Some upheld, recommendations

Summary

Ms C, who works for an advocacy and support agency, complained on behalf of Miss A that a locum GP working at her GP practice inappropriately prescribed her antibiotic medication which she was allergic to. Miss A suffered a severe allergic reaction to the medication, resulting in an emergency hospital attendance that evening. Ms C also complained that, when Miss A returned to the practice the following day, the GP failed to appropriately examine her allergy rash.

We took independent medical advice and found that the medical records noted that Miss A had previously had a reaction to the medication. As it should not, therefore, have been prescribed, we upheld the complaint. However, it was noted that the GP had already acknowledged and apologised for the prescribing error, which we were assured was down to human error and not systemic in nature. We did not, therefore, make any recommendations in this regard.

In relation to the subsequent attendance, the adviser noted that Miss A had already been examined and treated at the hospital the previous night and that a detailed examination was not required. We did not uphold this aspect of the complaint.

Ms C also complained that the practice had not responded appropriately to the complaint. We noted that the practice passed the correspondence to the GP (who was by then working at another practice) to respond to directly. This resulted in delays. We concluded that the practice should have retained ownership of the complaint and managed it in line with their complaints process. We upheld this aspect of the complaint.

Recommendations

We recommended that the practice:

• write to Ms A and apologise for their failure to properly handle her complaint.

Summary

Mr C was referred to the neurology department at the Southern General Hospital for the investigation of pain that he had suffered since he was involved in a road accident. Mr C attended at the neurology service for an extended period of time without a formal diagnosis of his condition being made. While we were investigating Mr C's concerns about delay in diagnosis and the way his complaint had been handed by the board, he advised us that he had received a diagnosis from a private health provider.

After taking independent advice from a consultant neurologist, we did not uphold Mr C's complaint about the delay in diagnosis. The advice we received was that while Mr C had a long patient journey, this was not unreasonable in the context of his complex case. The adviser considered that if the board had not carried out all the tests they had before Mr C received his private diagnosis, it was likely that these would still have been necessary before a diagnosis could be reached.

We upheld Mr C's complaint about the way the board handled his concerns. We found that there were some instances where the board's complaint responses did not accurately reflect the information in his medical records. This related to a test which they advised was carried out at a consultation. However, the record of the consultation made no reference to this taking place. We made three recommendations in relation to this matter.

Recommendations

We recommended that the board:

• ensure that the appropriate tests are conducted and documented at consultations;
• apologise for the complaints handling failing identified in this investigation; and
• ensure that complaint responses accurately reflect the medical records.

Summary

Mr C complained to us on behalf of his constituent, Ms A. He said that on being transferred from a mental health unit outside Scotland to Forth Valley Royal Hospital, Ms A was not provided with reasonable mental health care and treatment, in particular that the diagnosis of personality disorder she had been given did not fit her symptoms. Mr C also complained that Ms A was not provided with reasonable out-patient treatment when she was discharged from the hospital, and that the board did not take reasonable steps to change incorrect information on her discharge documents.

We took independent psychiatric advice. We found that the in-patient care and treatment provided to Ms A was not reasonable. Whilst we found that the treatment strategies offered to her were appropriate, the diagnosis of personality disorder was not sufficiently evidenced and documented. We found that no valid diagnostic assessment tool was used to assess Ms A and that her diagnosis was given without sufficient consideration of her previous diagnoses. We also found that the way this diagnosis was communicated was inconsistent, sometimes being reported as a provisional diagnosis and sometimes as confirmed. We found that there was a lack of documentation surrounding decisions taken about Ms A's care, including the decision not to implement the recommendations of a clinician who gave a second opinion, not to trial certain medications and the decision to change Ms A's lead clinician. We therefore upheld this aspect of Mr C's complaint.

In terms of Ms A's out-patient mental health care and treatment, we found that it was reasonable for the staff involved to provide care on the basis of Ms A's diagnosis of personality disorder, and that out-patient care and treatment had been planned in a collaborative way with Ms A in line with treatment for personality disorders.

When considering whether the board had taken reasonable steps to remove incorrect information from Ms A's records, we saw evidence that when the board became aware of this incorrect information, they apologised and arranged for the documents to be replaced with amended versions. We also saw evidence that they took steps to ensure all incorrect electronic records were amended. We considered the steps the board took to have been reasonable in this regard.

Recommendations

We recommended that the board:

• apologise to Ms A for the failings identified in this investigation;
• remind relevant staff of the caution advised when assessing personality disorder traits in patients with prominent mood or anxiety symptoms;
• consider using a valid diagnostic assessment tool (not just a screening tool) to aid diagnosis and formulation of personality disorders;
• remind the relevant staff of the importance of being clear and consistent in documenting any diagnoses and whether such diagnoses are provisional or confirmed;
• remind the relevant staff of the importance of, in cases where clinicians have sought second opinions, the recommendations made being fully considered before being implemented, and, if not implemented, the reasons why not being clearly documented and explained to the patient;
• remind the relevant staff of the importance of ensuring prescribed medication is regularly reviewed; and
• remind the relevant staff of the importance of documenting changes of responsible medical officer or consultant psychiatrist, and the reasons for these changes.

Summary

Ms C complained about the treatment she received for an eye infection from the out-of-hours service at Dumfries and Galloway Royal Infirmary. In particular, Ms C complained that a GP wrongly tried to dissuade her from attending the primary care clinic and that when she did attend, she did not receive treatment and was told she needed to give the antibiotics already prescribed more time to work. Ms C also complained about the board's complaints handling.

During our investigation we took independent medical advice from a GP. The adviser considered it was reasonable Ms C was told to allow more time for the antibiotics her own GP had given her to work. The adviser did not consider the care provided to be inadequate. We therefore did not uphold Ms C's complaints about the care she received.

As we considered there were some errors in the board's complaints handling, we upheld this aspect of Ms C's complaint. The board acknowledged that they were not always efficient in responding to and progressing Ms C's wider concerns and said that they were in the process of making improvements to their complaints handling practices.

Recommendations

We recommended that the board:

• apologise to Ms C for the errors made in the handling of her complaints.

Summary

Ms C complained that the university failed to follow the correct procedures when assessing her exam. She was also unhappy that when she requested a copy of their standard operating procedure (SOP) for the assessment of the exam they provided the incorrect document. She also complained that they failed to consider her appeal in line with their appeals process.

We found that the university should have provided the SOP when this was requested. We also noted that they failed to arrange an appeal hearing within the timescale required by their appeals process. As a result, we upheld these elements of the complaint.

We did not find failings in the way Ms C's exam was assessed and did not uphold this element of her complaint. We did accept that the SOP was open to interpretation and we suggested to the university that they give consideration to reviewing this document to provide greater clarity.

Recommendations

We recommended that the university:

• write to Ms C to apologise for the initial failure to provide her with the correct documentation she requested;
• ensure that staff know how to respond to a freedom of information request; and
• write to Ms C to apologise for the delay in arranging the panel hearing.

Summary

Mr C complained on behalf of his daughter (Miss A), a student at the university. Mr C's complaints were about the university's handling of the Fitness to Practise (FtP) process in relation to Miss A, and the university's handling of his complaint.

We found that, in general terms, the FtP regulations were followed by the university. However, we had to consider whether the university's handling of this matter was reasonable. We had specific concerns about the introduction of new evidence at an investigatory meeting and an apparent lack of contemporaneous documentary evidence in relation to concerns about Miss A's fitness to practise. We also had concerns about Miss A and her student adviser not being given a copy of the investigatory meeting notes to check for accuracy and an apparent failure to provide an FtP panel hearing with information from Mr C.

Given these concerns, we concluded that the university's handling of the FtP process in relation to Miss A was unreasonable and, therefore, we upheld Mr C's complaint.

We had some minor concerns about the university's handling of Mr C's complaint, in particular that the university did not provide us with a complaint file of all evidence considered in respect of the complaint. Nevertheless, the university's written response to Mr C dealt with each of the points he made. Having considered the complaint correspondence between Mr C and the university, overall we regarded the response Mr C received was reasonable in the circumstances, as it sought to outline the facts relevant to the points made in his complaint and to provide a proportionate response giving the university's definitive position. We did not see evidence to conclude that the university's handling of Mr C's complaint was unreasonable and therefore we did not uphold this aspect of Mr C's complaint.

Recommendations

We recommended that the university:

• ensure that the nature of all alleged causes for concern are notified to students before an investigatory meeting takes place as part of the FtP process;
• ensure that the FtP file includes copies of evidence relevant to all alleged causes for concern, such as contemporaneous documentary evidence from placement records;
• ensure that, where alleged causes for concern are based on anecdotal evidence, the anecdotal evidence is tested, for example by obtaining corroborating documentary evidence or by interviewing relevant people;
• ensure that all evidence considered by an investigating officer and submitted by a student is forwarded to FtP panel hearings;
• consider revising the FtP regulations to allow a student, and the person supporting or representing them, an opportunity to review the content of investigatory meeting notes for accuracy; and
• ensure they keep a copy of all evidence considered in respect of complaints.

Summary

Mr C complained about the handling by the Scottish Prison Service (SPS) of his complaints about confidential matters. During our investigation we found no evidence of fault in the SPS's handling of Mr C's complaints and we therefore did not uphold this complaint.

Mr C also complained that the SPS had failed to facilitate his contact with the police. In particular, that they had incorrectly advised him that he could contact the police directly. While we were satisfied that Mr C was advised that his legal team could contact the police on his behalf, we were concerned that he had been given inaccurate information about contacting the police directly. We were also concerned that he had not been advised that managers could contact the police on his behalf. We therefore upheld this aspect of Mr C's complaint.

Recommendations

We recommended that the SPS:

• apologise for incorrectly advising Mr C that he could contact the police directly.

Summary

Miss C complained that the council failed to ensure that the school attended by her daughter (Miss A) had an anti-bullying policy in place. She also complained that the council had failed to take reasonable action in response to the bullying of Miss A at this school.

We upheld Miss C's complaint about the anti-bullying policy. Although the council's overarching policy was thorough, we found that the school did not have its own policy in place that sufficiently met the requirements of the council's policy.

We did not uphold Miss C's complaint about the council's action in relation to reports of Miss A's bullying. We found that overall the council had taken significant action in line with the requirements of their policy to address the concerns raised and we found this to be reasonable.

Recommendations

We recommended that the council:

• apologise to Miss C and Miss A for the failings identified in this case; and
• reflect on the failings identified and advise us of the actions they will take to address these.

Summary

A mutual boundary wall between Ms C's property and another property was the subject of a statutory repair notice issued by the council. The notice required the wall to be demolished and re-built.

No action was taken until two years later, when the council notified Ms C and other owners that they had 14 days to indicate whether they were undertaking the work to the wall before the council would do so. Ms C said that despite informing the council that she and the other owners would do so, the council did not adhere to the timeline and instead instructed their own contractor to carry out the work. The council said they were unable to trace any record of contact from Ms C about this. Given the conflicting evidence and the period of time that had elapsed, we were unable to conclude what had occurred and to conclude definitively when the work began. We also considered it was the responsibility of Ms C and the other owners to have ensured that the council knew that she and the other owners intended carrying out the work to the wall. Therefore we did not uphold this aspect of Ms C's complaint.

However, we considered that certain aspects of the council's administration of the notice in relation to the appointment of the contractor, how the share of the costs of the work had been apportioned and a delay in providing Ms C with a copy of the final account was unsatisfactory and had caused her to reasonably question the cost of the work charged to her. On balance we therefore upheld this aspect of Ms C's complaint and recommended that the council apologise to her. However, we were unable to conclude that the final account for the work was incorrect.

In reaching our decision, we took into account that an independent resolution complaints panel review had concluded that the invoiced account was correct and that owners had only been invoiced for the amounts they were liable for.

Ms C also complained that she had not received a satisfactory response from the council to her enquiries and concerns in relation to the notice. We found that there was a lack of evidence about what occurred prior to a certain point. However, we considered the action taken by the council thereafter, taking account of the available evidence, to have been reasonable and so we did not uphold this aspect of Ms C's complaint.

Recommendations

We recommended that the council:

• apologise to Ms C for the failings identified in the administration of the notice.

Summary

Miss C complained about the council's response to her concerns about statutory notices issued at her property. In particular, she complained that the council had failed to follow the relevant procedures.

During our investigation we found no evidence that the council had failed to follow the correct procedures. We were satisfied that owners had been notified of the statutory notices and subsequently that, as owners had failed to carry out the required work, the council had authorised the organisation of the work. We were satisfied that evidence available demonstrated that owners had been kept updated on progress of the works. We therefore did not uphold this aspect of Miss C's complaint.

Miss C also complained that the council had failed to handle her complaint reasonably. While we were satisfied that the council had responded to Miss C's representations, the council accepted that they had failed to deal with her complaint within the timescales detailed in their complaints process. We therefore upheld this complaint.

Recommendations

We recommended that the council:

• apologise to Miss C for the delay in dealing with her complaint.