Some upheld, recommendations

Summary

Mr C complained about the treatment he received from the prison health care service and from the hospital he attended. In particular, he was concerned about the treatment he received for both a hand injury and hip pain, withdrawal of medication and how his complaint was handled.

We took independent advice from a consultant orthopaedic surgeon and from a GP adviser. Mr C said that he had not received reasonable and appropriate treatment in relation to an injury to his hand. We found that the treatment Mr C had received when he attended the accident and emergency department about the injury had been reasonable. Mr C was also referred to an orthopaedic consultant in another board for a second opinion. However, we found that there had been an unacceptable delay in supplying Mr C with a physiotherapy exercise ball in relation to the injury. Therefore, we upheld this aspect of his complaint. We noted that the board had already apologised for this.

Mr C also complained that the board had failed to provide reasonable and appropriate treatment in relation to his hip pain. Whilst there had been a delay in informing Mr C of the result of a scan, this had been carried out by another board and it was their responsibility to act on this. We found that the treatment Mr C had received from the board for his hip pain had been appropriate. We did not uphold this aspect of his complaint.

Mr C complained that the board had withdrawn his medication after he was found to have too many tablets in his possession. We found that the prison health care service's actions in relation to this matter had been reasonable. We did not uphold this aspect of Mr C's complaint.

Finally, Mr C complained that the board had failed to deal with his complaints adequately. Mr C had made a large number of complaints, but we found that there had been a significant delay in responding to one of the complaints. Therefore, we upheld this aspect of his complaint.

Recommendations

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

• The board should ensure that physiotherapy equipment that has been approved for prisoners is provided within a reasonable timescale.

In relation to complaints handling, we recommended:

• Staff should be aware of the timescales for responding to complaints.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

Summary

Ms C complained about the way that the council dealt with a planning application. In particular, she raised concerns about the pre-application consultation (PAC) process to give the local community an opportunity to provide their views. Ms C was also concerned that the council did not hold a biodiversity duty document. Ms C also complained about the way the council responded to her complaints.

We took independent advice from a planning adviser. We found that the PAC process had been carried out appropriately, and we did not uphold this aspect of the complaint.

We found that the biodiversity document was not held by the council, despite a statutory requirement for them to hold this. We upheld this part of Ms C's complaint.

Regarding the council's complaints handling, we found that, until the related planning application had been finally determined, it was premature for complaints about its handling to be made to the council. However, we found that this was not explained to Mrs C and that there were delays in responding to her. We, therefore, upheld this aspect of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms C for failing to deal with her complaints appropriately. 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:

• Staff should be familiar with the council's stated complaints procedure and follow it as required.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

Summary

Mr C fell on a pedestrian railway crossing and injured himself. He complained to the council that they had not taken steps to ensure that the walkway was safe for members of the public, including providing adequate lighting and warnings of steps on the approach to the bridge. The council responded that they considered the footbridge was adequately maintained and that there was no obligation to provide lighting. Mr C was unhappy with this response and brought his complaint to us.

We found that the council had entered into an agreement with the rail company, and their predecessors, that stated the rail company was responsible for the maintenance of the footbridge. They were also responsible for specifying what lighting was required. Therefore, we determined that it was not the responsibility of the council to ensure that the footbridge was safe. We did not uphold this aspect of Mr C's complaint.

Mr C also complained that the council unreasonably failed to respond to his complaint. We found that the council's response was insufficient as it failed to explain that the rail company was responsible for the maintenance of the footbridge, and that they were the appropriate party to deal with the complaint. We also found that there was an unreasonable delay in providing Mr C with a response to his complaint. 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 for unreasonably failing to respond to his complaint and provide Mr C with a full explanation. The apology should meet the standards set out in the SPSO guidelines on apology available at https://www.spso.org.uk/leaflets-and-guidance.

In relation to complaints handling, we recommended:

• Complainants should be informed of any delays in providing a reponse ahead of the deadline set and revised timescales should be agreed.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

Summary

Mrs C complained about the care provided to her mother (Mrs A) by the practice. In particular, Mrs C complained that the practice unreasonably failed to re-start Mrs A's diuretic medication (medication that can help reduce fluid build-up in the body which occurs when the heart is not functioning properly) which had been stopped in hospital. Mrs C felt that this resulted in a deterioration of Mrs A's longstanding heart condition. Mrs C complained that the practice unreasonably failed to liaise with Mrs A's cardiologist in this regard. Mrs C also raised concerns about the decision to commence Mrs A on anti-depressant medication. Mrs A was subsequently reviewed by a consultant geriatrician (a doctor who specialises in the medicine of the elderly) who restarted the diuretic medication and stopped the anti-depressants.

We took independent medical advice from a GP. We found that there was no evidence that Mrs A's diuretic medication should have been restarted earlier, or that the practice missed any significant signs of deteriorating heart failure. We also took independent advice from a consultant geriatrician on the timescale for restarting this medication. They explained that restarting diuretic medication is difficult to balance as restarting too soon can worsen dehydration, but leaving it too late can worsen the heart condition. The adviser considered that Mrs A's diuretic was restarted within a reasonable timeframe. We also found that an earlier cardiology review was not indicated, and that there was not a failure by the practice to liaise with Mrs A's cardiologist. As such, we did not uphold these aspects of Mrs C's complaint.

In terms of the decision to prescribe anti-depressants, we found that Mrs A had indicated that she was feeling low and anxious and that, as such, the prescription was not unreasonable. We did not uphold this aspect of the complaint. However, the GP adviser said that the medical records kept by the practice were sparse in detail and were not consistent with the General Medical Council's Good Medical Practice (GMC GMP) guidance on record-keeping. We made a recommendation regarding this.

Mrs C also complained about the practice's handling of her complaint. The practice accepted that they did not respond to the complaint within the required timescale, and they explained that there were exceptional circumstances which contributed to this delay. We found this explanation reasonable, however, we considered that their eventual response to Mrs C's complaint lacked detail and thorough explanation. We upheld this aspect of Mrs C's complaint. We were satisfied with the remedial action already taken by the practice to address the identified complaints handling failings, however we noted that their website could provide more information about their complaints handling procedure, and so we made a recommendation in relation to this.

Recommendations

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

• Medical records should be consistent with GMC GMP guidance on record-keeping, and the practice should familiarise themselves with this guidance, available at: https://www.gmc-uk.org/guidance/good_medical_practice/record_work.asp.

In relation to complaints handling, we recommended:

• The practice should provide more information on their website about their complaints procedure.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

Summary

Mr C underwent nasal surgery at St Johns Hospital and subsequently had ongoing issues with nasal obstruction, facial pain, breathing issues and sinus infections. Mr C complained that he was not warned of the recognised risks associated with the procedure and that the surgery itself was not performed to a reasonable standard. Mr C also complained that the board did not handle his complaint reasonably.

We took independent advice from an ear, nose and throat consultant. We found that appropriate information was provided to Mr C regarding the recognised risks of the surgery. We also considered that the nasal surgery was performed to a reasonable standard. We did not uphold these aspects of Mr C's complaint. However, we noted that there was a delay in removing Mr C's nasal splints (temporary splints which are used to stabilise the nose after surgery) and made a recommendation in light of this.

In relation to complaints handling, we found that there was a delay in issuing a response to Mr C and that there was insufficient detail about the surgery included in the letter. We considered that the board did not handle Mr C's complaint reasonably and upheld this aspect of his complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for the lack of advice about nasal splints following the surgery, and the failings in complaints handling. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/leaflets-and-guidance.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

Summary

Ms C complained about the care and treatment provided to her by the board. She complained that, when she suffered a slipped disc in her back, she was not given appropriate neurosurgical treatment during two periods of care. Ms C also complained that she was later not provided with reasonable treatment by the department for infectious diseases, cardiology, or rheumatology.

We took advice from a neurosurgeon, a consultant in infectious diseases, a cardiologist and a rheumatologist. We found that, whilst overall the neurosurgical care given to Ms C was reasonable, there was a failure to properly document an appointment; that there was no evidence that the likely outcome of surgery was discussed with Ms C; and that there was a delay in follow-up after Ms C underwent surgery. We upheld this aspect of Ms C's complaint.

We found that the care and treatment provided by the department for infectious diseases, cardiology, and rheumatology was of a reasonable standard and we did not uphold this aspect of Ms C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms C for the documentation of the neurosurgical appointment falling short of the standard expected; for the lack of evidence that that the likely outcome of surgery was discussed with Ms C as part of the consent process; and for the unreasonable delay between surgery and Ms C's follow-up appointment. 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:

• Documentation of appointments should be in line with General Medical Council guidance. The likely outcome of surgery should be discussed and documented as part of the consent process. Follow-up after surgery should be carried out in a timely manner.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

Summary

Miss C complained to us on behalf of her late mother (Mrs A). Mrs A was admitted to Victoria Hospital with stomach pain, which was thought to have been gallstones (small stones that form in the gallbladder). Mrs A was later diagnosed with cancer. Miss C complained that there was an unreasonable delay in diagnosing Mrs A's cancer.

We took independent advice from a consultant surgeon and a consultant radiologist. We found that the board carried out appropriate investigations into Mrs A's condition. However, we found that the board's interpretation of a scan was not reasonable as the scan results raised the possibility that Mrs A had liver cancer or a liver infection and that further investigations should have been recommended as a result of this. We found that there was an unreasonable delay in giving Mrs A an appointment to discuss those scan results and we noted that the board had identified this failing. We considered that the failings in the interpretation of Mrs A's scan led to an unreasonable delay in diagnosing her cancer. Therefore, we upheld this aspect of Miss C's complaint.

Miss C also complained about an unreasonable delay in proceeding with surgery on Mrs A's gallbladder. We found that it was appropriate that the board tried to treat her without surgery first. We, therefore, did not uphold this aspect of Miss C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Miss C for the delay in diagnosing Mrs A's cancer. 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:

• As far as possible, scan findings should be accurately reported.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

Summary

Mrs C complained about the clinical and nursing care and treatment she received when she was admitted to Victoria Hospital. In particular, that there was an unreasonable delay in surgery being carried out to remove her ovaries and an unreasonable delay in arranging surgery for the repair of an incisional hernia (a type of hernia caused by an incompletely-healed surgical wound). Mrs C also complained that the nursing care and treatment of her wound following surgery was unreasonable.

We took independent advice from a consultant in obstetrics and gynaecology (the medical specialty that deals with pregnancy, childbirth, and the post-partum period and the health of the female reproductive systems and the breasts), a consultant general surgeon and a nursing adviser.

In relation to the clinical care and treatment provided to Mrs C, we found that the delay in carrying out surgery to remove Mrs C's ovaries was not unreasonable. However, we were concerned that some of Mrs C's medical records were missing. We did not uphold this aspect of Mrs C's complaint but made a recommendation about the missing medical records.

With regard to arranging surgery for the repair of an incision hernia, we found that the board failed to meet the legal treatment guarantee time, which states that health boards should take all reasonable steps to ensure that patients receive in-patient and day case treatment within 12 weeks of treatment being agreed. We also found that there was no evidence that Mrs C was advised of her options given the failure to meet this guarantee. Therefore, we upheld this aspect of Mrs C's complaint.

In relation to the nursing care and treatment provided to Mrs C's wound, we found that there was no evidence of failings in care and that the treatment she received was reasonable. Therefore, 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 arranging surgery for the repair of an incisional hernia. 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:

• Records should be kept in accordance with the Scottish Government Records Management: NHS Code of Practice (Scotland).
• The board should inform patients as soon as possible of any inability to meet treatment targets and provide them with information about the options available to them in the circumstances.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

Summary

Mrs C raised allegations in her academic appeal that she was victim of racial discrimination, both in the marking and supervision of her dissertation. The university refused Mrs C's academic appeal and failed to address the allegations of racial discrimination. Mrs C complained to us that the university failed to consider and respond to her allegations of racial discrimination and that they had inappropriately appointed a member of staff to mark her dissertation.

We found that the university unreasonably failed to consider the allegations raised during the academic appeals process or register them as a complaint. The university should have identified the complaint and dealt with this appropriately, as part of either the academic appeal or complaint process. Therefore, we upheld this part of Mrs C's complaint. However, we were satisfied that this would not have affected the outcome of her academic appeal.

In relation to the university staff marking her dissertation, we found that Mrs C had not raised a complaint against the member of staff in question, despite being advised to do so if she had concerns. Therefore, we found that the university did not act inappropriately when appointing the markers of her dissertation. We did not uphold this part of Mrs C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C for failing to address the allegations that she raised in her academic appeal. The apology should comply with the SPSO guidelines on making an apology, available at https://www.spso.org.uk/leaflets-and-guidance.

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

• University staff considering academic appeals and complaints should be reminded of the academic appeals procedure and the complaints handling procedure, together with the importance of identifying and addressing all allegations and concerns brought to their attention.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

Summary

Mr C lives near the site of a former opencast mine where works were taking place. He accesses his home via a road running adjacent to the site. Mr C complained that the Scottish Environment Protection Agency (SEPA) failed to properly consider an application he made to them. He was also unhappy that SEPA had accepted the local authority's view that the works involved had permitted development status. Mr C said that, as a result of SEPA dealing incorrectly with the application he made to them, his access to his home was sometimes impeded by flood water.

We took environmental health advice. We found that, with regards to the application, the developer had made an explicit statement that planning consent for the site was not required, and that this statement had been confirmed by the local planning authority. We found that SEPA, as a licencing authority, had no capacity in the matter of flood risk that Mr C had complained about, and that this was a matter for the planning authority. As such, we did not uphold the complaint.

Mr C also complained that SEPA had not dealt reasonably with his complaint. We found that there had been delays in SEPA handling Mr C's complaint, and that it had not been dealt with in accordance with the stated complaints handling process. We upheld this aspect of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for the delay in responding to his complaint. The apology should meet the standards set out in the SPSO guidelines on apology available at https://www.spso.org.uk/leaflets-and-guidance.

In relation to complaints handling, we recommended:

• Complaints should be dealt with in accordance with the stated complaints handling procedure.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.