Some upheld, recommendations

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.

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.