Some upheld, recommendations

Summary

Ms C complained on behalf of her late mother (Mrs A) about the care and treatment she received from her GP practice. Ms C considered that Mrs A's medication was changed inappropriately, that Mrs A was not given appropriate treatment for her symptoms and there was a failure to communicate reasonably with Mrs A and her family about her condition. Ms C also complained about the handling of her complaint.

During our investigation we took independent GP advice. We found that Mrs A's practice gave appropriate treatment for her symptoms, but delayed in making an urgent referral to a consultant geriatrician and a routine referral to a dietician. They also delayed in issuing Mrs A with a prescription. In light of these delays, we upheld this aspect of Ms C's complaint and made recommendations to address this.

We found that it was reasonable that Mrs A's medication was changed, and did not consider that there were failings in communication by the practice. We considered the handling of Ms C's complaint to be reasonable and, therefore, we did not uphold these aspects of her complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms C for the delay in referring Mrs A to the consultant geriatrician and for the delay in issuing her the prescription. The apology should comply with the SPSO guidelines on making an apology.

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

• The GP should review their clinical management plans, following house visits, to ensure their prescribing is complete.

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 her husband (Mr A) received when he was admitted to prison. In particular, Mrs C complained that, on admission, the health centre's handling of Mr A's medication was unreasonable. She also complained that there was an unreasonable delay in treating Mr A's stomach condition.

The board explained to Mrs C that Mr A was uncooperative and would not engage with the admission process when nursing staff tried to take his medical history. They advised that Mr A would have been asked to confirm his GP detail's so that his prescribed medications could be checked.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr A for failing to issue the medication to him following the doctor's consultation on 7 September 2016.

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 husband (Mr A) from Lochhead Day Hospital, which is a specialist assessment unit for people with known or suspected dementia. Mrs C complained that she was not adequately consulted about the decision to discharge Mr A. Mrs C also complained that no alternative day time care was offered to Mr A following his discharge.

During our investigation we took independent medical advice from a psychiatric nursing adviser.

The adviser considered that it was reasonable that Mr A was discharged from Lochhead Day Hospital, due to safety concerns. We did not uphold this aspect of Mrs C's complaint. However, the adviser considered that there was an unreasonable failure to involve Mrs C in agreeing a follow-up plan for Mr A's care before his formal discharge. Therefore, we upheld this aspect of Mrs C's complaint and we made recommendations in light of our findings.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C for failing to involve her in agreeing a clear and effective follow-up plan for Mr A's care before his discharge.

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

• At the point of discharge from a day hospital or clinic, secondary care services should work with primary care services and partner agencies to ensure that there is a clearly formulated plan in place for follow-up care. Relatives and carers should be involved in this in a meaningful way.

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 her late mother (Mrs A) had received at Biggart Hospital and University Hospital Ayr. Mrs C said that staff at Biggart Hospital had failed to treat her mother's deteriorating condition. We took independent advice from a consultant in acute medicine and from a nursing adviser. We found that there had been prompt recognition of Mrs A's deteriorating condition and that the care and treatment provided to her had been reasonable. We did not uphold this aspect of Mrs C's complaint.

During her treatment Mrs A was transferred from Biggart Hospital to University Hospital Ayr. She was subsequently transferred back to Biggart Hospital. Mrs C complained about the decision to transfer Mrs A back to Biggart Hospital given that she had tested positive for sepsis, MRSA (a bacterial infection that is resistant to a number of widely used antibiotics) and E.coli (bacteria found in the digestive system). We found that Mrs A's condition had improved at the time to the point that it was reasonable to consider her transfer back to Biggart Hospital. We did not uphold this aspect of the complaint.

Mrs C also complained that the communication between Biggart Hospital and University Hospital Ayr was unreasonable. We found that there was no clear documentation of communication between the hospitals about the fact that Mrs A had E.coli and MRSA. We therefore upheld this aspect of the complaint.

Mrs C further complained that Biggart Hospital had prescribed her mother a form of morphine, despite the fact that Mrs A had previously had an adverse reaction to morphine. We found that Mrs A's allergies, drug intolerances and drug interactions could have been better documented, and we made a recommendation in relation to this. However, we found that it had been reasonable to give Mrs A small doses of morphine, as the effect on her was being monitored. We did not uphold this complaint.

Finally, Mrs C complained about the medication Mrs A received at University Hospital Ayr. We found that it had been reasonable to try alternative medications given that Mrs A was able to tolerate them. In addition, nursing staff had observed Mrs A for adverse side effects. That said, Mrs A had not been given her routine medication when she was admitted to University Hospital Ayr and the reasons for this had not been adequately recorded. 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 lack of clear documentation and communication.

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

• The policy on communication between hospitals regarding patient transfer should be reviewed.
• The computer system for recording allergy information should be reviewed.
• A review policy around prescribing medication on admission, including who is responsible for this if the admitting team are too busy, should be produced.

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 enrolled as a postgraduate student at the university. During and in the period following her course, Ms C had a number of concerns, including about supervision, the administration of the programme, assessment, communication and the cancellation of the postgraduate show.

Ms C submitted a complaint to the university regarding these matters. In their complaint response the university acknowledged a number of shortcomings and outlined steps that would be taken to improve administration. The university also apologised to Ms C for the distress and inconvenience she experienced throughout the programme.

In the course of our investigation, we did not find evidence that the university had failed to adequately meet Ms C's request for a new supervisor without delay. We were also satisfied that the university provided Ms C with feedback following assessment. Although Ms C felt that the university failed to address her concerns about group work on the course, we found that the university met with Ms C to discuss this issue and we were therefore satisfied that the university acted appropriately. We did not uphold these aspects of Ms C's complaint.

Ms C said that the university had failed to inform her that part of her work would not be assessed. We did not find evidence to support this, and we did not find that the university acted inappropriately. Ms C also said that an assignment posted online had changed after it had been made available to students. Similarly, we did not find evidence that this had happened.

Ms C also complained that the university did not provide adequate access to workshops during the course. We did not find evidence that the university failed to follow its procedures in relation to this matter.

Ms C complained that the university failed to provide her with a reasonable space in order for her to display her work for assessment. We did not find that the space given to Ms C was materially different to that afforded to other students. Ms C was concerned about the university's actions in relation to the postgraduate show. We did not find that the university had acted inappropriately in relation to this matter.

However, we upheld Ms C's complaint that the university failed to provide support to her to apply for a grant. We noted that the university had since created an office for scholarships and we were therefore satisfied that appropriate learning had been implemented.

The university acknowledged to us that there had been a delay in informing Ms C whether her extension request had been granted, and a delay in providing information to Ms C in relation to the assessment and return of her work. The university said that they would review the process of managing extensions. We upheld these aspects of Ms C's complaint.

Finally, we found that the university did not appropriately acknowledge Ms C's complaint and did not contact Ms C in relation to a delay in responding to the complaint. We therefore concluded that the university did not handle Ms C's complaint in accordance with their procedure.

Recommendations

We recommended that the university:

• provide us with evidence that a review of the extension request process has taken place; and
• feed back our findings on complaints handling to the relevant staff so that complaints are handled in accordance with the university's procedure.

Summary

Mr C complained that the college unreasonably failed to deliver his course in line with the course criteria and that they failed to respond to his subsequent complaint in accordance with their responsibilities.

We were satisfied that the college acted in line with the Scottish Qualifications Authority criteria for Mr C's course, and we did not uphold this aspect of his complaint. However, we upheld Mr C's complaint about the way the college responded to his subsequent complaint as we found that the college did not communicate reasonably with Mr C in response to his requests for information.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for failing to respond as required to his requests for information.

In relation to complaints handling, we recommended:

• Staff who are responsible for responding to complaints should recognise and respond appropriately to any information requests contained within 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 complained about the way the council managed his planning application to build a new home. Approval was granted by the council but a condition was placed which stopped development starting until works had been carried out on a new section of public road. Mr C was concerned that the council had not followed the relevant procedures. He was also concerned that when his case was considered by the local review body, their decision to maintain this condition was based on inaccurate information. Mr C also complained that the council's handling of his complaint was unreasonable.

After taking independent advice from a planning adviser, we upheld Mr C's complaint about the council's failure to follow the relevant processes and procedures, as we found there had been a number of delays. However, we did not find any other failings in the determination of the application. The council acknowledged that their guidance for applicants on the local review body process could be clearer and we made a recommendation with regards to this.

We did not uphold Mr C's complaint about the condition placed on the planning consent. Although we found that there were some inaccuracies in the information considered by the local review body, the advice we received was that their decision was not based on these inaccuracies.

We upheld Mr C's complaint about the way the council handled his complaint. We found that Mr C's concerns were clear from his correspondence with the council but that their response did not properly address these concerns. The council accepted this. The council also accepted that they had not dealt with the complaint within the timescales set out in their complaints handling procedure. They advised us that a number of steps had been taken to address these failings and we asked that they provide evidence of this.

Recommendations

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

• The council should ensure that guidance for applicants about the local review body process is clearer regarding timescales.

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 began to experience an increase in cooking smells from the cafe above which he lived. Mr C contacted the council's Land and Environment Services (LES) department to report a nuisance. Two months later, he wrote to the council's Development and Regeneration Services (DRS) department to report that the cafe had breached the planning permission granted. Mr C was not satisfied with the way that either department responded to his correspondence, and he submitted a complaint to the council. He was also not satisfied with the way his complaints to LES and DRS had been handled by the council.

We noted that throughout Mr C's correspondence with LES, he had raised concerns that the cafe did not have an extraction system and was not meeting ventilation requirements. In response to our enquiries regarding ventilation, the council informed us that in a previous planning consultation response, LES had recommended to DRS that a high-level flue was required for the cafe. The council advised that this was not considered by DRS at the initial stage of the planning process, or by the Local Review Committee at the review stage of the planning process.

We took independent planning advice. The adviser noted that the council was not obliged to attach a planning condition regarding a flue as the Local Review Committee had discretion in deciding which planning conditions, if any, to attach to any planning permission.

Overall we found that the council had taken appropriate steps to investigate the first reported nuisance. However, we noted that the council's records were not clear regarding the reason for a delay in the investigation. The council acknowledged that they had not updated Mr C appropriately about the progress of the investigation. We also found that Mr C's report of nuisance had not been acknowledged and that he had not been advised of the outcome of the nuisance investigation in writing. We also found that the council had not acted appropriately in response to a nuisance subsequently reported by Mr C. For these reasons, we upheld this aspect of Mr C's complaint and made recommendations.

In relation to Mr C's concerns about the service he received from DRS, we noted that the department had also failed to acknowledge Mr C's initial letter. Although this was a requirement of DRS's service standards, we were satisfied that an appropriate planning enforcement investigation was carried out in response to Mr C's letter, and on balance we were satisfied that the investigation was broadly carried out in accordance with the council's service standards. Although Mr C felt that the cafe had breached the planning permission granted, we were advised that the decision on whether there is a requirement for enforcement action rests with the council as the planning authority. Although we did not uphold this aspect of Mr C's complaint, we made a recommendation in relation to it.

We also considered how the council had handled Mr C's complaints. We found that on one occasion LES had failed to respond to Mr C's query about to whom he should make a complaint, and we found an instance where DRS did not consider one of Mr C's complaints under the council's complaints procedure. Furthermore, we noted a number of occasions where Mr C's complaints were not acknowledged in accordance with the procedure, and we found that the council's final response contained inaccuracies. Although we found instances of good practice in complaints handling, on balance we upheld Mr C's complaint in this regard.

Recommendations

We recommended that the council:

• feed back the importance of keeping clear and accurate records to officers in the Environmental Health Department;
• feed back the adviser's comments on this case to planning officers in the Planning Department;
• take steps to ensure that the Environmental Health Department has a system in place to ensure that nuisance complaints are acknowledged and the outcomes of investigations are communicated in writing;
• undertake further monitoring of the reported odour nuisance, and consider whether any further action would be appropriate;
• remind staff in the Planning Department of the importance of ensuring that planning enforcement complaints are acknowledged in accordance with the service standards, and that clear and informative outcome notification letters are sent to complainants;
• apologise to Mr C for the failings identified during this investigation;
• take steps to ensure that complaints are acknowledged in writing within three working days of receipt; and
• feed back the findings of this investigation to staff involved in handling Mr C's complaints to ensure that complaints are recognised and handled in accordance with the council's complaints procedure.

Summary

Ms C complained about the care and treatment provided by the physiotherapy service at Stonehouse Hospital, and that a scan had not been recommended despite her severe back pain.

We took independent physiotherapy advice and found that the initial assessment carried out was inadequate and had not followed the board's local guidance on lower back pain. We upheld this aspect of the complaint and made a number of recommendations to address these failings.

Whilst we found that a scan would not have been appropriate, we were critical that the reasons for this were not clearly explained to Ms C. We did not uphold this aspect of the complaint, but made a recommendation to address the lack of record-keeping in this respect.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms C for the failings identified in this investigation.

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

• The physiotherapist should be reminded about the importance of good record-keeping which should include a detailed history and comprehensive discussions with the patient.
• Conduct a review of current local physiotherapy assessment management of chronic low back pain alongside the board's local low back pain guidance and national guidance.
• Draw the findings of this report to the attention of the physiotherapist involved.

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 treatment his wife (Mrs A) received at Raigmore Hospital. Mrs A had ongoing problems with both of her knees and underwent physiotherapy treatment and surgery. Due to post-operative complications and continuing problems with her right knee, Mrs A had to undergo further treatment.

Mr C complained that there had been unreasonable delays in providing Mrs A with appropriate treatment and that Mrs A's surgical treatment was not of a reasonable standard. Mr C was also dissatisfied with the way that the board dealt with his complaint.

We obtained independent medical advice and we found that the time Mrs A waited for knee surgery exceeded national standards with no exceptional circumstances to justify this. We upheld this part of the complaint.

We found that the surgical treatment Mrs A received was appropriate and of a reasonable standard, and that the orthopaedic treatment was within the range of accepted good practice. We did not uphold this aspect of the complaint.

We found that the board took an unreasonable amount of time to respond to Mr C's complaint, and that they did not address all of his concerns. We upheld this aspect of the complaint.

We noted that the consent form Mrs A signed for her surgery should be updated to reflect current guidance on obtaining consent in relation to ensuring there is an appropriate section to document risk. We made a recommendation to address this.

Recommendations

What we asked the organisation to do in this case:

• The board should issue a written apology to Mrs A for failing to provide treatment for her within the appropriate timescale.
• The board should issue a written apology for the failings in their response to Mr C's complaint.

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

• The board should take action to meet the 18 weeks referral to treatment time standard for knee replacement surgery for at least 90 percent of patients.
• The board should ensure that consent forms signed by patients comply with current guidance on obtaining consent in relation to ensuring that there is an appropriate section to document risk.

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.