staff intervention. They also said that in line with normal practice Mr C had been asked to clean up after, not during, the visit. They could not recall the request for access to the toilet but they explained the normal practice that should be followed when such a request is made.

We noted that the prison had not addressed this latter issue in their response to Mr C. We also noted the allegations of discrimination were not directly addressed. Given the nature of this allegation, and the fact that there were conflicting accounts of events, we considered that it would have been reasonable for the prison to have examined CCTV footage and drawn upon this in their response. In the circumstances, we upheld this complaint and made recommendations to address this.

Mr C also complained that the prison unreasonably delayed in taking three weeks to respond to his complaint. We noted that a holding response was issued within the seven day target timescale and, following this, we did not consider an additional two weeks to be excessive or unreasonable. We, therefore, did not uphold this complaint. However, we made a recommendation because the holding response did not offer an explanation for the delay and did not provide a specific timescale for responding.

Recommendations
We recommended that the Scottish Prison Service:
• highlight to staff that any allegations of discrimination should be recorded and treated as such, and should be appropriately investigated and addressed in the complaint response;
• apologise to Mr C for failing to respond to all aspects of his complaint; and
• in line with rule 124, the governor should ensure that, where he is unable to respond to complaints within seven days, he takes steps to explain the reasons for the delay and provides a target timescale for responding.