Some upheld, recommendations

Summary

Ms C complained about a number of aspects of the care and treatment provided to her late mother (Mrs A) during two admissions to Queen Elizabeth University Hospital. Ms C complained that the standard of clinical care and treatment provided to her mother was not reasonable. Ms C also complained that the nursing care provided to Mrs A was not reasonable. Ms C's third concern was regarding the board's communication with Mrs A and the family during the admissions.

We took independent advice from a cardiologist and a nursing adviser. We found that the clinical care and treatment provided to Mrs A was reasonable. We found that the medications prescribed were appropriate and that Mrs A was reasonably reviewed. Whilst there was a failure to refer Mrs A to a heart failure nurse when she was discharged, we found that this was picked up at a later out-patient appointment and that an earlier follow up would not have impacted on Mrs A's treatment. We did not uphold this aspect of Ms C's complaint.

With regards to nursing care, we found that, whilst for the most part the nursing care was reasonable, the fluid balance charts were not always complete. We found this to be unreasonable and we upheld this aspect of Ms C's complaint.

Finally, based on the records available, we found that the board's communication with Mrs A and the family was reasonable. 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 failing to complete fluid balance charting.

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

• Nursing staff should complete all care rounding charts, including fluid balance charts, 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

Mrs C complained to us about the care and treatment provided to her late husband (Mr A) at the Victoria Infirmary. Mr A had been referred to the board for investigation of macroscopic (visible) haematuria (blood in urine). Mr A had subsequently died from cancer of the bladder.

Mrs C complained that a discharge letter inappropriately referred to Mr A as having been treated for microscopic (non-visible) haematuria. We found that the letter did incorrectly say that Mr A had undergone a cystoscopy (a procedure to look inside the bladder using a thin camera) for microscopic haematuria instead of macroscopic haematuria. The board said that this had been due to a typing error. We upheld the complaint and recommended that the board apologise to Mrs C for this. However, we noted that the investigations that had been carried out where appropriate for a man presenting with macroscopic haematuria and that this typing error had not impacted on Mr A's care.

Mrs C also complained that the board failed to carry out a CT scan (a scan that uses x-rays and a computer to create detailed images of the inside of the body) at the time that Mr A underwent the cystoscopy. We took independent advice from a consultant urologist and we found that there had been no requirement at that time for the board to carry out a CT scan. We did not uphold this aspect of Mrs C's complaint.

Mrs C also complained that the board's response to her complaint had incorrectly stated that there had been no subsequent contact between Mr A's GP practice and the hospital after Mr A's cystoscopy. Mrs C provided evidence which showed that the GP practice had phoned the hospital after Mr A's cystoscopy to report that there was still blood in Mr A's urine. We found that, in line with the relevant guidance, this should have prompted the board to request a CT scan at that time. However, we found that even if a CT scan had been carried out, it was unlikely that Mr A's outcome would have been significantly different. Due to the evidence we saw that there had been contact between the GP and the hospital, we upheld this aspect of Mrs C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C for the incorrect information on the discharge letter which inappropriately referred to microscopic haematuria. Also apologise for incorrectly stating in the complaints response that there was no subsequent contact from Mr A's GP practice after the cystoscopy. These apologies should be in line with SPSO guidelines on apology, available at www.spso.org.uk/leaflets-and-guidance.

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

• When a GP surgery contacts a hospital with additional information, it should be recorded and acted on.

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, an advocacy and support worker, complained on behalf of her client (Ms B) about the care and treatment provided to Ms B's daughter (Miss A) in the final months of Miss A's life. Miss A had Fanconi anaemia (a genetic disease that can lead to bone marrow failure and cancer) and had a complex medical history of complications following a bone marrow transplant. Miss A received treatment at the Beatson West of Scotland Cancer Centre over a number of admissions. She was treated for numerous health issues, including a bowel condition.

Ms C raised concerns that staff failed to inform the family of the severity of Miss A's bowel condition. We took independent advice from a consultant haematologist and from a registered nurse. We were unable to find evidence that staff had discussed with Miss A, or Ms B, the severity of Miss A's bowel condition. We concluded that communication with the family was poor and we upheld this complaint.

Ms C also complained that the board did not provide a reasonable standard of treatment during Miss A's final admission. We found that the treatment provided for Miss A was in line with the relevant guidance, but the advice we received was that no consideration appeared to have been given to the fact that Miss A was dying and needed palliative therapy to keep her comfortable. We found that this was unreasonable and we upheld this complaint.

Ms C also raised concern that the board did not make reasonable transport arrangements when Miss A was discharged on one occasion when she became unwell in the car of a volunteer driver. We found that Miss A was noted to be well prior to discharge, and that it seemed that she became suddenly unwell during the journey. We were satisfied that the transport arrangements in place were reasonable and we did not uphold this complaint.

Finally, Ms C complained that the board refused to admit Miss A on one occasion when Ms B called the hospital in the early hours of the morning. The advice we received noted that Miss A was advised to attend the clinic later that day, but to call back if she became more unwell. The adviser did not find evidence that admission was requested and considered that the board's advice in this situation was reasonable. We did not uphold this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise for the failure to communicate with Ms B and Miss A reasonably about the severity of Miss A's bowel condition and for the failure to provide palliative care and support to Miss A at the end of her life. 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 provided with any information on their condition that they want or need to know in a way that they can understand. This should be communicated in a way that is considerate to those close to the patient. Staff should be sensitive and responsive in giving patients and families information and support. Communication with patients and their family members should be documented.
• Patients who are approaching the end of their life should receive high-quality treatment and care that supports them to live as well as possible until they die, and they should be supported to die with dignity.

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 given to her late husband (Mr A) when he attended the out-of-hours primary care emergency centre at the Victoria Ambulatory Care Hospital. He was discharged home but a few days later was admitted to the emergency department of Queen Elizabeth University Hospital, where he was treated for a severe chest infection with possible underlying heart problems. After some hours Mr A's condition was considered to be near to death and it was indicated that he was suffering from aortic stenosis (a narrowing of the left ventricle of the heart, which can cause problems such as heart failure) and fluid on his lungs. Mr A was later transferred to the medical high dependency unit where he was reviewed and underwent numerous tests. He was then transferred to the intensive care unit, where he later died.

Mrs C complained to the board and when she remained unhappy with their response she brought her complaints to us. Mrs C complained to us that:

the assessment of Mr A at the out-of-hours service was unreasonable

the care and treatment provided to Mr A at Queen Elizabeth University Hospital was unreasonable

the communication with herself, Mr A, and the family during Mr A's admission was poor

the board failed to respond fully to her complaints.

We took independent advice from a nurse practitioner and from consultants in emergency medicine and cardiology. We found that Mr A had been reasonably and appropriately assessed at the out-of-hours service and we did not uphold this aspect of the complaint.

We found that it would have been better if Mr A had been seen and assessed by the cardiologist shortly after his admission to Queen Elizabeth University Hospital, rather than the cardiologist only speaking to the emergency medicine team on the phone, which is what had happened. A face-to-face assessment would have allowed for a better assessment, and for a discussion with Mr A and Mrs C about Mr A's symptoms, treatment and prognosis. We also found that opportunities were missed to keep Mrs C updated on Mr A's condition. As such, we upheld Mrs C's complaints about the care and treatment provided to Mr A, and about the communication with the family.

With regards to the board's complaints handling, we found that the board addressed all of the concerns that were raised with them. We were satisfied that the responses were provided promptly and with appropriate detail. We did not uphold Mrs C's complaint about the board's complaints handling.

Recommendations

What we asked the organisation to do in this case:

• Apologise that a cardiologist did not see Mr A sooner. The apology should meet the standards set out in the SPSO guidelines on an apology available at www.spso.org.uk/leaflets-and-guidance.
• Apologise for missing opportunities to keep Mrs C fully updated on Mr A's condition.

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

• In cases of aortic stenosis, a cardiologist should assess and physically examine the patient as soon as possible.
• Relatives should be updated on their family member's condition and care.

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 that staff at Forth Valley Royal Hospital provided to her over a number of years.

Mrs C was seen by the board's consultant orthopaedic surgeon and elected to have knee replacement surgery. She experienced some pain and discomfort following the surgery, and was seen during this time by an orthopaedic nurse. Approximately three years later, Mrs C continued to experience pain and discomfort and was then seen by two additional consultant orthopaedic surgeons.

Mrs C raised concerns that the knee replacement surgery was carried out inadequately as she felt that the board had provided her with a knee prosthesis that was too small. She also raised concerns about the monitoring that the board provided following her surgery. She also complained about the level of care and treatment that the board provided when she was seen by consultant orthopaedic surgeons over the following years.

We took independent advice from a consultant orthopaedic surgeon. We found that there was no evidence from the records and x-rays that the prosthesis was the wrong size, or that there was any other error in the initial surgery. We noted that there is an inherent risk that surgery will result in a patient experiencing ongoing pain and difficulties, without this being caused by any failure in the surgery. We did not uphold this aspect of Mrs C's complaint.

We upheld Mrs C's complaint about monitoring. We found that there was evidence of Mrs C expressing pain and discomfort during her reviews with an orthopaedic nurse that should have led to her being reviewed by a consultant orthopaedic surgeon, or should have led to some communication from a consultant.

We did not uphold Mrs C's complaint about the subsequent care and treatment she received when she reported problems with her knee in the following years. We found that the documented views of the board's consultant orthopaedic surgeons were not unreasonable, and that the treatment provided was appropriate.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C for the failings in monitoring following her surgery. 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

Mrs C complained about the care and treatment that the board provided to her late brother (Mr A).

Mr A attended the emergency department at Forth Valley Royal Hospital. After performing an examination and taking blood tests, staff considered that he had gastroenteritis (inflammation of the stomach and intestines). Mr A returned the next day, and staff continued to feel he was suffering from a viral illness. Mr A was seen the following day by an out-of-hours GP. He was then admitted to the board's acute assessment unit, who performed a range of further tests. The tests were normal, and Mr A returned home. He was seen the next day by a further out-of-hours GP. Mr A returned to the board's emergency department the following day, and was again admitted to the acute assessment unit. Over the subsequent days, Mr A's condition deteriorated and he was diagnosed with carcinomatous meningitis (a type of cancer). Mr A died a number of days after his second admission to the acute assessment unit.

Mrs C complained that the board unreasonably delayed in diagnosing Mr A with carcinomatous meningitis. She also said that staff unreasonably discharged Mr A from the hospital on several occasions. Finally, she said that staff unreasonably failed to provide effective pain relief.

We took independent advice from a consultant in emergency medicine, an out-of-hours GP, and a consultant in acute medicine. We found that carcinomatous meningitis is a rare form of cancer that is aggressive and that it presented atypically in this case. We found that staff carried out appropriate investigations, and that it was not unreasonable for them not to identify the cancer at an earlier stage. We identified one delay in reporting an x-ray, although this did not appear to impact on the timescale for diagnosis. As such, we did not uphold Mrs C's complaint about an unreasonable delay in diagnosing Mr A.

Regarding Mrs C's complaint about the discharges, we found that staff had a reasonable basis for considering Mr A was suffering from gastroenteritis, and therefore, it was appropriate to discharge him. We did not uphold this aspect of Mrs C's complaint.

In relation to Mr A's pain relief, we found that this could have been managed better during Mr A's final admission. While we noted the board's concern to balance pain control with consciousness level, we considered that the dosage could have been adjusted to a more appropriate level. We upheld this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr A's family for the failings in pain control and the delay in reporting the x-ray. 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:

• X-rays should be reported promptly, to minimise the danger that results are missed.
• In similar cases, staff should effectively balance pain control with level of consciousness.

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 Business Stream's handling of his water charges, and their subsequent handling of his complaint.

Mr C had an existing water account for his business premises based on a particular supply point identification number (SPID) (a reference number used to identify a water connection). A field visit was carried out by Business Stream, and a second account for Mr C was created in error based on a duplicate SPID. This resulted in a significant bill for Mr C. Business Stream recognised the error, and requested that Scottish Water remove the duplicate SPID. However, Scottish Water removed the SPID for the original account, as well as the duplicate. As a result, Business Stream requested a new SPID and account for Mr C. This was created by default as a water and waste water account, however, Mr C's original account was a water only account. He therefore, requested that the new account be amended. A significant period of time passed during which the account was assessed by Business Stream and Scottish Water.

Mr C complained to us that Business Stream had:

unreasonably charged him when he had no SPID

unreasonably had the new account created for him following the field visit

unreasonably charged him under the duplicate account

had a new account created as a water and waste water account, which meant that Mr C was unreasonably charged for waste water which he was not liable for

handled his complaint unreasonably

Business Stream acknowledged that there had been a number of failings in the case, but noted that, following the removal of the accounts, they had effectively provided credit for approximately five years, and had made a further payment to Mr C in recognition of his experience.

We took independent advice from a chartered engineer with experience in the water industry. We upheld three of Mr C's five complaints. We found that Business Stream appropriately levied charges prior to the time that the second account was opened. We also found that it was reasonable for Business Stream to charge Mr C under the new account once this was created, as this was consistent with the rules under the Market Code. We did not uphold these two aspects of Mr C's complaint.

We found that Business Stream should have requested the new SPID and account as water only, given that this was to replace Mr C's previous account. We found that it was unreasonable of Business Stream to create the new account following the field visit. We also identified a number of failings in the handling of Mr C's complaint, including delay, the limited consideration of the field visit issue, and some failures to respond to correspondence. We upheld these three aspects of Mr C's complaint and made a number of recommendations to address these issues.

Recommendations

What we asked the organisation to do in this case:

• Business Stream should apologise to Mr C for the failings in the handling of his accounts and the failings we identified in the complaints process. The apology should meet the standards set out in the SPSO guidelines on apology available at https://www.spso.org.uk/leaflets-and-guidance.
• Provide Mr C with an explanation for the extent of the bill he received after the new account was opened.

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

• Field agents should collect appropriate information and know how to correctly determine whether a property is paying charges or not so that duplicate accounts are not set up in error.
• There should be systems in place between Business Stream and Scottish Water to ensure requests to deregister SPID numbers are handled correctly.
• Where default SPID numbers are created, they should accurately reflect the services provided to the property.

In relation to complaints handling, we recommended:

• Complaints should be handled in a timely manner, and a full response covering all of the issues raised should be provided.

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 moved into business premises and she received a phone call from Aimera Ltd, advising that they were the licensed water provider for the premises. Ms C provided a meter reading, but did not at that stage receive any information about her contract, terms and conditions or the charges she could expect to pay. Two months later Ms C was asked for another meter reading, which she provided. She then heard nothing further for another two months, when she received an invoice. She disputed the amount due and ultimately brought her complaints to us.

Aimera Ltd explained that there had been a discrepancy between the last meter reading and the one provided by Ms C. They said that this required further investigation, which resulted in a delay in an invoice being issued. We found that the delay was unreasonable, and we also found that Ms C should have been sent details of the deemed contract she was under, which would have given her information about the charges she could expect, as well as giving her the opportunity to consider her options with regards to alternative water suppliers.

We upheld Ms C's complaints about Aimera's failure to provide information about the account, failure to provide information about the possibility of changing supplier, failure to meet the terms of the deemed contract, and the delay in issuing the initial invoice.

Ms C also complained about Aimera Ltd's application of the wrong Rateable Value (RV) of the premises when calculating her invoice. The RV had changed, but Aimera were billing with reference to the original RV. We accepted Aimera's explanation that it was the responsibility of the proprietor or tenant to notify them of any such changes. We were satisfied that as soon as Aimera were notified of the change they had applied it and had issued a revised invoice. We did not uphold this complaint.

Recommendations

What we asked the organisation to do in this case:

• Provide Ms C with a formal apology for the shortcomings in the way her account was handled and the delays in providing her with an initial invoice. The apology should comply with the SPSO guidelines on making an 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

Mr C complained about a number of issues related to his son (Mr A)'s primary school. Mr A had special adjustments in place which Mr C felt had been disclosed inaccurately to other parents by teaching staff. Mr C was also dissatisfied with the way in which his complaint about the matter was handled by council staff.

We found that the council had apologised to Mr C and his family for making inaccurate comments at a public meeting. We considered various possible factors raised by Mr C, but did not find evidence to clearly identify that any specific teacher or council officer had released confidential information about Mr A's special adjustments.

However, we considered that certain remarks made to Mr C were not appropriate; that a council officer should not have notified elected members not to respond to Mr C's correspondence; and that the handling of Mr C's complaint regarding this matter was not adequate. We upheld these aspects and recommended that the council apologise to Mr C and share our findings with relevant staff.

Recommendations

We recommended that the council:

• apologise to Mr C for the failings identified and draw these findings to the attention of relevant staff.

Summary

Mr C was experiencing difficulty negotiating with his neighbour about a repair to the chimney head at his property. Mr C complained that the council provided inconsistent information about the council's roles and responsibilities in relation to the communal repairs. Mr C also complained about the way the council handled his complaint.

The council issued a notice to Mr C and his neighbour, requesting that they take the appropriate action to repair the chimney head. The council explained that they would only carry out default repairs in exceptional circumstances. They also advised that the best option for Mr C would be to take civil action against his neighbour. The council acknowledged that they did not correctly follow their complaints handling procedure, and said that they have since recruited a complaints handling officer and provided training to their staff.

We found that the council did provide consistent information about their role in relation to communal repairs and that they did not at any point advise that they would carry out the default repairs. We did not uphold this aspect of the complaint. In relation to complaints handling, we found that the council did not correctly follow their complaints handling procedure as they failied to advise Mr C of his rights to bring his complaint to us. 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 failing to deal with his complaint appropriately. 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.