Some upheld, recommendations

Summary
Mrs C complained about the care and treatment provided to her late father, Mr A. Mr A was diagnosed with myelodysplasia and acute myeloid leukaemia. He was admitted to hospital and treated with chemotherapy. He also agreed to take part in the clinical trial of a new drug and signed the relevant consent form. After he started treatment with the trial drug mylotarg, Mr A developed gastrointestinal bleeding and fever. An ultrasound scan showed that he was suffering from veno-occlusive disease (an inflammatory condition of blood vessels in the liver). He deteriorated further, suffered multiple-organ failure and died. A post mortem established that the cause of death was acute myeloid leukaemia and its complications. Mrs C complained that Mr A had not been properly warned about the risk of developing veno-occlusive disease, that pain relief was not effective and that the board failed to communicate adequately. Our investigation found that the board did not specifically discuss with Mr A the risk of developing venal-occlusive disease from the drug trial. However, the risk was small and the information sheet provided to him before he took part in the trial referred to the risk, so we did not uphold this complaint. We did, however, uphold Mrs C's complaint about failures in the end of life care provided to Mr A in that the board failed to manage his pain in a reasonable way (although we recognised the difficulties they faced in doing so) or to properly communicate with Mrs C and her family.

Recommendations
We recommend that Fife NHS Board:
• ensure staff record discussion with patients when they are obtaining consent for treatment;
• review its procedures in line with 'Living and Dying Well' with particular reference to pain relief and communication;
• ensure that staff document in patients' medical records their communication with relatives and carers, in line with the guidelines; and
• apologise to Mrs C for the failures identified.

Summary
Ms C complained that a nursing assistant did not adhere to proper hygiene controls when Ms C's sister was being barrier nursed, in that she entered the room without protective clothing. Ms C also complained that no-one told the family that barrier nursing was no longer required. We upheld the complaint about hygiene control as the board accepted that the nursing assistant failed to use proper protective clothing. They explained that this was because she had understood that she was urgently needed in the room. As the board had already discussed this incident with the nursing assistant, however, we made no recommendations on this. We also upheld Ms C's complaint that staff failed to tell the family when barrier nursing was no longer required. We did not uphold complaints that the nursing assistant failed to use a side plate and gloves when serving toast and about the way the charge nurse handled the complaint.

Recommendations
We recommend that Ayrshire and Arran NHS Board:
• remind the staff involved in this complaint of the need to provide information about, and to involve relatives in, decision-making about barrier nursing; and
• remind the staff involved in this complaint about the need to keep good records both about the nursing care provided (in this case barrier nursing) and details of important communication with relatives.

Summary
Mrs C complained about the care and treatment provided to her late mother, Mrs A, by her medical practice. While under the care of the practice Mrs A received treatment for leg ulcers and symptoms relating to her underlying vascular condition. Mrs C complained that over a two month period the practice failed to refer Mrs A to hospital within a reasonable time, which meant that her vascular condition was not investigated until she was admitted to hospital. Mrs C also complained that after Mrs A was discharged from hospital the practice failed to refer her back there when the condition of her left heel deteriorated and she experienced continued leg pain. Mrs C also said that the practice failed to refer Mrs A to social work for home care assistance despite the fact that she lived alone and was incapable of self caring. Our investigation found that the delay in referring Mrs A to hospital was not reasonable, and we upheld this complaint as well as the complaint about referral to social work. However, we found that the standard of care Mrs A received from the practice after she was discharged from hospital was acceptable, as during that time she was also seen as a hospital out-patient.

Recommendations
We recommend that the medical practice:
• review the management of patients with peripheral vascular disease, seeking advice from hospital colleagues where appropriate;
• review their procedures for liaison with district nurse staff, particularly where concerns are raised by them;
• review their procedures for referral to social work;
• conduct a significant event audit into the clinical management of Mrs A and ensure lessons are learned; and
• apologise to Mrs C for the failures identified.

Summary
Mr A suffers from a degenerative muscular disease. His sister, Ms C, complained on his behalf. She explained that Mr A lived alone in a ground floor flat and moved about with the use of a wheeled zimmer. She told us that, as the council had failed to resolve access problems to his home, Mr A was virtually housebound. We noted that the council had agreed that the ramp to Mr A's home was too steep for use with his zimmer. Their architect, after inspection, had said that the safest and most appropriate method of access would be to install a step lift. Ms C and her brother did not find this solution acceptable. As, however, our investigation found that the council offered this after considering all the facts and after discussion with their professional officers, we did not uphold Ms C's complaint. (It was Mr A's decision not to accept the council's offer of a step lift. He was free to make this choice even though it appears that installing a lift would resolve his access problems.) We did, however, uphold Ms C's other complaints. After investigation, we agreed that they had failed to carry out adaptation work to allow Mr A access to his front and rear gardens. They had also failed to discuss the close entry system with him prior to installation, and had failed to fit an entry system to his front door. All this meant that Mr A was, indeed, virtually house bound. Finally, there had been confusion over the number of housing application points to which Mr A was entitled. This was clarified as part of our investigation.

Recommendations
We recommend that South Lanarkshire Council:
• apologise to Ms C for giving her incorrect information;
• review the communication between the departments of social work services and housing and technical resources;
• apologise to Mr A for their failure to discuss the installation of the entry system with him; and
• formally apologise to Ms C and Mr A for the confusion over his medical points.

Summary
Mr C lives on a main road opposite a public park. He was unhappy when a planning application was made to build a skate park on an open space in the park, and objected to the application. When the council approved the proposals, Mr C complained to them that the noise assessment was flawed; that there had been material changes in the proposals but the council had not considered them to be such; that there was a conflict of interest of a council officer (who was a skateboarder) working on the project; and that the access provided was not as agreed. We upheld only one of his complaints, however, that the council did not put plants in place to screen the skate park. Although the council explained why this did not happen, we were concerned that this meant that there had been no effective screening to reduce loss of amenity to local residents. We therefore recommended that the council take steps to see if they could resolve this by dense planting.

Recommendation
We recommend that Renfrewshire Council's planning services liaise with the council’s landscaping officer to evaluate whether an effective dense screen of planting can be introduced, compatible with existing trees and shrubs in the park.

Summary
Mr and Mrs C applied for a disabled parking space outside their home. Their neighbour immediately opposite applied for one at the same time. The road was not wide enough to accommodate both spaces outside the respective properties. The council's area committee considered the matter and decided to situate Mr C's space on the opposite side of the road. He found this to be unacceptable due to the nature of his medical condition. Mr and Mrs C then complained that the information presented to the area committee was misleading and inaccurate. They were unhappy with the process leading up to the decision, and the council's complaint investigation. We found that the report presented to the area committee included some subjective opinions as fact, and misrepresented the situation somewhat. We also found that Mr and Mrs C were not given enough notice of the deadline for submitting documents for the area committee. We found that the council did not respond to all of their complaints and that the investigation was clouded by personal opinion and did not concentrate solely on the facts. After their investigation, however, the council had agreed to refer the matter back to the area committee, so we made recommendations with this in mind.

Recommendations
We recommend that Aberdeenshire Council:
• compile a new report on the options for Mr C and his neighbour's disabled parking space applications;
• refer Mr C and his neighbour's disabled parking space applications back to the area committee for their consideration;
• remind complaint handling staff of the importance of responding to all points raised;
• consider reviewing the format of their investigation reports;
• set a deadline in advance for submissions from both parties prior to Mr C and his neighbour's parking space applications being reconsidered by the area committee; and
• review their procedures for the preparation of committee reports to ensure that interested parties are given clear deadlines for submissions.

Summary
Mr C was admitted to the Royal Edinburgh Hospital following a brain injury. He raised a number of complaints about his treatment while staying there. In particular, he raised concerns about the approaches and techniques used by staff members when dealing with incidents on his ward. He felt that he was not sufficiently involved in the planning of his treatment and did not receive adequate drug rehabilitation support. Mr C raised a number of verbal complaints with staff during his stay but he did not feel that these were listened to or followed up. The Board explained that raising frequent verbal complaints was a feature of Mr C's brain injury. They demonstrated that they had implemented a plan to set aside specific times each day for him to raise concerns with staff. However, we found no evidence that Mr C had been told about the arrangements that were in place for him. It was clear that the board recognised the need for Mr C to receive drug rehabilitation support, but based on our adviser's opinion we did not feel that the support offered to him best suited his particular requirements. We also found that the Board could have done more to involve Mr C in the planning of his care, or to record that he had chosen not to be involved. We were satisfied with the Board's approach to incident management, room searches and patient confidentiality.

Recommendations
We recommend that Lothian NHS Board - Royal Edinburgh and Associated Services Division:
• introduce a system of recording verbal complaints raised by patients and the action
taken as a result;
• review their approach to Mr C’s drug rehabilitation with the adviser's comments in mind
to ensure that patients in the brain injuries unit are given the most effective support for
their personal circumstances;
• take steps to ensure all patients' involvement in the planning of their care;
• remind staff that if patients decline to be involved in the planning of their care, this is
recorded in the records and a review date set; and
• consider taking steps to ensure that the uniform and name badge policy is adhered to by bank staff as well as permanent staff. 
 

Summary
Mrs C was unhappy about the process used by the Board to when deciding to put a drop-in community mental health service out to tender. She complained that the consultation exercise was inadequate, a report was flawed and that there was inadequate consideration of the matter at the meeting that decided to re-tender for the service. Our investigation found that the consultation had been appropriately carried out and that users themselves were consulted. We did, however, find that the report contained an inaccuracy.

Recommendation
We recommend that Lothian NHS Board remind relevant staff to check the accuracy of reports prior to them being finalised.

Summary
Mr C raised concerns on behalf of his son, Mr A, about the care and treatment that Mr A received from the local community addiction team. He complained that Mr A had been given inconsistent information and contradictory advice about methadone prescriptions. He was also concerned about what he considered to be inconsistent attitudes from members of staff, which had caused Mr A distress and anxiety. In addition Mr C complained about the tone and content of the Board's funding application letter, written for the purpose of referring Mr A to a full time residential placement. We found that overall the treatment options were reasonable and consistent with good practice. However, we upheld Mr C's complaint about methadone prescriptions, in that the explanations provided for prescription changes were not always adequate. We also found that the Board's letter setting out the funding application provided an unjustified negative clinical opinion and failed to set out details of the criteria for funding.

Recommendations
We recommend that Borders NHS Board:
• apologise to Mr A and his family for their failure to adequately communicate the reasons for their prescribing decisions to him and for the distress this caused him and his family;
• apologise to Mr A and his family for the negative comments contained in the funding referral letter dated 20 October 2009; and
• review the procedure for funding applications to ensure staff and applicants are aware of a) the process and b) the criteria used in reaching decisions.

Summary
Mrs C complained that, when she complained about her son’s deputy head teacher, the council’s education department failed to conduct a fair investigation or to handle the complaint within a reasonable time. She also said that they did not give her enough information about the outcome of their investigation into her complaint.

From our enquiries it became apparent that a better approach to investigating Mrs C’s complaint would have resulted in a more timely response. While we were concerned about the council’s handling of Mrs C’s complaint, we did not find any evidence to support her claim that the conduct of the investigation was unfair.

Recommendations
We recommended that:
• the Director of Education and Lifelong Learning issue an apology to Mrs C for the way her complaint was handled and for the delay in response.

We also recommended that when, for clear and justifiable reasons, the council are unable to issue a decision on a complaint within the timescale in their complaints handling procedures, they should, in agreement with the complainant, set revised limits on any extended timeline for bringing the investigation to conclusion. This should be made within the complaints procedure.