Some upheld, recommendations

Summary
Ms C broke a bone in her foot and attended Accident and Emergency at hospital on 9 May 2010. A backslab plaster cast was fitted that day and she was asked to return on 10 May when a below the knee cast was applied. Replacement casts were fitted on 24 and 25 May but she had to return on 26 May because the cast had become loose and uncomfortable. The cast was removed by a nurse. Ms C alleged that she did this without proper consultation and that its removal was contrary to all the advice Ms C had been given previously. Ms C said that although she told the nurse this, she removed the cast regardless. Later, when Ms C complained about the circumstances, she says the nurse failed to provide a truthful account of what happened.

Our investigation showed that Ms C had an unusual fracture which needed to be held in a cast for up to eight weeks. After taking advice from one of our professional medical advisers, we found that the cast was removed too early and that there were deficiencies in the record-keeping. We also confirmed that Ms C's complaints about this were not properly investigated and that there was delay in responding to her. We did not uphold the complaint about the nurse’s account of events as, although there was some doubt about it, there was no evidence that it was untruthful.

Recommendations
We recommend that Highland NHS Board:
• apologise to Ms C for any pain and inconvenience she suffered as a consequence of her cast being removed on 26 May 2010;
• remind staff of the importance of listening to their patients and to be alert to the fact that their initial assumptions of a situation may not be correct;
• emphasise to staff the necessity and importance of maintaining a full and correct clinical record of patients' care and treatment; and
• apologise to Ms C for their failure to investigate her complaint properly.
 

Summary
Ms C was concerned at the level of care and treatment given to her late mother (Mrs A) while she was in hospital immediately prior to her death. When Mrs A was admitted to hospital she was suffering from shortness of breath, a respiratory infection and heart failure. She had ankle oedema. Regrettably, while she was in hospital she became increasingly unwell despite episodes of care in the Coronary Care Unit. She was also diagnosed as having clostridium difficile. Mrs A died just over a year later, and Ms C complained that the care and treatment her mother had received was totally inadequate in that she was not kept clean and comfortable, nor was she given proper nutrition. She alleged that some staff appeared unhelpful and uncaring.

Our investigation established that the board failed to ensure that Mrs A was clean and comfortable and they did not communicate appropriately with her, or with Ms C and her family (which meant that Ms C was unaware of a fee due to the Procurator Fiscal because of the board’s contact with that office). However, we were satisfied that Mrs A's nursing care was reasonable and that her food intake had been properly monitored and recorded.

Recommendation
We recommend that Greater Glasgow and Clyde NHS Board:
• reimburse Ms C the cost of any separate fee required by the Procurator Fiscal in connection with her complaint.
 

Summary
Mr C and Ms D were involved in extra-curricular activities at their son’s school. They were uncomfortable with the actions of another parent, who they felt was promoting unacceptable racist and sexist views among the school community. Ms D, in particular, felt the parent was using bullying behaviours to make it impossible for her to continue her involvement with the school and they decided not to have their younger son attend the school. Mr C and Ms D raised complaints with the school, but were dissatisfied with the conduct of the investigations, believing that assurances that had been made were not followed through. They were similarly dissatisfied with the council’s handling of the complaint and information provided by the council during that process.

Our investigation confirmed that the council dealt satisfactorily with these complaints. However, they did not carry out the investigations that Mr C and Ms D were led to believe would be carried out, and we upheld this element of their complaint. We did not uphold the complaint about the information given to Mr C and Ms D as we found it was generally appropriate.

Recommendation
We recommend that Glasgow City Council:
• apologise to Mr C and Ms D for the failure to investigate comments which were alleged to have been made.

Point of clarification - it was the nursery school from which the parents withdrew their younger son's application.
 

Summary
Mrs C's neighbour notified Mrs C that he was applying for planning consent for dormer extensions. He assured her that no window was planned for the elevation facing her property. Mrs C checked the council's online planning portal and found that that was the case, so she did not object. The council's case officer then suggested changes to the submitted scheme, including a window in that elevation. However, his delegated report was not amended and the changed plans were not assessed, and Mrs C only became aware of the change when construction started. She complained that the plans had changed without anyone telling her; that there had been a delay in placing the amended applications on the council website; and that the council had been inconsistent in the handling of this application compared with the treatment of another nearby application. We upheld her complaints about the changes and placement of the amended application online, as the amended plans were not readily available and this meant that Mrs C did not know about the new window before construction started. We did not uphold the third complaint as we did not find inconsistency of treatment.

Recommendations
We recommend that Perth and Kinross Council:
• apologise to Mrs C for the shortcomings in dealing with the application;
and
• offer to meet the costs of Mrs C’s neighbour installing obscure glazing on
both panes of the side dormer window.
 

Summary
Mr C complained that the council had failed to follow their anti-bullying policy in relation to recording and monitoring alleged incidents of bullying involving his son. The investigation found that the council had initially failed to complete the relevant forms as the school had allowed for a settling in period before using the forms. The council did, however, provide evidence that they had recorded all incidents of bullying and had used the appropriate forms as the school term had progressed.

Recommendation
We recommend that Inverclyde Council:
• ensure that their staff act in accordance with their anti-bullying policy in
relation to the use of the appropriate forms for recording and monitoring.
 

Summary
Mr C made a number of complaints about the council's handling of planning applications for an agricultural shed and house close to his home. We found that the council failed to follow their standard procedure that they do not display responses from internal consultees on their website until after an application is determined. Due to an internal error, the website displayed the response from the roads officer, but did not initially display responses from the environmental health manager. We upheld this complaint. However, we did not uphold a number of other complaints Mr C made about the handling of the applications and about the council's investigation into the points that he raised about this, as we generally found their actions to be reasonable. We did, however, make recommendations where relevant.

Recommendations
We recommend that Perth and Kinross Council:
• consider whether they should log all relevant consultation documents on their website as soon as they are received; and
• apologise to Mr C for the delay in responding to his complaint to the Chief Executive and for failing to keep him updated.

Summary
Mr C complained that the council failed to carry out effective risk assessments when deciding to house a vulnerable adult in accommodation next door to his mother-in-law, Mrs A. He was of the view that the council also failed to deal with reports of anti-social behaviour by their tenant and by visitors to his home. Mr C also said that the council failed to provide any support to Mrs A following a fire at the neighbour's home and also failed to offer to pay for her insurance excess. Following our examination of the case we did not find evidence to suggest that the council failed to carry out appropriate risk assessments or that the neighbour had been housed in unsuitable accommodation. We also did not uphold the complaint that the council failed to investigate the concerns about anti-social behaviour. We found that the council had explained how Mrs A could make a claim to the council's insurers. We did, however, find that the council failed to offer any support to her after the fire. We considered that providing some support would have been appropriate under the circumstances and we upheld this aspect of the complaint. We recommended that the council apologise to Mrs A for this failing and also consider whether there is a need to introduce a procedure to deal with incidents such as this and to address the potential needs of elderly neighbours.

Recommendations
We recommend that North Ayrshire Council:
• provide a further apology to Mrs A for their failure to provide her with support; and
• consider whether there is a need to introduce a procedure to deal with incidents such as this and to address the potential needs of elderly neighbours.

Summary
Mr C and his family had been registered with a medical practice for several years. However, when he called for an appointment he was told that he had been removed from the list and would have to re-register. He complained to the practice about this and was told that he had been removed because correspondence sent to him had been returned unopened. We found that the practice should have checked to see if he was still at the address, but that a clerical error meant that he had instead been wrongly noted as 'no trace' on their list. We also found that they did not properly explore the reasons for this when Mr C complained and that these only became known after we investigated his concerns. Finally, following discussions with the NHS, we were able to tell Mr C that although he would have to re-register, he would be able to have a medical appointment in advance of that process. We did not uphold a complaint that the practice failed to warn him that he would be removed.

Recommendation
We recommend that the medical practice apologise to Mr C for their error.

Summary
Mr C was admitted to the Western General Hospital for an operation to remove a testicular cyst and to undergo a vasectomy. Five months later, he was referred to another consultant and was told that during the operation the original planned surgery had not taken place. They said that the cyst had not been removed but instead he had had a hydrocele repair and vasectomy. (A hydrocele is an abnormal collection of fluid in a sac-like space such as the testicles.) Mr C complained that he was told nothing about the hydrocele problem and that he had to have a further operation to remove the cyst. Our investigation concluded that although Mr C's treatment was appropriate, the reasons for providing the alternative treatment were not adequately documented. Because of this we upheld his complaint about treatment. We also found that the board's handling of Mr C's complaint was inadequate. We did not uphold his complaint that the hydrocele procedure was performed without informed consent as the consent given included authorisation of any justified procedure found to be necessary during surgery. Our medical adviser confirmed that the procedure was justified.

Recommendations
We recommend that Lothian NHS Board:
• share the decision letter with the consultant and remind him of his responsibilities to maintain a standard of record-keeping which is in line with General Medical Council guidance;
• remind staff about the need to adhere to the timescales as set out in the NHS Complaints Procedure and to provide relevant updates; and
• apologise to Mr C for the failings identified in our decision letter.

Summary
Mr C raised concerns that he was unreasonably discharged from the Glasgow Dental Hospital to his own dentist. He also felt that the hospital failed to adequately communicate with him and his dentist about the reasons for discharge and the treatment plan. We sought the opinion of our independent dental adviser who reviewed the relevant records and explained that the outstanding work required on Mr C was within the competence level of the average dentist and so the discharge decision was not unreasonable. However, the adviser explained that the information communicated to Mr C's dentist about the outstanding work did not include four teeth which were noted in the clinical record as requiring treatment but which were not included in the letter to Mr C's dentist about the outstanding treatment. We upheld this aspect of Mr C's complaint and made recommendations to the board.

Recommendations
We recommend that Greater Glasgow and Clyde NHS Board - Acute Services
Division:
• ensure that Glasgow Dental Hospital revisit their records and, if necessary, contact Mr C's dentist to discuss his remaining treatment plan and any amendments required; and
• ensure that Glasgow Dental Hospital remind staff of the importance of ensuring that the outstanding treatment plan as noted in the records is accurately conveyed to the dental practitioner and, if there is any difference between the treatment plan as noted in the patient's record and the treatment plan communicated to the dentist, the reasons for this are
noted on the records.