Some upheld, recommendations

Summary
Mr C complained that the council, in their capacity as landlord, did not tell him whether self-closing fire doors need to be fitted in his home or if the door that they had fitted in June 2011 met the Building Standards Regulations (Scotland) Act 2006. He also complained that the council did not respond to his complaint within a reasonable timescale and did not give him sufficient information to evidence that their actions were in line with the relevant building regulations.

We upheld some of Mr C's complaints. We found that the property had been built prior to new regulations which apply only to new buildings or existing buildings undergoing major structural change. There was, therefore, no requirement for the council to replace Mr C's door to the current building regulations. However, we found that the council did not clearly explain this to him following his enquiry. We also considered that they did not respond to the complaint according to their complaints procedure, and did not provide information (that they had agreed to give Mr C) until after the complaint had been raised with us.

We did not find any evidence to show that Mr C had asked the council whether the kitchen door that had been replaced met the relevant building standards regulations.

Recommendation
We recommended that the council:
• highlight to the housing department management team the importance of updating complainants on the progress of their complaint and ensuring clear and full responses are provided at all stages of the complaints procedure.

Summary
Mrs C received care and treatment from her GP (in a practice administered by the board) in relation to pneumonia, bunion pain and multiple sclerosis.

In 2006, Mrs C phoned her GP in the early morning, complaining of being unwell. The GP visited her at home and referred her to hospital, where she was diagnosed with pneumonia. Mrs C complained that because her GP visited after 09:00 there was a delay in admitting her to hospital. Later that month, Mrs C saw her GP about her sore bunion. In 2009, a locum GP referred Mrs C to an orthopaedic surgeon for an operation on it. Mrs C complained that the clinical picture did not alter significantly between 2006 and 2009 and that her GP should have referred her to an orthopaedic surgeon in 2006.

In November 2009, Mrs C saw a consultant neurologist (specialist in the nervous system). In February 2010, Mrs C approached her GP to follow-up on this, but said that her GP took no action. A locum GP arranged a follow-up appointment with the consultant the following month. Following investigations by the consultant, Mrs C was diagnosed with multiple sclerosis in August 2010. Mrs C complained that her GP's failure to act in February was not reasonable.

After taking advice from one of our medical advisers, we found that Mrs C's GP provided reasonable care and treatment in relation to her pneumonia and bunion. In terms of the time it took the GP to visit Mrs C after her telephone call, there were differing views about how long it was before the GP arrived. We found, however, that delay would not have affected the clinical outcome of Mrs C's condition. We did not uphold these complaints.
We did find, however, that the GP's failure to follow up on the consultation with the neurologist in February was not reasonable. Our adviser said that the GP should have been more proactive in seeking a definitive diagnosis, and that their failure to do so represented a deficiency in care. We upheld Mrs C's complaint about this.

Recommendation
We recommended that the board:
• ensure that the GP reflects on the diagnosis and management of multiple sclerosis with particular reference to the discussion of the diagnosis with patients.

Summary
Mr C had several complaints about the care and treatment received by his late mother (Mrs A) in 2008 and 2010.

We upheld Mr C's complaint about the care she received in 2008. Mr C's mother had been admitted for acute pulmonary oedema (fluid in the lungs), and as part of her treatment, an arterial line (a thin tube) had been inserted into her arm so her blood pressure could be monitored. Swelling developed around the line which was then removed, and a pseudo-aneurysm (a collection of blood under the skin from a leak in an artery) developed. We found no errors in relation to the way the line had been inserted, and our medical adviser said that a pseudo-aneurysm is a recognised complication of the use of an arterial line. However, because clear records were not kept of the management of this complication and as Mrs A had moved between units during this time, the cause of the swelling was not properly identified at first. There was also a failure to conduct a prompt medical review of the event.

Mr C was also concerned that when Mrs A had a scan of her abdomen, she had to drink a large quantity of liquid. He felt that, as Mrs A had fluid retention problems, this caused her to collapse in the scanner. We found no evidence to suggest that intake of the fluid caused his mother to collapse. We also found that the scan and giving the fluid in preparation for it were appropriate clinical treatments in the circumstances. However, we were critical that fluid balance charts were not completed for Mrs A at this time, considering her complex fluid management situation. We made recommendations to address these failings.

We did not uphold Mr C's complaint that a doctor had inappropriately noted Mrs A as a 'do not resuscitate' patient without the family knowing about this. We found that a doctor can make this decision without consultation with a patient or their family, in circumstances when resuscitation is considered ineffective. We noted that it is good practice to discuss such a decision when appropriate, and found evidence that such discussions had taken place with Mr C.

We did not uphold Mr C's complaint about Mrs A's care in 2010. We found that the use of intravenous (administered into the vein) antibiotics had been appropriate, even when giving regard to Mrs A's fluid retention problems. This was because she had a severe infection, and other clinical issues indicated that intravenous antibiotics were an appropriate method of treatment. Although Mr C was also concerned that Mrs A had difficulty passing urine, which he felt was not adequately recognised or treated, we found that this was due to kidney failure, rather than because of any clinical mismanagement.

Recommendations
We recommended that the board:
• provide evidence to the Ombudsman that staff within the hospital have received training for the care of arterial lines and the complications that can occur, including the need for prompt medical review of any complication;
• undertake an audit of record-keeping within the hospital to ensure medical records are completed timeously and comprehensively, including for patients who are moved between units within the hospital; and
• provide evidence to the Ombudsman to demonstrate that staff in the hospital are aware of the importance of completing fluid balance charts for patients with complex fluid management requirements.

Summary
Ms C attended the accident and emergency department of a hospital with abdominal pain three times in two months. Clinicians diagnosed a possible urinary infection and discharged her with pain relief. Ms C complained about the care and treatment she received during these visits to hospital. She said that clinicians failed to investigate her symptoms properly and arrange appropriate referrals.

Ms C had an ultrasound scan a couple of months later, which identified fibroids (non-cancerous tumours that grow in or around the womb) and a mass near her pelvis. This was confirmed by an MRI scan which was taken shortly after. Ms C complained that the board's response to the ultrasound scan lacked urgency and that a more senior doctor should have looked at it to avoid the need for an MRI scan.

About two months later, a consultant gynaecologist reviewed Ms C and provisionally diagnosed a degenerating fibroid. Ms C underwent a full hysterectomy (removal of the womb) shortly after. During the operation, numerous fibroids were noted in addition to a large mass, and it was later confirmed that the mass was a tumour. Ms C complained that she underwent a hysterectomy that might not have been necessary and which could have been avoided if she had been referred to an oncologist and/or had a biopsy carried out beforehand. She also complained about the board's response to her complaint saying that it contained a number of inaccuracies.

We upheld two of Ms C's complaints. After taking advice from our medical adviser, we found that she should have been reviewed by a more senior doctor when she went back to the hospital with the same problem. The adviser also said that the doctor concerned should have widened the range of possible diagnoses they were considering, after the results of a dipstick test ruled out a urinary tract infection. However, we found that their response to the ultrasound scan was reasonable and that ordering an MRI scan as a result was appropriate. We also found that the decision not to involve oncology or conduct a biopsy was reasonable in light of Ms C's presenting condition at the time, as was the decision to proceed with a hysterectomy.

Finally, although we found that much of the board's response was accurate, it did contain two inaccuracies. More seriously, the board did not respond appropriately to Ms C's complaint about her hysterectomy.

Recommendations
We recommended that the board:
• forward a copy of the decision letter and Ms C's letters of complaint to the relevant clinician to reflect on;
• draw up a written policy clearly stating the need for senior review when a patient presents to accident and emergency complaining of the same problem; and
• apologise to Ms C for the inaccuracies contained in their response and their failure to provide a substantive response to her concerns about her hysterectomy.

Summary
Mr C complained about cataract surgery carried out by a trainee surgeon. During the operation the iris of his eye was damaged. Mr C's concerns were that he had not been advised that a trainee surgeon was to carry out the surgery and that it was not appropriate for a trainee to have done so.

We took advice from one of our medical advisers who is a consultant ophthalmologist. We did not uphold the complaint that it was inappropriate for the trainee, an experienced cataract surgeon who had nearly completed their training, to have carried out the operation. This is normal practice and there was adequate supervision. However, before the surgery took place, Mr C should have been told of the possibility that the surgeon might be a trainee. As he was only told that the doctor who operated might be a different doctor from the consultant he had been seeing, we upheld this complaint.

Recommendation
We recommended that the board:
• take steps to make patients aware that procedures could be carried out by trainee staff under supervision. This advice could be incorporated in a patient information leaflet, consent form, or documented in the patient's records.

Summary
Mr C complained on behalf of his partner (Ms A) who was a hospital in-patient receiving treatment for schizoaffective disorder (a mental disorder affecting thinking processes and mood). Ms A was prescribed unilateral electroconvulsive therapy (ECT – a treatment that involves sending an electric current through the brain). This was to be provided at another hospital, as there was renovation work taking place in the ECT unit at the first hospital. After three sessions of ECT Ms A complained of gaps in her memory as well as a general feeling of her mind being blank. It was found that she had received bilateral ECT (electrical current passed through the whole brain) instead of the prescribed unilateral ECT (electrical current passed through only one side of the brain).

Mr C complained that Ms A was not reasonably administered her prescribed medication in the first hospital, as she was asleep when medication rounds took place and she was not woken. He also complained that the second hospital provided bilateral ECT without Ms A's consent and that the information provided before the treatment was not reasonably relevant to his partner's circumstances.

We did not uphold the complaints about medication and information. We were satisfied that the information provided prior to the treatment was appropriate. We found that Ms A missed medication doses on around 20 occasions, mainly of ibuprofen. However, we accepted the advice of our medical adviser that patients would not be woken for such pain medication. Ms A also missed two doses of depakote (a mood stabilising anti-epileptic drug). We found that this drug should be maintained at a certain level in the blood stream and, as such, patients should not miss their dose. However, recommended practice is for the dose to be provided as soon as possible after the patient wakes up. If they wake closer to the time when the next dose is due, then a dose can be missed rather than a double-dose being provided.

There was insufficient evidence for us to determine exactly when Ms A woke up on the occasions in question or how close this was to the planned delivery of her next dose of medicine. We also found that such episodes were rare, and our medical adviser said that they did not happen close enough together to have had a significant impact on Ms A's overall wellbeing.

The board accepted and apologised unreservedly for the fact that bilateral rather than unilateral ECT was performed. This was due to different practices in the two hospitals. The board pointed out that Ms A signed a consent form allowing staff to decide what type of ECT was provided. We found that the consent form did allow bilateral ECT, but that any decision about this should be linked to clinical need and the patient's preference. We found that unilateral ECT is recommended in most cases and that by providing bilateral ECT the board increased the likelihood that Ms A would experience side effects. There was no clinical indication for bilateral ECT. The board failed to record any reasons for deviating from the prescribed treatment, and communication between the prescribing team and the team providing the treatment was poor.

In this respect, the board failed to comply with standards set out by the Scottish ECT Accreditation Network (SEAN). So although Ms A's signed consent allowed the board to carry out this treatment, we did not consider that they went about deciding to do so in the way that the consent form suggests, and we upheld this complaint.

Recommendation
We recommended that the board:
• provide us with evidence of their standardised procedure for prescribing and recording treatment within their ECT departments including specific detail as to how specific SEAN standards (10.2 and 11.8) are being complied with.

Summary
Mrs C had root canal treatment from her dentist. She complained that the dentist did not tell her that there was a risk that, if the root canal treatment failed, Mrs C could lose the tooth and ultimately need a crown. Mrs C did lose her tooth and felt that the treatment was unnecessary and that the tooth could have been saved had another form of treatment been given. She also complained that other possible treatment options were not discussed with her and the response to her complaint was unreasonably delayed and contained inaccurate information.

Dentists have a duty to explain any commonly encountered or serious risks and any risks of particular concern to the patient. We found that there was no evidence to show that the dentist had done so in Mrs C's case. Nor was it clear whether the dentist discussed other treatment options (in this case, extraction of the tooth) with Mrs C. We upheld this complaint.

We did not uphold the complaint that root canal treatment was inappropriate. Although the results of such treatment can be uncertain, our dental adviser said that it was the only long term treatment with any possibility of success for the symptoms Mrs C was experiencing.

Finally, we upheld the complaint about the dentist's complaints handling. We found that ten weeks was an unreasonable length of time for Mrs C to wait for a response to her complaint, that she had not been proactively updated on its progress by the dentist and that the letter contained inaccuracies.

Recommendations
We recommended that the practice:
• apologise for unreasonably failing to explain the risks associated with root canal treatment or to discuss other options available with her;
• apologise for the unreasonable time it took to respond to her complaint; and
• ensure complainants are updated on the progress of their complaint in a timely manner and advised of the date by which they can expect a response.

Summary
Mr C told us he had a history of chest tightness, chest pain and severe heartburn. He said he twice raised concerns about these symptoms with his GP. Shortly afterwards, while working overseas, Mr C suffered a heart attack and had a coronary artery bypass graft (a surgical procedure to improve blood supply). When he came back to the UK, he asked his GP to refer him to a cardiologist (heart specialist) for review. His GP felt that this was unnecessary as Mr C had already received the best treatment for his condition and appeared to be recovering well. As Mr C needed a fitness to work certificate, he was ultimately referred to a cardiologist, but this was done privately.

Mr C complained that the practice failed to appropriately assess the symptoms that he had reported before he had the heart attack. He also complained that it was unreasonable of them not to refer him to a cardiologist after he returned to the UK.

We found no evidence in Mr C's clinical records that he had told the practice about his chest tightness and heartburn. Whilst recognising that he may have provided this information without it being recorded, we were unable to say conclusively that the records were deficient or that the practice failed to act on information that Mr C provided about these symptoms. We did not uphold this complaint.

We did, however, uphold his complaint about referral. Mr C was ultimately referred to a cardiologist and we did not find it unreasonable that this was done privately, given his desire to return to work. However, we found that it would have been good practice for a referral to have been made when he returned to the UK, as a cardiologist was able to perform specific tests that would highlight the extent of residual damage to the heart. The cardiologist ultimately found that Mr C had a blood clot which necessitated a change in treatment plan. We felt that this highlighted the benefit of referral to cardiology but also considered that there was a strong argument for referral in the circumstances of Mr C's case, particularly as his surgery was performed overseas where practices may be different.

Recommendations
We recommended that the practice:
• apologise for their failure to refer him to cardiology; and
• share our adviser's comments with their GPs with a view to identifying any points of learning that can be taken from this case.

Summary
Mrs C visited a hospital accident and emergency department, where she was diagnosed as having suffered an allergic reaction. Medical staff advised her to visit her GP the next day. When she did so, she was dissatisfied with the care and treatment she received and the attitude displayed towards her.

She made a number of complaints about the GP, including that he questioned the diagnosis she had received (because the doctor who had seen her was a junior doctor); refused to look at the rash on her neck or to prescribe the anti-histamines that she said she had been advised to ask for; pulled her prescription away when she tried to take it from him and laughed at her, and referred to headaches she had been suffering as ‘supposed headaches.’

The GP whom Mrs C had complained about responded to her. He apologised that she had been caused upset and distress by the consultation. He explained that he had referred to ‘the headaches the neurologist is calling chronic migraine’. He also said that he understood Mrs C had been given advice by a junior doctor, but that he was not bound to agree with that advice. He apologised if his communication of this had caused upset. Mrs C was not satisfied with this response and raised her complaints with us.

The accounts of what happened at the consultation differ considerably and there were no independent witnesses to what happened. We found no evidence that could help us reach a conclusion on Mrs C's complaint about the care and treatment she had received, so we did not uphold that complaint. We did, however, uphold her complaint about the response she received from the practice, as we found evidence that they had considered matters that Mrs C had complained about but had not addressed these in their response to her.

Recommendations
We recommended that the practice:
• apologise to Mrs C that they did not reasonably respond to all the issues she raised in her complaint to them; and
• take steps to ensure that all issues raised in complaints are reasonably addressed in their written responses to complaints.

Summary
Mr C complained about the procedures adopted by Scottish Enterprise to investigate his complaints about what happened when, some time ago, a Scottish Enterprise regional office was involved with Mr C and his companies in an advisory capacity. He made serious allegations of conflict of interest against former employees of the regional office. Because of the nature of the allegations, a senior officer was appointed to investigate. The officer met with Mr C at the start of the investigation.

Over a year later, Mr C was provided with a copy of the investigator's report. Mr C complained that the written statement to the investigating officer was not reasonably considered during the investigation, that the final report did not acknowledge his views, and that the time taken to investigate and to provide a final response was unreasonable. We did not uphold Mr C's first complaint as we found no evidence that his statement was not reasonably considered. We upheld the other complaints, however, as we found that Mr C was not given the opportunity to comment on issues of fact before the end of the investigation, and that the length of time taken was unreasonable.

Recommendation
We recommended that Scottish Enterprise:
• seek to agree with Mr C a set of points he believes to be outstanding and to answer those points within a timescale of three months