Some upheld, recommendations

Summary

Mr C complained about the council's handling of a planning application. In particular that the council had failed to consider their waterside development policy (policy Des 9), had failed to consult with the Scottish Environment Protection Agency (SEPA) and had unreasonably accepted that works for the planning application were initiated on time. Mr C also complained about the council's communication with him.

We took independent planning advice. We found that that policy Des 9 should have been referred to in the report of handling (a report containing information on a planning application). It was not possible to know whether this policy had been taken into consideration during the processing of the planning application, as was required. We also found that it was not possible to say whether consideration of policy Des 9 would have resulted in a different outcome. We upheld this aspect of the complaint.

We also found that SEPA should have been consulted and we upheld this aspect of the complaint.

We did not find any evidence that the council had unreasonably accepted that works for the planning application were initiated on time and we did not uphold this part of the complaint.

Regarding communication, we found that some of the issues raised by Mr C had been not been adequately addressed, however, other issues raised by him had been reasonably clarified. We were concerned that a further response letter had had to be issued to Mr C. The council had accepted that there had been a delay in responding and that Mr C should not have had to submit a formal complaint to prompt a full response to his enquiries. We upheld this aspect of the complaint.

Recommendations

What we said should change to put things right in future:

• Development plan policies relevant to the processing of any particular application should be referenced in the report of handling.
• Where a statutory consultation appears to be required as part of the processing of a planning application, but has not taken place, this should be explained in the report of handling.

Summary

Mr C raised a number of concerns about the council's handling of his planning application.

Firstly, he complained that the council granted and then withdrew planning permission. The council had acknowledged that they had made an error when issuing his listed building consent, by using the template for planning consent rather than the correct listed buildings consent template. They were of the view that this was an administrative error and that, as such, the planning consent had not been legally granted. We were critical that the council had issued a decision on the wrong template, and we highlighted to the council that this could give the impression that plannng consent had been granted. As a result of this failure, and the failure to promptly and clearly clarify why the mistake was made and what would be done to correct the error, we upheld this aspect of the complaint.

Secondly, Mr C raised concern that the council unreasonably disputed that his planning application included an access through a wall into a council car park. We took independent planning advice and concluded that the council had not disputed that access arrangements were included in the application. We did not uphold this aspect of the complaint.

Lastly, Mr C complained that the council unreasonably withdrew permission for him to form the access in the wall, despite having granted others access. He said that the council failed to take account of information he provided them with, which he considers proves his right of access. We were satisfied that the council had taken Mr C's evidence into account. Who has title or right of access is not something that we can determine, and this issue would need to be pursued through legal channels. We did not uphold this aspect of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Write to Mr C to apologise for failing to promptly notice the error regarding the template, which gave the impression that planning consent had been granted. Also apologise for failing to provide Mr C with a reasonable explanation for what happened, and why, and for failing to provide an appropriate apology for their errors at that time. The apology should meet the standards set out in the SPSO guidelines on apology available at https://www.spso.org.uk/leaflets-and-guidance.

What we said should change to put things right in future:

• The public should be confident that when a formal notice is issued by the council, the notice is correct and can be relied upon. Any incorrectly issued notices should be identified promptly and steps should be taken to put right any errors, an investigation should be carried out in order to identify why the errors occurred and steps should be taken to ensure that the errors will not re-occur.

Summary

Mr and Mrs C complained that the ambulance service delayed in sending an ambulance after Mr C suffered multiple fractures in an accident at his home. They also complained that there was a further delay in sending an ambulance when his local hospital asked the ambulance service to transfer him to a major trauma centre. Mr C subsequently developed fat embolism syndrome (a life-threatening condition where fat particles within the bone are released into the bloodstream) and went into a coma. He considers that this was at least partly due to the ambulance service's delay in sending ambulances to both his home and his local hospital.

We took independent advice from a paramedic. We found that a dispatcher in the ambulance control centre had failed to identify a paramedic crewed ambulance that was available at the time of Mr C's 999 call. This had caused an unreasonable delay by the ambulance service in sending an ambulance to Mr C's home. In view of this, we upheld this aspect of Mr and Mrs C's complaint, although we acknowledged that the ambulance service had already apologised for this and had taken some action to try to prevent this happening again.

We found that the delay by the ambulance service in sending an ambulance to transfer Mr C from his local hospital to a major trauma centre had not been unreasonable. Mr C was in a place of safety and could have been upgraded to an emergency by the hospital at any time. We did not uphold this aspect of Mr  and Mrs C's complaint. However, we considered that the communication between the ambulance service and clinicians in the hospital could have been better and we provided some feedback to the ambulance service in relation to this. We also provided some feedback to the ambulance service on trauma care and the documentation of this.

Recommendations

What we said should change to put things right in future:

• Dispatchers should be able to identify available resources and, where appropriate, ensure that these are dispatched promptly.

Summary

Mr C complained about a Do Not Attempt Cardiopulmonary Resuscitation decision (DNACPR - a decision taken that means a healthcare professional is not required to resuscitate the patient if their heart or breathing stops) taken when his mother (Mrs A) was a patient in Ninewells Hospital where she was being treated for heart failure. Mr C held Power of Attorney (POA, the authority to act for another person in specified or all legal or financial matters) in relation to his mother. He had been told of the decision in a public place, without being consulted. The doctor who spoke to him said he had spoken to Mrs A, who agreed with the decision. Mr C said his mother was very confused and unable to consent to this. Mr C complained that he had not had his views taken into account in relation to the DNACPR decision despite having POA and that the board unreasonably spoke to Mrs A and gained her consent despite her lacking capacity to give consent at the time.

We took independent advice from a doctor with specialism in acute and general medicine. We found that it was inappropriate to have a discussion with Mr C about the decision in such a public setting, however, we found that the board had acknowledged and apologised for this. We noted that where a patient has granted a POA, the attorney should be involved in the decision wherever possible, with the patient as well if appropriate. However, if cardiopulmonary resuscitation (CPR - where the heart and/or breathing is re-started if it stops) is unlikely to be successful, healthcare staff are under no obligation to attempt CPR. The adviser considered that Mr C should have been involved in the discussions earlier, but ultimately it was the clinical team's decision to make. We did not uphold this aspect of Mr C's complaint.

In relation to gaining Mrs A's consent, we found that the board acknowledged that a discussion had taken place and, given it was recorded that she was confused at this time, they noted it would have been appropriate for a mental capacity assessment to have taken place. We acknowledged that assessing Mrs A's mental capacity was not the priority at the time the decision was taken as she was acutely unwell. However, the fact she was confused should have prompted an assessment of her capacity. We were also concerned that the board did not obtain a copy of the POA document. Therefore, we upheld this aspect of Mr C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C and Mrs A for failing to assess Mrs A's capacity and for failing to obtain a copy of the POA document. The apology should meet the standards set out in the SPSO's Guidance on Apology at: https://www.spso.org.uk/leaflets-and-guidance.

What we said should change to put things right in future:

• Staff should have a working knowledge of Adults with Incapacity legislation insofar as it applies to consent issues. Staff should be clear about the importance of Adults with Incapacity documentation.

Summary

Mrs C complained about the in-patient care she received at Ninewells Hospital. In particular, that there was a delay in diagnosing diverticulitis (where small pouches from the wall of the gut become inflamed or infected). She also complained that a consultant surgeon had not examined her when she attended an out-patient clinic appointment at Perth Royal Infirmary and that the care that she received from the out-of-hours service was unreasonable.

We took independent advice from a consultant colorectal surgeon (a specialist in the medical and surgical treatment of conditions that affect the lower digestive tract) in relation to Mrs C's concerns about a delay in diagnosing diverticulitis. We found that a computer tomography (CT) scan should have been carried out rather than an magnetic resonance imaging (MRI) scan because it would have provided a more complete examination of Mrs C's abdomen and pelvis. In addition, we considered that a CT scan should have been performed within a few days after Mrs C's discharge from Ninewells Hospital. We were also critical of the length of time it took for staff at Ninewells Hospital to contact the consultant surgeon at Perth Royal Infirmary to inform them about the results of the MRI scan. We also found that the letter to the consultant surgeon had not referred to Mrs  C's earlier hospital admission. In terms of the clinic appointment at Perth Royal Infirmary, we considered that the consultant surgeon should have examined Mrs  C given there was no evidence of her symptoms having settled. We considered that the time taken to diagnose diverticulitis was unreasonable and upheld this aspect of Mrs C's complaint.

In relation to Mrs C's out-of-hours appointment, we considered that the treatment she received was reasonable and appropriate. We did not uphold this aspect of Mrs C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C for the unreasonable delay in performing the MRI scan, for not ensuring that an urgent CT scan was performed, the unreasonable delay in the consultant surgeon being informed about Mrs C's hospital admission and MRI results, and for not conducting a physical examination at Mrs C's clinical appointment. The apology should meet the standards set out in the SPSO guidelines on apology available at: https://www.spso.org.uk/leaflets-and-guidance.

What we said should change to put things right in future:

• Staff should ensure that urgent CT scanning is performed when recommended.
• Staff should ensure timely and appropriate communication with other specialities where relevant.
• Staff should ensure that relevant information is clearly recorded and physical examinations carried out where appropriate.

Summary

Ms C, who works for an advice and support agency, complained on behalf of Miss  A about the medical and nursing care and treatment Miss A received at Stracathro Hospital following hip replacement surgery. Ms C raised a number of concerns, including that Miss A suffered a stroke after surgery which was not picked up on by staff, despite her repeatedly reporting visual disturbance and blurred vision.

We took independent advice from a consultant physician and cardiologist (a  doctor who specialises in disorders of the heart), a consultant orthopaedic surgeon (a surgeon who diagnoses and treats a wide range of conditions of the musculoskeletal system) and a nursing adviser. We found that there were no case note entries by the junior medical staff at any time in Miss A's post-operative notes (including in relation to the complaint of visual blurring) and that the board failed to assess Miss A's complaint of post-operative visual blurring in an appropriate manner. The failing was not that they did not diagnose a stroke as the cause of her visual blurring, but rather that they did not assess it at all. We also found that the medical staff failed to take Miss A's medical history or carry out a simple bedside assessment of her eyes. We noted that the board appropriately prescribed aspirin to Miss A on discharge. However, prescribing aspirin alone does not follow the board's protocol and there was no reason recorded in Miss A's notes to explain why this decision was taken. There was also no evidence of a 'venous thromboembolism (VTE - condition where a blood clot forms in a vein) risk assessment tool' being completed. We considered that the medical treatment provided to Ms A was unreasonable and upheld this aspect of Ms C's complaint.

In terms of the nursing care and treatment, we found that the nurses acted reasonably by informing the medical staff about Miss A's complaints of visual blurring and ensuring Miss A was seen by a doctor. Therefore, we did not uphold this aspect of Ms C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Miss A for failing to respond appropriately to reported visual blurring, the lack of record-keeping and for not giving her appropriate blood thinning medication. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/leaflets-and-guidance.

What we said should change to put things right in future:

• Medical staff should take a patient's medical history and respond to complaints of postoperative visual blurring in a timely and appropriate manner.
• Staff should complete patients' 'VTE risk assessment tool' forms in cases of this type, prescribe blood thinning medication following hip replacement surgery in line with national guidance, and give patients blood thinning medication in accordance with the board's protocol and, if the board consider it appropriate to deviate from the protocol, to record the reason for this in patients' records.

Summary

Mr C complained about the care and treatment his late father (Mr A) received during his two admission to Wishaw General Hospital. Mr A was diagnosed with bowel cancer and Mr C complained that the board failed to provide Mr A with appropriate medical and nursing care and treatment.

We took independent advice from a consultant in acute medicine, a consultant in colorectal surgery (a specialist in disorders of the rectum, anus and colon) and a nurse. In respect of Mr A's first admission, we considered that Mr A's underlying issues were all reasonably investigated, treated and resolved. In respect of Mr  A's second admission, we found that all appropriate investigations were carried out and that, overall, Mr A received appropriate medical treatment. However, we noted that there was an unreasonable delay before Mr A was seen by the speech and language therapy service (SALT) given that there was concerns regarding his ability to swallow. Therefore, we upheld this aspect of Mr  C's complaint.

In relation to the nursing care, we found that there was no evidence to indicate any failings in nursing care and that the nursing records were of a reasonable standard. We did not uphold this aspect of Mr C's complaint.

Mr C also complained that the board failed to communicate appropriately with Mr  A's family regarding his condition at a meeting. In particular, that only two family members were allowed to attend the meeting when there were twice as many hospital staff in attendance and that he was not allowed to record the meeting. We considered it was unreasonable that Mr C had been restricted to two family members while double the number of hospital staff attended the meeting. Mr C also appeared to have been open with hospital staff that he wanted to record the meeting and the reason for this. Therefore, we considered it would have been reasonable to have allowed him to record the meeting. We upheld this aspect of Mr C's complaint. We also noted that that these issues could have been avoided if the board had a policy that ensured both parties were aware of the ground rules for such meetings in advance. We made a recommendation to the board in light of this finding.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for the unreasonable delay by hospital staff in referring Mr A to SALT, for restricting the number of family members who were permitted to attend the meeting and not allowing the meeting to be recorded. The apology should meet the standards set out in the SPSO guidelines on apology available at https://www.spso.org.uk/leaflets-and-guidance.

What we said should change to put things right in future:

• Patients with impaired ability to swallow should receive an appropriate and timely referral to SALT.
• Both staff and patients and/or their families should be clear about what to expect in advance of a meeting.

Summary

Ms C, who works for an advocacy and support agency, complained on behalf of her client (Mrs B) about the care and treatment provided to Mrs B's late husband (Mr A) at Belford Hospital. Mr A was admitted to hospital on a number of occasions over a short period of time for breathlessness and chest pain. Ms C complained about the clinical care and nursing treatment provided to Mr A, the board's communication with Mrs B about her husband's deterioration, and the post-mortem care (care after death) provided to Mr A.

We took independent advice from a consultant physician and from a nursing adviser. We found that there were a number of failings with regards to the clinical treatment provided to Mr A, and we upheld this aspect of the complaint. However, we found that the nursing care had been reasonable and so we did not uphold this part of the complaint.

Regarding communication, we found that there was a failure to discuss Mr A's deterioration with Mrs B in a timely manner, and so we upheld this part of the complaint.

We found that the post-mortem care provided to Mr A was reasonable, and we did not uphold this aspect of the complaint. However, we found that the board had not addressed Ms C's concerns around post-mortem care in their original complaint repsonse. We, therefore, made a recommendation regarding this.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs B for the failure to provide Mr A with reasonable clinical treatment, and for the failure to communicate reasonably with her about Mr  A's deterioration. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/leaflets-and-guidance.

What we said should change to put things right in future:

• Patient care should be in line with the Scottish Intercollegiate Guidelines Network guideline 139: Care of the Deteriorating Patient, and Healthcare Improvement Scotland guidance on Structured Response to the Deteriorating Patient.

In relation to complaints handling, we recommended:

• All issues raised in complaints letters should be addressed.

Summary

Ms C complained about the care and treatment provided to her late mother (Mrs  A) by the practice. Mrs A reported hip and back pain to her GP, and was later found to have breast cancer which had spread to her stomach and bones. Ms C complained that the practice failed to identify that Mrs A's back and hip pain was due to cancer in her bones.

We took independent advice from a GP adviser. We found that, when Mrs A presented with back pain she was directed to physiotherapy, which was reasonable, and that there were no signs or symptoms of cancer at this point. We found that the practice provided reasonable care and treatment to Mrs A for her back and hip pain, and we did not uphold the complaint.

Ms C also complained about the way the practice handled her complaint. We found that the practice had not handled her complaint in line with the model complaints handling procedure and, therefore, we upheld this part of Ms C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms C for failing to respond to her complaint in a reasonable manner.The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/leaflets-and-guidance.

In relation to complaints handling, we recommended:

• Complaints should be handled in line with the model complaints handling procedure. The model complaints handling procedure and guidance can be found here: www.valuingcomplaints.org.uk/handling-complaints/complaints-procedures/nhs.

Summary

Ms C complained about the care and treatment she received at Queen Elizabeth University Hospital. Ms C attended a follow-up orthopaedic (the branch of medicine involving the musculoskeletal system) clinic at the hospital after hip surgery and explained she was experiencing discomfort in her ankle. She was found to have deep vein thrombosis (DVT, a blood clot in a vein) in her calf. However, other tests also showed that she may have secondary liver cancer. It was later found that she had primary breast cancer which had spread to her liver. Ms C complained about the way she was told about her diagnosis and that she was given inconsistent information about her illness. She also complained that her care was not appropriately personalised for her.

We took independent advice from consultants in acute medicine and clinical oncology (cancer treatment). We found that the doctor who told Ms C about her diagnosis had made a conscious decision to wait overnight before giving her the details because they wanted the opportunity to discuss the matter first with the breast cancer team. While we considered that this was a reasonable approach, when Ms C was told the following day, she was alone. This does not follow Scottish Cancer guidelines and Ms C appeared not to have been appropriately supported. Therefore, we upheld this aspect of Ms C's complaint. However, we did not find that Ms C had been given inconsistent information and we found that staff had adapted her care, as far as possible, to suit her needs. Therefore, we did not uphold these aspects of Ms C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms C for failing to support her properly when giving her bad news. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/leaflets-and-guidance.

What we said should change to put things right in future:

• Patients should be adequately supported when being given bad news and discussions with patients/relatives should be fully documented in medical records.