Some upheld, recommendations

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.

Summary
Ms C lived in a three-bedroomed council house with her adult daughter. Ms C told the council that she was getting married and intended to move. She asked if the tenancy could pass to her daughter, Ms A. A council officer visited and gave Ms C a change of tenancy form and housing application for Ms A, which were  completed.  Ms C was told that it was unlikely Ms A would be allowed to take on the tenancy as the house was a family home and she was a single person, but that Ms A could apply for housing on her own behalf. Ms C said she asked for, and received, confirmation that Ms A would, at no point, become homeless.

Almost immediately after this, the council wrote to Ms C refusing the application to transfer the tenancy. They said that they were not required to provide Ms A with
alternative accommodation. They told Ms C to vacate the house within 28 days. Ms C wrote to the council with several questions about this. The deadline by which she was to leave the property was about two weeks later, and she asked for a response before she left. She did not get one, and wrote twice again after leaving. She received a detailed response to her letter about six weeks after moving out. This said that the council now regarded Ms A as 'statutory homeless' and they would make an offer of accommodation as properties became available. Ms A was by then staying with friends, but was offered a property within a couple of months.

We found that it was unreasonable of the council not to respond to Ms C’s letter until after she had vacated her property. The council told us they initially regarded her letter as an appeal against their decision and assumed Ms C would stay in the property until this was resolved. As she then vacated the property they assumed she had accepted the decision. However, we took the view that the initial letter was a request for information rather than an appeal and that in it Ms C pointed out the deadline concerned. We upheld both this complaint and the complaint that the council did not explain the options to Ms C. The council said that they told Ms C that if the transfer application was refused she could either remain in the property or, if she moved, Ms A could present as homeless. We found, however, that the council did not send out their standard termination advice letter nor did they explain that Ms C could have stayed in the house longer to organise, for example, the disposal of belongings. We noted that the council apologised for the delay and waived certain costs at the end of the tenancy.

Given this, we made recommendations only to deal with matters that we considered were still outstanding.

We did not uphold a complaint that the advice provided was misleading. Ms C felt that the council did not make it clear that Ms A could become homeless if her application was not approved. There was conflicting information about the advice given, and we agreed the council should have followed this up by providing information about how to terminate a tenancy. (They did, however, write and explain that they were not required to home Ms A - the implication of this is that, on a change of tenancy, she would become homeless.)

Recommendations

 We recommended that the council:

• issue an apology to Ms C for their shortcomings with regard to providing her with adequate information following the refusal of her request to transfer her tenancy; and
• review their current procedures to ensure that due process is followed when terminating tenancy agreements and ensure firstly, that a distinction is made between a refusal to transfer tenancy and the formal decision that a tenancy is being terminated: and secondly, that sufficient information is provided to their tenant. A copy of the revised process is to be sent to the Ombudsman.

These recommendations were amended on July 20 2011, because the original wording was incorrect. We apologise for this error and have taken steps to ensure that it is not repeated.

Summary
Mr C is a tenant of Albyn Housing Society Ltd (the Society). He moved from one of
their properties to another. He said that before he moved out they inspected the house he was leaving and did not find any problems. After he moved, they carried out a further inspection and decided that the kitchen and bathroom needed a ‘hygiene clean’.  They did this and billed him for the cost. Mr C complained that the Society did not give him the chance to question the decision to clean the house. He also said they applied inconsistent standards as the property to which he moved was not cleaned to a similar standard.

We asked the Society for their complaint file, relevant documents and  procedures.  After seeing these, we decided not to uphold Mr C’s complaint. We took the view that the Society were entitled to use their professional judgment to make the decision to charge for the cleaning and there was no evidence that they had not followed the proper process when doing so. Nor did the Society need to tell him in advance about the decision to clean the house. Mr C had signed a document acknowledging that this would happen and that he would be charged if he did not leave the property in a suitable state. As the same officer carried out the post-inspection reports on both properties, we also believed that it was unlikely that different cleaning standards had been applied.

Mr C also said that the Society did not act appropriately on financial aspects of the cost of cleaning and did not handle his complaint properly, including not telling him the date of his appeal. We upheld both of these complaints. We found that the Society did not provide all relevant information about charges and that they should have checked their invoice before sending it to him. They also took payment of the amount due by deducting it from rent that Mr C had overpaid, rather than offering him the opportunity to repay it in another way, and they had not repaid a small amount that they agreed to refund after considering his appeal. There were delays in complaints handling and they did not contact Mr C about his offer to attend the appeal meeting, nor tell him when it was to be held.

Recommendations
We recommended that the housing association:
• put steps in place to ensure that they check, approve and, where appropriate,
clarify the charges on invoices before they send them to tenants. Any additional
information obtained should then be passed on to tenants;
• put steps in place to ensure that they contact tenants before they deduct monies
due to them from refunds that are due to tenants. They should offer tenants the
opportunity to make the payment by another method;
• refund a small sum in mileage charges that they agreed Mr C should not have to pay; and
• write to Mr C to apologise for failing to contact him about his offer to attend the
Complaints Committee and for failing to provide him with enough detail about the
Committee’s decisions.

Summary
Mrs A was an elderly resident of a nursing home. She suffered from severe
Alzheimer’s disease and a range of other health problems. She was admitted to
hospital for assessment as she was becoming increasingly agitated. At the time of admission, Mrs A had a wound on her left leg. She was in the hospital for just over two weeks, and was discharged back into the care of the nursing home, where she died about a month later.

Mrs A’s son, Mr C, complained to the board about the care and treatment of his mother in hospital. He said that staff did not communicate with him adequately and that record-keeping was poor. The board upheld his complaint. They acknowledged gaps in record-keeping, that the scales used to weigh Mrs A were inaccurate and that communication was not good. They said they had taken steps to resolve these problems. After complaining to the board, Mr C remained dissatisfied. In his complaint to the Ombudsman he said that he was particularly concerned that Mrs A suffered unacceptable weight loss and inadequate wound care. He also complained of inadequate communication with Mrs A’s family and poor record-keeping, in that the records contained conflicting information about where the wound on Mrs A’s leg actually was.

We took advice on Mr C’s complaint from one of our clinical advisers. Having seen Mrs A’s nursing records, our adviser said that the care and treatment was reasonable. There was evidence that the board carried out appropriate nursing care. This included attending to hygiene needs, action, although initially minimal, to improve nutrition, eating and drinking, wound care and referral to a dietician and a speech and language therapist. In addition, the adviser said it was not unexpected that Mrs A may have lost weight as her condition deteriorated. Dementia sufferers have to be reminded to eat and drink, and in some cases they refuse to eat due to a loss in cognitive ability. It is common for older, frail people to lose weight in hospital but there are, of course, national nutrition standards in place. Having said this, our adviser was critical of the initial nutritional assessment. This noted that Mrs A was at low risk of malnutrition, so
minimal action was taken at that time to improve her nutritional status. However, after considering all the evidence about this complaint, on balance we did not uphold it although we did make a recommendation on nutritional care. The adviser said that, based on the available evidence, the assessment, care and treatment of Mrs A's leg wound was reasonable.

We did, however, uphold Mr C’s complaints about communication and record-keeping.  Hospital staff have a duty to keep the next of kin well informed. The records show that communication with Mr C appeared to have been poor. There were only two references to communicating with him during Mrs A's stay in hospital and there was no record of how Mr C wanted to be told about any change in his mother’s condition. Given that Mrs A was incapable of making decisions Mr C should, for example, have been consulted about any treatment changes. On the complaint about record-keeping, we noted that on admission to the hospital, the initial nursing notes were completed by a student nurse. It appears that this was when the wound was noted to be on the right side rather than the left. The initial notes were countersigned by a charge nurse, but they continued to record the ulcer as being on the right side, and there was not enough cross-referencing to the wound chart. Our clinical adviser therefore said that aspects of the record-keeping were below an acceptable standard.

Recommendations
We recommended that the board:
• provide the Ombudsman with a copy of their nutritional care strategy as outlined in the NHS Quality Improvement Scotland Clinical Standards for Food, Fluid and
Nutritional Care in hospitals. They should also provide details of the action plan
appropriate for the hospital;
• ensure that sufficient communication tools are in place to ensure families and
carers of patients at the hospital are informed of care and treatment issues. The
board should also inform us of how, in practice, they will ensure families and carers will be better informed; and
• put in place a plan to monitor the quality of record-keeping at the hospital, to ensure records are kept in line with the principles outlined in the Nursing and Midwifery Council’s record keeping guidance for nurses and midwives, and inform us of this plan and its results.

Summary
Mr C complained about the care and treatment of his son, Mr A, who has multiple
sclerosis and diabetes and suffers severe spasticity (involuntary and continuous
contraction of muscles) due to his condition. Mr C felt that treating Mr A’s spasticity with phenol injections was unsuitable, inadequately explained and caused further problems. He said that Mr A’s condition had greatly deteriorated after the injections.  Mr A had become significantly less able to move, and this caused bowel and bladder management problems. Mr A has since had his right leg amputated above the knee.

Mr C felt that his son should not have been offered this treatment because of his
already limited mobility. Mr C has power of attorney for Mr A, and felt that he should have been involved in this decision before Mr A took it. He normally discusses options with Mr A before decisions are taken, but in this case Mr A had consented to treatment without Mr C being involved. Mr C was concerned that Mr A, who has memory difficulties, couldn’t make a proper decision without having everything, including any negative aspects, explained in a way that he could fully understand. Mr A’s quality of life significantly deteriorated after treatment and he now requires much more care than before. Mr C also believed that pressure sores and other skin infections contributed to the need for amputation. This further impacted on Mr A’s quality of life and added to the distress of his family.

When Mr C came to us, we obtained his son’s medical and nursing records, took
advice from our independent medical adviser and made enquiries of the Board. The NHS guidance on consent says that a patient must have information that they can understand about any proposed treatment. Because the doctor was aware of Mr A’s memory difficulties, our medical adviser was of the view that it would have been reasonable to include Mr C in these discussions. I am satisfied that there were discussions with Mr A and that he consented to the treatment. I am not, however, able to say whether the information was presented in sufficient detail or in a way that he was able to understand in light of his memory problems. We noted that the Board had already apologised to Mr C for this, and we upheld this complaint.

We did not, however uphold the complaint about phenol treatment. Our medical
adviser explained that there is a range of escalating treatments for Mr A’s condition.  He said that it was reasonable to treat Mr A with these injections, although they probably did cause bladder and bowel function to deteriorate. However, the medical team knew about and expected the possible side effects of the treatment. They said they were able to manage these during Mr A’s hospital stays but were unable to establish a routine that he could maintain at home. Our adviser also noted that the medical records show that the injections seemed to have an immediate positive effect on Mr A’s spasticity. Finally, on the complaint about care, our medical adviser said that diabetics have increased skin sensitivity and a reduced healing capacity. In his view it was this, combined with leg weakness and spasticity, that was the likely main cause of the skin problems that developed and that resulted in the need for an amputation. He said that the injections played, at most, a minor part in Mr A’s skin problems and that Mr A’s care plan was appropriate for the acknowledged side-effects of these injections.
Because of this we did not uphold this complaint.

We acknowledge that Mr A, Mr C and the rest of the family have suffered a great deal of distress from the side-effects of Mr A’s treatment.

Recommendations
We recommended that the Board:
• apologise to Mr C and Mr A for their failure to ensure NHS Scotland guidance on
obtaining consent was properly followed; and
• consider, as a matter of good practice, providing supplementary, written information to patients about the use and possible side effects of such phenol injections.

Summary
Ms A started to feel unwell while working abroad. She attended a hospital there for scans before returning to Scotland. Ms A attended her GP and explained the problems she was experiencing. She gave him the scans and medical reports, but as these were not in English, he was unable to read them. He agreed to send the scans to a hospital for interpretation, but the radiologist there did not look at them. Ms A attended the surgery again and asked for a private referral, which the GP made. She was also to be referred for an ultrasound scan but the GP did not send the form and assumed his secretary had done so. It was six weeks before the referral took place and Ms A was eventually diagnosed with ovarian cancer. She underwent major surgery, including a hysterectomy, removal of a bowel tumour and the fitting of a stoma. Ms A’s parents, Mr and Mrs C, felt that it took too long for their daughter’s concerns to be taken seriously, and complained on her behalf that treatment was delayed. They said this was because there was delay in diagnosing Ms A’s condition, including a failure to translate the test results into English. Mr and Mrs C were also unhappy with the aftercare provided in the community and felt it was inadequate.

We did not uphold the complaint about aftercare. We found from looking at the medical records and taking advice from one of the Ombudsman’s professional medical advisers that the aftercare provided was appropriate. We found that various healthcare professionals in appropriate disciplines saw Ms A. Her medical records show that she received appropriate levels of advice, care and support. We did not uphold the complaint about the delay in diagnosis either. Our adviser said that it would not have been appropriate for the GP to have attempted to interpret the scan, as he was not qualified to do so. This was an issue appropriate for a radiologist and as requested by Ms A the GP sent the scans to a hospital radiologist for interpretation, although ultimately the radiologist did not do this. The GP also arranged appropriate tests. However, he failed to request an appointment for an ultrasound scan despite intending to do so. He did not realise this until some six weeks later when Ms A said that she had not yet received an appointment. Ms A had attended a private consultation during that time and her symptoms were under review. If the ultrasound scan had been ordered earlier, however, the results would have been available more quickly and could have led to an earlier diagnosis.

Recommendations
We recommended that the medical practice formally apologise to Ms A for the failure to order an ultrasound scan.