Some upheld, recommendations

Summary

Mr C complained on behalf of his neighbour (Mr A) about the care and treatment provided to Mr A for kidney stones at Raigmore Hospital. Mr A had a number of surgical procedures over the course of a year to remove his kidney stones, however none of these were successful and Mr A was referred to a different health board for further treatment.

We took independent advice from a consultant urologist. We found that both the medical and surgical management of Mr A's kidney stones had been reasonable, despite the procedures failing to be successful. Therefore, we did not uphold this aspect of Mr C's complaint. However, we did find that the referral to the other health board was not appropriately recorded in Mr A's medical records and we made a recommendation regarding this.

Mr C also complained about the board's communication with Mr A. He said that it had not been explained to Mr A what the treatment plans were, and that the surgeon failed to visit him after his most recent surgical procedure to explain the next steps. We found that, although communication throughout much of the time Mr A was receiving treatment was reasonable, it was not reasonable that the surgeon failed to make plans for post-operative discussions. We also found that there was a failure to make a note of a phone call the surgeon had with Mr A. Additionally, we found that the board's complaint response was poor as it failed to sufficiently cover the points complained about. We upheld this aspect of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr A for the failure to communicate with him reasonably. 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:

• Referrals to other health care providers should form a part of a patient's record.
• In similar situations, surgeons should proactively make arrangements to meet with patients post-operatively in order to discuss the operation and further management plans. Where this is not possible this should be raised with the patient in advance and an agreement on how to do this should be reached.
• Phone consultations which are part of clinical care should be recorded in writing in the patient's medical records.

In relation to complaints handling, we recommended:

• Complaint responses should fully address all issues raised by the initial complaint.

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 about the care and treatment he received from the board in relation to a urodynamics assessment (a test which uses pressure readings to assess the function of the bladder) carried out at the Queen Elizabeth University Hospital. Although Mr C returned home on the day of the assessment, he later became unwell and was admitted to the hospital for over two weeks. Mr C considered that the urodynamics assessment had not been carried out appropriately and he complained that this resulted in his subsequent symptoms, including haematuria (blood in the urine) and urine retention (the inability to completely empty the bladder). Mr C also complained that, after he had received treatment as an in-patient, his discharge was unreasonably delayed.

After taking independent advice on this case from a consultant urologist, we upheld Mr C's complaint about the urodynamics assessment as we found that there were technical problems with the way that the assessment was carried out. We did not, however, find that these failings had resulted in Mr C's later symptoms. We found that verbal consent had been obtained from Mr C before the procedure, and we made a recommendation to the board that they consider obtaining consent in writing in the future. We made a number of further recommendations on the basis of our findings, including that the board review their patient information leaflet for urodynamics procedures.

Regarding Mr C's discharge, the advice we received was that there had been no unreasonable delay in discharging Mr C from hospital and we did not uphold this part of his complaint.

Recommendations

What we asked the organisation to do in this case:

• Provide Mr C with an apology for the failure to carry out the urodynamics assessment in line with relevant guidance and advise him if any re-assessment is necessary. 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 be aware of the guidance on good urodynamics practice.
• Consideration should be given to introducing a documented informed consent process for urodynamics assessments.
• The patient information sheets should be reviewed and consideration should be given to including reference to urinary retention and haematuria, plus advice on what to do if these symptoms are experienced.

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 had a vaginal hysterectomy (a surgical procedure to remove the uterus through the vagina) at the Royal Alexandra Hospital. Two weeks after the surgery, Ms C started to experience sharp pains in her vulva (the skin surrounding the entrance to the vagina). She attended the gynaecology clinic at Inverclyde Royal Hospital on three occasions over the following months for treatment and was seen by a consultant and an associate specialist. Ms C's pain persisted and by the following year was intolerable. Ms C continued to try to obtain treatment for her pain and, nearly three years after her hysterectomy, was diagnosed with vulvodynia (persistent unexplained pain in the vulva). She then started treatment for this condition.

Ms C complained that the board unreasonably failed to make her aware, prior to her surgery, that vulvodynia was a possible complication of the hysterectomy surgery. She also raised concerns that the consultant and the specialist at Inverclyde Royal Hospital failed to provide her with adequate care and treatment in the three months following her surgery. She also complained that in their response to her complaint, the board failed to adequately acknowledge that the pain she experienced, and continued to experience, was directly linked to the hysterectomy surgery.

We took independent advice from a consultant gynaecologist. The adviser said that vulvodynia following vaginal hysterectomy is rare, but that there is no data to quantify how rare it is. They said that the average surgeon might never encounter it and that they would therefore not have expected Ms C to have been made aware during the consent process that vulvodynia could be a possible complication of her surgery. We did not uphold this part of Ms C's complaint.

The adviser said that Ms C should not have been discharged from care after each of her appointments with the gynaecological team at Inverclyde Royal Hospital, as her core problem was still unresolved. We upheld this aspect of Ms C's complaint.

In relation to complaints handling, the adviser explained that although Ms C's pain being directly liked to her vaginal hysterectomy was a rare risk, the timing of her symptoms in relation to the surgery was undeniable. The adviser said that at least a strong association should have been acknowledged by the board. On balance, we upheld this aspect of Ms C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms C for discharging her from care after each of her appointments at Inverclyde Royal Hospital, as her core problem was unresolved. Also apologise for failing to acknowledge the strong association between the surgery and the pain Ms C experienced.

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 on behalf of her brother (Mr A) about the care and treatment provided to him across numerous admissions to Aberdeen Royal Infirmary. Mr A underwent various surgeries to treat spinal cord compression and a spinal abscess. After surgery to drain the spinal abscess, Mr A was left paralysed from his waist down and was left with only partial movement in his upper body.

Miss C complained to the board as she felt that Mr A had not been properly cared for and treated. She believed that opportunities were lost to treat him sooner, and that his outcome may have been different if these opportunities had been taken. The board responded, however Miss C remained unhappy and brought her complaints to us.

Miss C complained that the board did not provide reasonable treatment to Mr A across his numerous admissions to the hospital. We took independent advice from consultants in radiology and neurosurgery, and from a nurse. We found that there was an opportunity missed to drain the spinal abscess. Had the abscess been drained at that time we considered that Mr A's outcome may have been different. We found that a scan that was carried out by an outsourced company out-of-hours did not meet a satisfactory standard, however this was not identified as having impacted Mr A's outcome. We also found that Mr A's case could have been considered in a more holistic way. We upheld this aspect of Miss C's complaint.

In relation to Mr A's discharge home from hospital, Miss C complained that he was unreasonably discharged on one occasion, and that the board unreasonably failed to ensure that there was a suitable home care package in place for him following that discharge. We found no evidence to suggest that Mr A was discharged unreasonably. We found that the relevant paperwork had been completed, and that Mr A had capacity and was in agreement with the decision to discharge him at that time. We also found that there was no evidence of a need for Mr A to have a home care package in place on his discharge home. We therefore did not uphold these aspects of Miss C's complaint.

Miss C also complained that the board did not respond reasonably to her complaints. We found that the board delayed in providing a response to Miss C's complaints and that she was not kept updated. We upheld this aspect of her complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr A for not draining his abscess at an earlier time and for the lack of a holistic approach to his care. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/leaflets-and-guidance.
• Apologise to Miss C for the failure to provide a timely response to her complaint and for failing to reasonably update her. 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:

• In circumstances similar to those of Mr A, consideration should be given to draining any abscess. The decision should be fully documented and care should be considered holistically.
• All outsourced advice on scans should reach the same standards as those provided in-house.

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 about the care that his late wife (Mrs A) received from the board's out-of-hours GP service and the care she received from Victoria Hospital after she was admitted with symptoms of ongoing diarrhoea. Mr C was concerned that Mrs A's bowel cancer, which was at an advanced stage, would have been identified sooner had a CT scan been carried out sooner. He also raised concerns that there was a delay in pain relief medication being provided and that the board's response to his complaint was poor.

We took independent advice from a general practitioner and from a consultant in acute medicine. We found that the care provided by the out-of-hours GP service was of a reasonable standard because Mrs A's symptoms, and their duration, were in keeping with a working diagnosis of infective diarrhoea. We found that there was no evidence of an abdominal mass and that her vital observations (pulse rate, blood pressure and oxygen saturates) were stable with no indication of an acute emergency. We also considered that there were appropriate reasons for not carrying out the CT scan earlier. These reasons included the initial working diagnosis of infection, Mrs A's fluctuating kidney function, her warfarin (blood thinning) levels and Mrs A's preference to avoid further investigations. We did not uphold these aspects of Mr C's complaint.

We were critical that there was a delay in providing Mrs A with pain relief and we upheld this aspect of Mr C's complaint. The board have acknowledged and apologised for this. Whilst the board have taken some action, which we have asked them to provide evidence of, we made a recommendation for them to address the lack of available anticipatory medications (medicines that might be required at any time of the day or night in end of life care).

With regards to complaints handling, we found that the board's letter of response lacked clarity and should have been more accurate. We also found that some of their comments in the response letter were unneccesary. The board accepted that some of the information contained within their letter was conveyed inadequately and have taken action to ensure learning from this case. We upheld this part of Mr C's complaint. We have asked the board to provide evidence of the action they have taken and to apologise to Mr C.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for the complaints handling failings. 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:

• Staff should ensure that appropriate anticipatory medications are prescribed and administered for relevant patients in line with NHS Scotland's palliative care guidelines.

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 was in the early stages of pregnancy when she had a miscarriage. Ms C complained about the care that she received when she contacted the board's early pregnancy service by phone and she was concerned that appropriate testing had not been carried out following the miscarriage. Ms C also complained about the way that staff had communicated both with her and between departments, as she had to explain to a member of staff carrying out a scan that the pregnancy had miscarried.

We took independent advice from a nursing adviser and from a midwifery adviser. We found that the clinical advice Ms C was given was reasonable and that the management of the miscarriage was in line with relevant guidance. We also found that some testing had been carried out following the miscarriage and that further investigations were not required in Ms C's circumstances. We did not uphold Ms C's complaint about the care provided to her by the early pregnancy service.

Regarding communication, we found that, on some occasions, it had been difficult for Ms C to reach someone at the early pregnancy service. We found that the board had identified a programme of enhanced communication training to be implemented as a result of Ms C's concerns. We also found that the board planned to change their process when referring women for scans so that more information was available to the scanning staff. We upheld this aspect of Ms C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms C for the failing in communication between staff. 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 should have a 24 hour contact phone number for the early pregnancy service, in line with national 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 complained about a consultation that his brother (Mr A) had with an out-of-hours service doctor. Mr A was referred to the on-call doctor by NHS 24 when he called to report pain in his chest and both arms. Mr A was examined by the on-call doctor who considered that muscular pain was the likely cause. Mr A returned home, however, later that evening he was taken to the emergency department by Mr C and was ultimately diagnosed with a heart attack. Mr C complained to the board about the consultation with the on-call doctor as he considered that Mr A's condition should have been identified sooner. Mr C was also concerned that the board's response to his complaint was unreasonable.

We took independent advice from a GP experienced in out-of-hours care. We found that Mr A did not have the typical presentation of a heart attack and consequently, this could not have been foreseen by the on-call doctor. We found that arriving at what later turned out to be an incorrect diagnosis did not mean that the on-call doctor was at fault and we found that there was evidence that they had adequately and appropriately assessed Mr A. We did not uphold this aspect of Mr C's complaint.

Regarding Mr C's complaint about the board's response to his concerns, we found that there was a minor inaccuracy in the response and that there was a lack of evidence that Mr C had been kept properly updated when the timescale for responding to his complaint passed. We upheld this aspect of Mr C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C that the timescales for responding to his complaint were not made clear. 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 complained about the care and treatment provided to his mother (Mrs A) during her admission to University Hospital Crosshouse. He raised particular concerns about an initial cancer misdiagnosis for what was a chest infection / pneumonia. We took independent medical advice from a consultant physician who considered that it was reasonable for medical staff to have considered the possibility of a cancer diagnosis given Mrs A's presentation and background. They advised that this did not impact on the treatment provided as reasonable steps were taken to continue to treat for infection, while planning appropriate investigations. However, the adviser said it appeared that communication with the family may have been unduly weighted towards the likelihood of cancer. In addition, they noted that there was a delay in the clinical team receiving an x-ray report, which might have contributed to the lack of clarity and prolonged the apparent overestimation of the probability of an underlying cancer. On balance, we did not uphold this aspect of the complaint but we made some recommendations.

Mr C complained that the focus on a cancer diagnosis led to a delay in commencing appropriate treatment. He noted that Mrs A's blood pressure rose unchecked resulting in her suffering a stroke. While the adviser reiterated that treatment for infection was appropriately continued, they identified that the treatment choice for the initial 24 hours was unreasonable. They noted that Mrs A's CURB 65 score (a score which guides treatment for community acquired pneumonia) should have been calculated and this would have indicated the need for a second antibiotic. After the initial 24 hours, however, the adviser noted that a stronger antibiotic was appropriately administered. The adviser noted that there were factors preventing optimal monitoring and treatment of Mrs A's blood pressure, but they considered the management of this was reasonable in the circumstances. They noted that there were other potential factors which might have contributed to Mrs A's stroke and could not solely attribute this to her blood pressure. On balance, we did not uphold this aspect of the complaint but we made a recommendation for action by the board in relation to the initial choice of antibiotic.

Mr C also raised concerns about the board's handling of his complaint. We were critical of the board in this regard. We did not consider there to be sufficient evidence to demonstrate that the issues raised were thoroughly investigated. In particular, no written report of the investigation was produced. A meeting was held and this was followed by a short letter detailing some action points. This was issued outwith the required 20 working day period and no explanation for the delay was given. Mr C then had to chase on several occasions for updates on actions taken and, even then, the board did not sufficiently demonstrate learning from the complaint. There was also an oversight by the board in terms of timely further contact with Mr C, for which they had already apologised. We upheld this aspect of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to the family for the failings in relation to communication, medical treatment, and 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.

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

• Medical staff should be guided by the CURB 65 score when treating for community acquired pneumonia.
• Medical staff should communicate clearly with patients and relatives to ensure they understand any diagnostic uncertainty, and the purpose and aims of the treatment options being explored.
• Clinicians should know how to easily ask for a radiology opinion and, where a formal x-ray report is required, this should be returned to the clinical team within a reasonable timeframe.

In relation to complaints handling, we recommended:

• The board should review their handling of this case with a view to making improvements and ensuring compliance with their statutory responsibilities regarding complaints handling, as set out in the Can I help you? 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 was studying for a PhD at the university. She was concerned about the conduct of her final oral examination. She complained that her supervisor was asked to leave the examination, contrary to university regulations. She also complained that she was not permitted to finish her answers during the examination and alleged that the external examiner had made comments to her supervisor that indicated he had a bias against students of her nationality.

Mrs C complained to us that there were administrative errors in the conduct of her oral exam, that some communication with her had been incorrectly headed and that the university did not respond reasonably to her complaints.

We found that it would have been reasonable for Mrs C to raise concerns about her supervisor being asked to leave the examination at the time, not after the fact, and we could not reach a finding in relation to her remaining concerns about the conduct of the examination. As such, we did not uphold her complaint of administrative errors in the conduct of the examination.

We found that there were two occasions where the university sent letters to Mrs C that contained incorrect headings, so we upheld the aspects of her complaint regarding this. However, we found that the university had already offered their apologies for these mistakes, and so we made no further recommendations in relation to this.

We found that the university's handling of Mrs C's complaints was unreasonable. We found that the university had not properly investigated the alleged statements of the external examiner which may have indicated that he had a bias against students of Mrs C's nationality. We also found that the university had not responded reasonably to Mrs C in relation to the other matters she raised. We upheld this part of her complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C that they did not respond reasonably to her complaints about the conduct of an oral examination. The apology should meet the standards set out in the SPSO guidelines on apology available at https://www.spso.org.uk/leaflets-and-guidance.
• Properly investigate Mrs C's allegation that an external examiner made comments to her supervisor that indicated he had a bias against students of Mrs C's nationality, and advise her of this.
• Following the conclusion of the investigation of Mrs C's allegation that an external examiner made comments to her supervisor that indicated he had a bias against students of Mrs C's nationality, consider what impact, if any, this may have had on the outcome of Mrs C's oral examination. Take any reasonable steps as a result and advise Mrs C of this.

In relation to complaints handling, we recommended:

• Respond to all specific and relevant points raised in 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

Mr C bought a second property with a view to renovating it and eventually moving into it. It took Mr C some time to bring the property up to habitable standards, and he moved into the property two and half years after buying it. When he moved in, he received a notification from the council about a council tax levy that was imposed on him from seven months earlier. Mr C complained to the council that they failed to inform him of this levy in writing at that time. He also believed the legislation from the Scottish Government gave local authorities flexibility and discretion when imposing the levy. We asked the council if the policy to impose a council tax levy on unoccupied properties was a blanket decision and whether they considered that they were not using their discretion when they could have been. The council confirmed that it was a blanket decision as they wanted to treat all home owners equally, and therefore it was not unreasonable to not consider Mr C's individual circumstances.

Following our investigation, the council accepted that they failed to take the Scottish Government's 2015 guidance into account when they originally drafted their policy. However, we also found that the council were correct in how they interpreted the relevant regulations and that they had the discretion to impose the levy on all cases and not take into account individual circumstances. Our investigation found that the Scottish Government's 2015 guidance on the regulations was not accurate and conflicted with the regulations. As a result, the Scottish Government has agreed to amend the guidance. We did not uphold this complaint, however we recommended that the council review their policy for council tax levies for unoccupied dwellings.

The council explained there was an administrative error when processing Mr C's account which explained why he did not receive notification of the council tax levy in writing. We upheld this aspect of Mr C's complaint.

Recommendations

What we asked the organisation to do in this case:

• The council should review Mr C's council tax account and reconsider his individual circumstances.

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

• The council's policy for council tax levies for unoccupied dwellings should include a provision to exercise discretion when considering whether to apply the levy on a case by case basis, in line with Scottish Government guidance on the regulations.

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.

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