Some upheld, recommendations

Summary

Mr C's father-in-law (Mr A) attended the Emergency Department (ED) at Victoria Hospital with severe facial injuries following a fall from a bicycle. He was reviewed by a doctor and transferred to oral and maxillofacial surgery (OMFS - surgery which treats diseases and injuries of the mouth, head, neck, face and jaws) for treatment of the cut to his face, then discharged.

Within the following week, Mr A attended two out-patient appointments at Queen Margaret Hospital to check his wound and remove the stitches. While waiting for the second appointment, Mr A collapsed at the hospital. Medical and nursing staff attended, but no record was made. They told Mr A to visit the ED after his out-patient appointment. However, Mr A remained quite unwell and the family returned to the hospital to ask for help. An ambulance was arranged to take Mr A to Victoria Hospital where a scan showed that he had a skull fracture and bleeding inside the skull. Mr A died shortly afterwards.

The board undertook a Rapid Event Investigation which found failings in the clinical care and processes. They said that there was no communication about head injury care when Mr A was transferred from the ED to OMFS. This meant that nursing staff did not carry out neurological observations (observations of the brain and nervous system), and Mr A was not given information about head injuries when he was discharged. Mr A was also given the wrong advice following his collapse in the hospital, as he should have been taken to the minor injuries unit for further assessment and transfer to Victoria Hospital. The board apologised for the failings found. The family felt that the board's response was unreasonable, and Mr C brought the complaint to us.

Mr C complained that the medical care and treatment provided to Mr A throughout his attendances at Victoria Hospital and Queen Margaret Hospital was unreasonable. We took independent advice from consultants in emergency medicine and OMFS. We found that regular neurological observations should have been taken while Mr A remained in hospital (either in the ED or OMFS) and he should have been given information on head injuries on discharge. Whilst we acknowledged that the board had taken appropriate action to address some of the failings, we were concerned that some of the Rapid Event Investigation recommendations were not specific and clearly linked to the failings found, and two recommendations had been marked off as complete without any evidence of action being taken. In light of this, we upheld Mr C's complaints about medical care and treatment.

Mr C also raised concerns that the nursing care provided to Mr A at Victoria Hospital was unreasonable. We took independent advice from a nurse. We did not find any evidence that nursing staff had missed any concerning signs or symptoms, and we found that the nursing care provided to Mr A was reasonable. Therefore, we did not uphold Mr C's complaint about the nursing care provided to Mr A.

Mr C also complained that the board's response to the complaint was unreasonable. We found that, although it could have been more clearly written at points, the board's response was reasonable. We did not uphold this part of Mr C's complaint.

Recommendations

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

• Patients with an injury to the head should receive neurological observations, regardless of where they are cared for.
• Patients with an injury to the head should be given head injury information on discharge from the ward.
• Recommendations arising from a review of a patient's care should clearly identify changes to prevent the situation reoccurring.

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 that her late mother (Mrs A) received at Dumfries and Galloway Royal Infirmary. Mrs A was admitted for emergency treatment of a bowel issue and after some time in the intensive care unit, she was moved to the high dependency unit (HDU). Mrs A's condition deteriorated while she was in the HDU and she later died. Ms C was concerned about the standard of both medical and nursing care that Mrs A received. Ms C also complained about the level of communication with family members and the way that the board dealt with her concerns.

We took independent advice from a critical care consultant and a nursing adviser. We found that the care and treatment provided to Mrs A by both medical and nursing staff was appropriate and reasonable. Therefore, we did not uphold these aspects of Ms C's complaint.

However, we found communication with the family during Mrs A's time in hospital to be unreasonable. The nursing adviser noted that staff will refer to the 'ceiling of care' indicating the level of intervention that is appropriate for that particular patient. We considered that the records made of discussions with Mrs A's family were insufficient as they did not document enough information about ceiling of care and to what extent this was discussed. Therefore, we upheld this aspect of Ms C's complaint. However, we noted that the board had already identified areas for improvement.

In relation to complaints handling, we found that there had been a short delay in issuing a final response to Ms C and that the board had not arranged an extension or apologised for this. Therefore, we upheld this aspect of Ms C's complaint. However, we noted that the board had acknowledged this failing and had made improvements to their approach to complaints handling.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms C for the delay in responding to her 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.

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

• Communication with patients and their families should be in line with the General Medical Council's Good Medical Practice guidance, particularly sections 33 and 49. Ceilings of care should be discussed, agreed, documented and reviewed with all involved (patient, medical and nursing staff). The board should consider using a separate section within the notes to document discussions with relatives or carers.

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 attended two consultations with the practice who had recently taken over from her previous practice. She had attended her previous practice five years earlier after she had experienced an increase in epileptic seizures.

Mrs C complained that, during these two consultations, the practice unreasonably focussed on the events of five years previously. She raised concerns that the practice placed undue focus on the reporting requirements of the Driver and Vehicle Licencing Agency (DVLA) and she found it difficult to get her health concerns across. Mrs C also complained that, during the first consultation, she was unreasonably prescribed the wrong dosage of epilepsy medication.

We found that the first of the two consultations was Mrs C's first with the practice altogether, following them taking over the running of her local practice. Her prior consultation with her previous practice noted concerns about the management of her epilepsy and an intention to notify the DVLA. We took independent medical advice from a GP, who confirmed that DVLA guidance requires patients with epilepsy to notify them. We considered that it was reasonable for the practice to discuss Mrs C's epilepsy and DVLA reporting requirements during her consultations. Therefore, we did not uphold this aspect of Mrs C's complaint.

Mrs C also complained that she was prescribed the wrong dosage of her epilepsy medication. We found that there had been a prescribing error and that the practice did not address this when responding to Mrs C's complaint. Therefore, we upheld this aspect of Mrs C's complaint. However, we noted that the practice acknowledged that the error was their fault and that this was fixed before any medication was actually issued.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C for the prescribing error and for failing to address her complaint about this.The apology should meet the standards set out in the SPSO guidelines on apology available at: https://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

Mrs C complained about the care and treatment provided to her late husband (Mr A) at University Hospital Ayr. Mrs C felt that Mr A was kept in the emergency department for too long before being admitted to the hospital, and that he was not appropriately assessed during this time.

We took advice from a consultant in emergency medicine and a stroke consultant. We found that, overall, the care provided to Mr A by the emergency department staff was reasonable but that they failed to complete transfer observations and handover documentation. We found that the initial assessment of Mr A by the stroke team was poor. We acknowledged that the diagnosis of a stroke, such as the one Mr A suffered, can be difficult to diagnose, however, we found that there was a failure to scan Mr A in the appropriate manner and reasoning for decisions made were not documented clearly. Therefore, we upheld this aspect of Mrs C's complaint.

Mrs C also complained that there was a lack of communication to keep her advised of Mr A's diagnosis and treatment. We found that, overall, the medical records showed a reasonable level of communication with Mrs C and, therefore, we did not uphold this aspect of her complaint.

Finally, Mrs C complained that the board's handling of her complaint was unreasonable. We found that, throughout the complaints process, there had been a number of failings including delays and a lack of communication. Therefore, we upheld this aspect of Mrs C's complaint. However, since these events occurred, a new complaints handling policy had been implemented by the board and we therefore made no further recommendations on this point.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C for failing to provide Mr A with appropriate clinical treatment; and for failing to handle Mrs C's complaint in a reasonable manner. 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:

• Transfer observations and handover documentation should be completed appropriately by the emergency department to ensure patients are safe to be transferred and appropriate information is passed on to the receiving ward area.
• Assessments made by members of the stroke team, and reasoning for any decisions made, should be documented clearly.

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 Scottish Qualifications Authority (SQA)'s marking of a handwritten exam script for her daughter (Miss A). Miss A's script was considered to be illegible when it was initially marked and this resulted in her not receiving the mark she had hoped for in that subject. Miss A had two places at universities that were conditional upon her receiving a higher award than she achieved in that subject. Miss A applied for a place at a university elsewhere and accepted that place the day after receiving her exam results. Miss A's school later submitted a marking review request for her, and she was awarded a higher grade. However, this was too late for her to take up one of the conditional university places she had previously been offered. Ms C complained that pre-certification quality assurance checks had not established an issue with Miss A's script and that the SQA had unreasonably failed to provide information at the time the results were issued to advise that a priority marking review could secure a conditional university place. Ms C was also concerned that the SQA had not handled her complaint reasonably.

After considering the available evidence, we did not uphold Ms C's complaint about quality assurance checking. We found that the initial marker followed the proper process when they considered that the script was illegible and escalated the matter appropriately. The script was then reviewed by a more senior assessor, who agreed that it was illegible. Although a higher award was given following the marking review request, we found that this was as a result of a subject specialist being asked to decipher the handwriting, and so we did not consider that the initial marker and the senior assessor had acted unreasonably.

We also did not uphold Ms C's complaint regarding the information available on priority marking reviews. We found evidence that this information on priority marking reviews was available from a number of different sources and was provided to all candidates ahead of the exam period starting. This included information that this process, rather than a standard marking review request, should be used to ensure deadlines for conditional university places were met.

We upheld Ms C 's concerns about how her complaint was handled as we found that the SQA's response did not address all of the key issues raised. The SQA acknowledged this in their response to our enquiries and we made two recommendations in this connection.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms C for failing to address all of her concerns in their response to her 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:

• Complaint responses should address the issues raised, in line with the 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.

Summary

Mr C's application for a blue badge was refused by the council. At the end of the appeals process Mr C raised detailed concerns about the assessment and the application of the guidelines. The council responded to the complaint by re-stating the decision to refuse the blue badge and addressing various other points raised with respect to the process. Mr C was unhappy with the response and brought his complaint to us. Mr C complained that the council failed to demonstrate that they took into account the information he provided in relation to his appeals and that they failed to address the specific points raised in his complaint.

We found that the correspondence between the council and Mr C showed that the council had taken into account Mr C's information, and supporting evidence, when considering his appeals. Therefore, we did not uphold this complaint. We did, however, provide feedback to the council that further explanation for decision to refuse applications, with specific reference to relevant guidelines, may help clarify their decision making.

In regards to the councils complaints handling, we found that their response to Mr C's complaint failed to address any of the points that he had raised with respect to the assessment process or inconsistencies in application of the guidelines to his circumstances. Therefore, we upheld this complaint.

Recommendations

What we asked the organisation to do in this case:

• Provide Mr C with a further response that appropriately addresses the complaints raised in his letter.

In relation to complaints handling, we recommended:

• Council staff should be reminded of the complaints handling procedure and the importance of ensuring people are directed to register their concerns as complaints where appropriate.

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 complained to the council about the smell coming from local industrial premises. After monitoring the situation, the council identified a statutory nuisance and issued an abatement notice to the owners of the company concerned. The company did not meet their original compliance date, however, a couple of months later the council confirmed that the problem of odour had been satisfactorily addressed and that as no recent complaints had been made, the company had complied with the notice.

Mr C disagreed that the odour had been addressed and continued to make complaints. He complained to the council about their failure to deal reasonably with his concerns. The council felt that no statutory nuisance remained and that no further complaints had been made. Mr C complained to us that he was unhappy with the council's reply to his complaint and that it contained incorrect information.

We took independent advice from a chartered environmental health officer. We found that the council had taken reasonable action in responding to Mr C's complaints by carrying out full investigations, issuing the correct notices, monitoring the action taken and keeping Mr C updated on the process. While the council subsequently took the view that the statutory nuisance had been remedied, Mr C continued to complain. However, assessment after Mr C's further complaints led the council to confirm that the level of odour was acceptable. Therefore, we did not find the council's response to Mr C's complaint to be unreasonable and did not uphold this aspect of Mr C's complaint. However, in writing to him, the council had said that no further complaints were made after they confirmed the nuisance had abated. This was incorrect in that Mr C maintained his complaints. We upheld this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for providing him with incorrect information. The apology should meet the standards set out in the SPSO guidelines on apology available at https://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

Mr C made several complaints to the housing association about the noise levels in his flat. Sound tests were carried out, which showed that the sound levels did not meet the required standards. The association agreed to carry out sound insulation to Mr C's floor and walls, if Mr C moved out of the flat during the works. Mr C was reluctant to do this, as he suffers from agoraphobia (a fear of being outside). Mr C also wanted the association to use specific materials for the works. Following some months of negotiation, the details of the works were agreed. The association agreed that Mr C could stay in the flat during part of the works, and that he would move out on a daily basis during other parts, being escorted to and from temporary accommodation by their staff each day. The association also agreed to use the specific materials that Mr C requested.

The works were undertaken over a three month period. Mr C was dissatisfied with the results, and he complained that the association did not use the agreed materials. He was also unhappy with the amount of time taken to complete the works, and was not satisfied with the work carried out in the kitchen recess, which had reduced the space available. He felt that the association had discriminated against him by requiring him to leave the flat unnecessarily and he said that his neighbour had received preferential treatment because works on their flat were carried out within a quicker timeframe, and they were not required to move out.

The association did not uphold Mr C's complaint at first, but when he provided photos and video evidence with his complaint to us, they agreed to carry out more investigations, including taking samples from Mr C's walls. They found that their usual materials had been used, instead of the different materials agreed, and they agreed to redo this work.

We took independent advice from an equalities adviser. As the association had failed to use the agreed materials, we upheld this part of Mr C's complaint. We did not consider the time taken for the works to be completed was unreasonable, as the work had to be undertaken in phases because Mr C was still living in the flat. We did not uphold this part of Mr C's complaint. We found Mr C did not object to the kitchen wall being modified as part of the work and he would have been aware that this work was planned. Therefore, we did not uphold this part of his complaint. We found that Mr C had agreed to move out while the association completed works to the floors, but they had also asked him to move out while they completed some of the works to the walls. We found that the association did not have clear records of why they asked Mr C to leave during the works to the walls, and that their overall record-keeping regarding reasonable adjustments was poor. However, on the whole we considered that the association had taken their equalities obligations into account, as they had made a number of adjustments in view of Mr C's disability. We did not uphold this aspect of Mr C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for failing to use the agreed specifications for the works. 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:

• Where a customer discloses a disability, there should be a clear record of this and the reasonable adjustments agreed (including any changes to the agreement).

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, who is an advocacy and support worker, complained on behalf of her client (Mr A). Mr A had an operation at Ninewells Hospital and continued to suffer pain for over a year after the operation. Ms C complained that:

Mr A suffered unreasonable pain after his operation;

Mr A had to wait an unreasonable amount of time to be assessed about his pain management;

the board took an unreasonable length of time to establish the source of Mr A's pain;

the board provided an unreasonable treatment pathway for Mr A's chronic pain; and

the board unreasonably failed to tell Mr A that he could have obtained alternative treatment outwith their area.

We took independent advice from consultants in surgery, anaesthetics and pain management. We found that Mr A did have to wait too long for a referral to the pain clinic, where there were further delays in him being seen. We upheld Ms C's complaint that Mr A had to wait an unreasonable amount of time to be assessed about his pain management.

We found that Mr A did suffer from pain after his operation, but that the care and treatment he had been given had been reasonable. We also found that the approach used to assess Mr A's pain was the correct approach, though it did take time. We found that Mr A's treatment options within the board had not been exhausted. We, therefore, did not uphold any of the other aspects of Ms C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr A for the delays in him being seen by the pain clinic. 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:

• Action should be taken to ensure that patients are seen 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

Mr and Mrs C complained that midwives at Gilbert Bain Hospital failed to recognise that Mrs C had hyponatraemia (low blood sodium levels). Mrs C was given advice to drink more fluids, which made her condition more severe. Mr and Mrs C also complained that the board failed to handle their complaint and the review into Mrs C's care appropriately. In particular, they considered the review wrongly concluded Mrs C had a condition called syndrome of inappropriate antidiuretic hormone production (SIADH - the excessive secretion of antidiuretic hormone resulting in, among other things, water retention and dilution of the blood) when she actually had hyponatraemia. Mr and Mrs C considered the board failed to identify appropriate learning from the review and share it with them.

The board accepted that Mrs C was given inappropriate advice to drink fluids by midwives. However, they said it was unreasonable to expect midwives to have recognised she had SIADH, as it is very rare. The board considered they had undertaken a thorough review of Mr and Mrs C's care and complaint. They explained they had taken learning from it forward by training staff on recognising SIADH.

During our investigation we took independent medical advice from a midwife and from a consultant in general medicine.

The midwife adviser considered that the midwives carried out appropriate observations and tests in light of Mrs C's symptoms. They considered the advice given to Mrs C to drink more fluids was reasonable in light of those symptoms. Therefore, we did not uphold this aspect of the complaint.

The midwife adviser considered that the board undertook an appropriate review into Mrs C's care. However, there was a delay in sharing the action plan with Mr and Mrs C. The general medicine adviser considered it was reasonable that the board diagnosed Mrs C with SIADH following the review. They explained that Mrs C had hyponatraemia, which can have many causes, one of which is SIADH. However, given hyponatraemia is much more common than SIADH, the general medicine adviser considered the board should have trained staff on recognising and treating hyponatraemia as well as SIADH. In light of the failings we found in identifying learning from the review and in sharing it with Mr and Mrs C, we upheld this aspect of the complaint. We made recommendations in light of our findings.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr and Mrs C for failing to appropriately identify the learning from their case and share it with them at the 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:

• Reviews should be transparent and any learning should be shared with all those involved in the adverse event, including patients.
• The board should provide a reasonable standard of care to patients with hyponatraemia, whatever its underlying cause, with adequate staff training in place to support this.

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.