Some upheld, recommendations

  • Case ref:
    201005162
  • Date:
    November 2011
  • Body:
    Greater Glasgow and Clyde NHS Board
  • Sector:
    Health
  • Outcome:
    Some upheld, recommendations
  • Subject:
    Clinical treatment / Diagnosis

Summary
Mr A was referred by his GP to a hospital urology department for review of his mixed urological symptoms at that time. He subsequently had a CT scan of his urinary tract which showed appearances of retro peritoneal fibrosis (RPF). Following a consultation with a consultant urologist, he was admitted to hospital for further investigation which showed that his right kidney was providing 90 percent of his renal function and his left kidney only accounted for 10 percent of this function.

After this investigation, a senior registrar in urology wrote to Mr A informing him of the possibility that his left kidney may have to be removed. This was the first time that Mr A had been made aware this was a possibility and that his left kidney was non functioning. Mr A was also referred to a vascular surgeon as he was diagnosed with aortitis. Mr A considered there was an unacceptable delay with this referral.

Mr A requested to be reviewed by another urology consultant for a second opinion. At this appointment it was discovered that the consultant did not have his case notes and had been given the case notes for another patient.

Mr A complaiend to us. He said that he felt that he had not been dealt with in an 'appropriate, timely or professional manner'. He said that there was both delay and failure to treat his condition and also a failure to communicate with him about his condition.

We obtained Mr A's medical records and took professional advice from our independent medical adviser. The adviser explained that RPF is a rare kidney condition which in the case of Mr A presented in an unusual manner. The adviser found that the initial investigation and management of Mr A's condition was conducted in a timely manner and there was no delay in diagnosis of the condition.

However, the adviser stated that following a failure to pass a ureteric stent there was no evidence in Mr A’s medical notes that there were discussions about possible other treatment for Mr A’s condition. For this reason we concluded that there was a failure to treat Mr A’s condition and we, therefore, upheld this element of the complaint.

In relation to the diagnosis and treatment of Mr A’s vascular condition, the advice received was that there was a delay in Mr A’s treatment and for this reason we also upheld this element of Mr A’s complaint. However, the adviser also stated that this did not impact on the treatment that Mr A received and that the treatment in this regard was appropriate for his condition.

We found that there was a failure to communicate with Mr A about his condition and we, therefore, upheld this part of his complaint.

We did not uphold Mr A’s complaint that there was a failure to transfer his medical notes to his consultant for an appointment. This was because while it was accepted by the board that the consultant did not physically have in his possession Mr A’s medical notes when he saw him, we accepted that the consultant was able to appropriately access all information pertinent to his case through the clinical portal.

Recommendations
We recommended that the board:
• review their procedures so that a robust system is put in place to ensure that the results of investigations are communicated quickly to clinical teams, particularly if they are abnormal;
• review their procedures so that all clinical letters to patients are typed promptly after dictation and any outcomes from these are actioned quickly;
• review their procedures so that discussions by multi-disciplinary teams are recorded and communicated to patients particularly if there is a delay before the patient can be seen in an outpatient clinic;
• apologise to Mr A for their failure to communicate with him effectively about his condition and outcomes; and
• review their systems so as to ensure a patient’s medical records, as appropriate, are available when they attend an appointment with a clinician.

  • Case ref:
    201100069
  • Date:
    November 2011
  • Body:
    Ayrshire and Arran NHS Board
  • Sector:
    Health
  • Outcome:
    Some upheld, recommendations
  • Subject:
    Clinical treatment / Diagnosis

Summary
Mr C was referred to the board's mental health team by his GP. Mr C was initially seen by mental health staff over a period of months. He was not satisfied with their response to his needs and so he complained to the board. Mr C was not happy with the board's response to his complaint, and complained to us. He complained that the board failed to provide him with appropriate care and treatment following the referral from his GP. He also complained that the board failed to provide him with adequate information on his assessment and treatment.

We did not uphold the complaint about appropriate care and treatment. We found from looking at the medical records, and taking advice from one of our professional medical advisers, that the mental health team's response to Mr C's clinical presentation was adequate, reasonable and based on assessed need and that, overall, the care and treatment provided to him following the referral from his GP was appropriate.

We did uphold the complaint about adequate information. We found that the board did not provide Mr C with sufficient detailed information about his care and treatment, in the form of a written and agreed care plan.

Recommendations
We recommended that the board:
• apologise to Mr C for failing to provide him with adequate information on his assessment and treatment, in particular failing to provide him with a written and agreed care plan; and
• review the Primary Care Mental Health Team's practice on written care plans, to ensure that all relevant information is included, and that patients are aware of the care plan and can countersign their agreement to it. This should be in line with the Mental Welfare Commission for Scotland's best practice guidance on Mental Health Act care plans, and NHS Quality Improvement Scotland's Standards for integrated care pathways for mental health.

  • Case ref:
    201100205
  • Date:
    October 2011
  • Body:
    The City of Edinburgh Council
  • Sector:
    Local Government
  • Outcome:
    Some upheld, recommendations
  • Subject:
    primary school

Summary
Mr C has a daughter who started primary three of school in August 2010. Mr C was concerned that his daughter's handwriting had deteriorated and sought a meeting with the head teacher. He was not happy with the outcome of that meeting and three other incidents involving his daughter's class teacher. He decided to remove his child from that primary school at the same time as making a complaint.

He complained to us after completing the council's complaints procedure. He was informed that we were precluded by paragraph 10 of Schedule 4 of the SPSO Act 2002 from looking into the giving of instruction or conduct, curriculum and discipline in any educational establishment under the management of an education authority. We considered three complaints from Mr C about the handling of his complaint by Education Services, and upheld one complaint about a delay in escalating the complaint.

Recommendations
We recommended that the council:
• ensure that the director of children and families apologise for the delay by that service in processing the second stage complaint; and
• note and act on the shortcomings identified in relation to the delay, to avoid a future recurrence.

 

  • Case ref:
    201100064
  • Date:
    October 2011
  • Body:
    North Lanarkshire Council
  • Sector:
    Local Government
  • Outcome:
    Some upheld, recommendations
  • Subject:
    political matters; committees; standing orders; requests for information

Summary
Mr C complained that the council had wrongly withheld information from him and had refused to apologise to him, even though their customer services strategy was to do so when they were wrong and do their best to put things right. Mr C also complained that his complaint about the handling of his request for information was not dealt with properly under the council's complaints procedure. Mr C said that he wanted the council to apologise to him face-to-face and in writing.

We considered that there was an opportunity to try to resolve the complaint and asked the council if they would be prepared to apologise to Mr C. The council told us that while they acknowledged there had been a slight delay in publishing information, they did not feel there was cause for an apology. We could not become more involved because we do not have the power to comment on or to reconsider matters which have been the subject of investigation by the Scottish Information Commissioner. We, therefore, did not uphold this complaint.

On complaint handling, the council acknowledged, with regret, that they had not responded to Mr C's formal complaint within the target time for complaints handling. We upheld this complaint.

Recommendation
We recommended that the council:
• apologise in writing to Mr C for not meeting the council's customer care standards in investigating his complaint.
 

  • Case ref:
    201004517
  • Date:
    October 2011
  • Body:
    Greater Glasgow and Clyde NHS Board - Acute Services Division
  • Sector:
    Health
  • Outcome:
    Some upheld, recommendations
  • Subject:
    clinical treatment / diagnosis

Summary
Mrs C made a number of complaints to the board. Her husband, Mr C, was referred by his GP to hospital in March 2010 with swallowing difficulties. Initial investigations proved negative and further tests were planned. However, in May 2010 Mr C attended as an emergency and it was established that he had stomach cancer. Mr C died in June 2010 at home.

Mrs C complained about a delay in diagnosis and that there was a lack of communication from staff about Mr C's condition. The investigation revealed that although the diagnosis may have been established slightly sooner, it would not have affected the final outcome. However, it would have allowed Mr C and his family more time to come to terms with the situation. The investigation also upheld complaints that there were failings in communication and that the record-keeping was inadequate. We did not uphold a complaint that the board handled the complaint inadequately.

Recommendations
We recommended that the board:
• share this letter with staff to note our adviser's comments with specific reference to referring Mr C for an urgent endoscopy following the results of the barium swallow rather than discuss the result at a planned appointment;
• remind staff of their responsibilities to communicate in an effective manner with patients and their relatives and to accurately record what has been discussed; and
• remind staff to obtain informed consent from patients prior to carrying out medical procedures.
 

  • Case ref:
    201004154
  • Date:
    October 2011
  • Body:
    A Medical Practice, Forth Valley NHS Board
  • Sector:
    Health
  • Outcome:
    Some upheld, recommendations
  • Subject:
    lists

Summary
Mrs C complained that she was removed from the practice list without warning or reasonable explanation. She also complained that the practice failed to give her advice about, or treat, a leg injury. In addition, Mrs C complained that the practice failed to refer her to appropriate specialists for treatment for ongoing health problems.

We did not uphold the complaint about referral to specialists. We found from looking at the practice's records and taking advice from one of our clinical advisers, that Mrs C was referred appropriately. We also found that, as Mrs C went to hospital for her leg injury, the practice were not responsible for treating it. The practice said they gave Mrs C appropriate advice about her leg injury. However, because they did not have a record of this, we upheld the complaint. We also upheld the complaint that Mrs C was removed from the list without warning, as we felt that the practice could have given one. However, we agreed that the practice had given Mrs C a reasonable explanation when they did remove her from the list.

Recommendations
We recommended that the practice:
• review their practice on making records of telephone conversations, with a view to making records where advice is given to a patient to attend a hospital department, or treatment advice is given; and
• review their policy on removal of patients from the list, to incorporate guidance on providing reasonable warning to patients who might be at risk of removal from the list.
 

  • Case ref:
    201003905
  • Date:
    October 2011
  • Body:
    Scottish Prison Service
  • Sector:
    Prisons
  • Outcome:
    Some upheld, recommendations
  • Subject:
    progression

Summary
Mr C complained that the Scottish Prison Service (SPS) had not told him why he was not allowed to progress to enhanced conditions when he believed he met the relevant criteria.

It is not for us to decide whether prisoners should progress to enhanced conditions. Such decisions are discretionary matters and are for the SPS and local management to take. It is for them to decide what information is important. What we have to determine is whether they have followed the proper processes and procedures and, where appropriate, explained the application of them to prisoners.

We found that Mr C was not in fact told that he was not being allowed to progress, or the reasons for this, until he made a complaint. Prisoners should not have to make a complaint to obtain this information. They should be informed promptly of the decision and the reasons for it. We, therefore, upheld this complaint.

Mr C also complained that his disability was not taken into account when the decision was made to transfer him to another prison. We did not uphold this complaint as we found that the SPS had carried out risk assessments before transferring him.

Recommendation
We recommended that the SPS:
• ensure that their new guidance on progression clearly states that prisoners should be informed promptly of the decision and reasons if their progression is not approved.
 

  • Case ref:
    201003746
  • Date:
    October 2011
  • Body:
    Education Scotland
  • Sector:
    Scottish Government and Devolved Administration
  • Outcome:
    Some upheld, recommendations
  • Subject:
    policy/administration

Summary
Mr C taught at a school which was the subject of an HMIE inspection. Mr C had a number of issues with the outcome of the inspection and this resulted in him raising his concerns in writing with HMIE. His complaint to the Ombudsman stemmed from the way in which HMIE dealt with his complaint.

Although we did not uphold one aspect of Mr C's complaint, we did find that there was an unreasonable delay in HMIE arranging a face-to-face meeting to discuss the complaint, contrary to HMIE complaints procedure. We made recommendations to redress this failing.

Recommendations
We recommended that Education Scotland:
• apologise to the complainant, in the circumstances of this complaint; and
• remind relevant staff of the terms of the complaints process and that when responding to complainants all the issues raised should be addressed.
 

  • Case ref:
    201002957
  • Date:
    October 2011
  • Body:
    Greater Glasgow and Clyde NHS Board - Acute Services Division
  • Sector:
    Health
  • Outcome:
    Some upheld, recommendations
  • Subject:
    complaints handling

Summary
Ms C suffers from Graves or Thyroid Eye Disease which is a complex and devastating condition. She complained that after 2007 her care and treatment was poor and likened it to a ‘production line’. She alleged that she had been examined and discharged without comment from either medical or nursing staff and that her condition has never been discussed with her. She maintained that there was no proper appreciation of her condition and its consequences and that little information has ever been made available to her. She also complained that she was incorrectly diagnosed with dry age related macular degeneration but this since turned out to be incorrect. She did not receive an apology. She also complained that when she submitted a complaint to the board, they failed to adhere to her request to keep some information confidential and delayed in responding.

While we did not uphold most of Ms C's complaints, we did find that she was misdiagnosed with age related macular degeneration and she was not adequately supported in relation to this. We made one recommendation to redress this failing.

Recommendation
We recommended that the board:
• apologise to the complainant for the confusion surrounding her diagnosis of dry age related macular degeneration.
 

  • Case ref:
    201002832
  • Date:
    October 2011
  • Body:
    Aberdeenshire Council
  • Sector:
    Local Government
  • Outcome:
    Some upheld, recommendations
  • Subject:
    council tax (incl community charge)

Summary
Mrs C complained that the council had failed to provide a winter maintenance programme for the roads in her area for 2009/10 and, as a result, there were occasions when the council were not able to get access to collect household waste because of the condition of the roads at this time. Mrs C and her husband received a reminder about payment of their joint council tax account for 2009/10. Mrs C wrote to the council asking whether an amended council tax bill would be issued to her and her husband to reflect the council’s failure to provide road clearing services and waste collection during a recent spell of bad weather. Mrs C also complained about the handling of her representations and the council’s actions in pursuing her for payment of arrears of council tax, and she complaints that her complaints were not investigated fully.

Our investigation found that, despite the advice provided to Mrs C and to this office that an operational plan was in place, we found no operational plan for snow clearing operations for the roads in her area for 2009/10. In light of the difficulties experienced by Mrs C and subsequently this office in obtaining accurate responses from the council about this matter, and given the length of time it had taken to bring this matter to a satisfactory conclusion, we recommended that the council should consider Mrs C’s request for compensation favourably.

With regard to the council’s handling of Mrs C’s request for an amended council tax bill, we established that this was not dealt with properly. We found that the council failed to make clear in their correspondence with Mrs C that an amended council tax bill would not be issued to her and her husband. They also failed to make clear that payment of council tax could not be withheld whilst a dispute or correspondence with the council was ongoing, and they failed to make clear that on payment of the arrears, the summary warrant would be cancelled. We found that the council had followed the procedures set down in legislation to pursue Mrs C and her husband for payment of the arrears but were at fault in not making the position clear in their correspondence before the summary warrant was issued. We made a recommendation to ensure that a clear process would be put in place which would be communicated effectively to all stakeholders.

We also found that the council had failed to deal satisfactorily with Mrs C's representations to them about her complaints. In recognition that Mrs C was not provided with a satisfactory level of customer service, we asked the council to make a formal apology to Mrs C for the inconvenience she had been caused in pursuing her complaint.

Recommendations
We recommended that the council:
• provide a formal apology from the chief executive for not providing the complainant with a satisfactory level of customer service;
• ensure that the revenues department undertake a review of the current procedures to ensure a clear process is in place and is communicated effectively to all stakeholders when responding to enquiries or disputes about council tax; and
• consider Mrs C's request for compensation.