Some upheld, recommendations

Summary

Mr C complained about the delay in the council responding to his complaint and that they failed to take reasonable action to address his concerns about anti-social behaviour.

The council took 11 months to respond to Mr C's complaint, and although they had apologised for the delay, we considered this delay to be unreasonable. We therefore upheld this aspect of Mr C's complaint.

The council said in their response to our enquiry that the complaint had not been recorded as a complaint. The council had partially upheld the original complaint but not explained why. We therefore made a recommendation in this regard.

We considered that the council had responded appropriately to Mr C's concerns about anti-social behaviour. We therefore did not uphold this aspect of Mr C's complaint.

Recommendations

We recommended that the council:

• explain to us the reason for their failure to record Mr C's complaint and to confirm what steps they have taken to ensure this does not happen again; and
• explain to us why the complaint was partially upheld.

Summary

Mr C complained regarding the council's handling of his reports of neighbour nuisance behaviour.

Mr C complained to the council about nuisance behaviour over a period of about a year. He said the council did not respond reasonably to his phone calls and emails, including to the council's helpline, and that they did not take reasonable action to address the behaviour. Mr C also said that the council did not respond reasonably to his complaint.

The council acknowledged that there were some issues with communication and complaints handling, and we therefore upheld these aspects of Mr C's complaint. However, they said they took reasonable action to address the nuisance behaviour.

Based on the information we received about the actions of the council and the circumstances of the case, we did not uphold Mr C's complaint that the council did not take reasonable action to address the nuisance behaviour.

Recommendations

We recommended that the council:

• feed back the findings of this investigation to the relevant staff; and
• provide an outline of the steps they will take to ensure messages via their helpline are handled better in the future.

Summary

Ms C, an advocacy and support worker, complained on behalf of Ms B. Ms B's concerns related to the medical and nursing care received by her mother (Mrs A) at Southern General Hospital. Mrs A had been diagnosed with lung cancer that had spread to her liver. She was admitted to hospital as she was suffering from pain, shortness of breath and confusion. A plan was made for Mrs A's transfer to a special cancer treatment centre but she suffered a fall and fractured her hip before this could take place. An incapacity certificate was completed and after assessment, surgery was carried out to Mrs A's hip, but her condition worsened. Mrs A was transferred to a hospice, where she died.

We took independent advice from a consultant in acute and respiratory medicine. We did not uphold Ms C's complaint about the standard of medical care. We found that the decision to proceed with surgery was reasonable in the circumstances of the case and that whilst pain had been poorly controlled for Mrs A, this was despite the best efforts of the team caring for her.

We also took independent nursing advice. The advice we received highlighted issues with the assessment of Mrs A's risk of falling. We found that Mrs A's cognitive difficulties and other factors had not been properly taken into account, resulting in an inadequate falls prevention care plan at the time of her fall. The advice we received also highlighted issues with the assessment of Mrs A's mobility. We therefore upheld this aspect of Ms C's complaint.

Recommendations

We recommended that the board:

• apologise for the failings identified in this investigation;
• ensure that all relevant issues, including documented cognitive difficulties, are properly accounted for during the falls risk-assessment process;
• ensure that mobility assessment documentation is appropriately completed and reviewed; and
• ensure that completed incapacity certificates are accompanied by a treatment plan when appropriate.

Summary

Ms C's mother (Mrs A), who was diabetic, injured her toe. Mrs A attended A&E at the Royal Alexandra Hospital a few days later. Mrs A's toe was found to be broken and there was evidence of infection. At that time, Mrs A was keen to avoid admission and she was sent home with antibiotics. After initial improvements in her condition, Mrs A had to re-attend at A&E and was admitted for around two weeks. During this admission, Mrs A became unwell and had to be resuscitated. On her discharge, Mrs A's injured toe was noted to be necrotic (where the cells or tissue are dead). Mrs A was readmitted to the hospital later that month after being seen at the diabetic foot clinic.

Ms C complained about the A&E care provided to Mrs A, the medical care and treatment provided to Mrs A while she was an in-patient, the nursing care, the standard of communication and the approach in the Coronary Care Unit (CCU) to visiting.

After taking independent advice from a consultant in emergency care, we upheld Ms C's complaint about the initial A&E attendance. We found that due to Mrs A's diabetes, a referral should have been made to a specialist foot team. Although the advice we received was that this did not affect the outcome for Mrs A, we considered this to be a failing. The board identified this during their own investigation and we considered that they had taken reasonable steps to address the issue.

In relation to Ms C's concerns about the standard of in-patient medical care and treatment, we took independent medical advice. The adviser found that Mrs A received optimal care and treatment. We therefore did not uphold this part of Ms C's complaint.

After taking independent nursing advice, we upheld Ms C's complaint about nursing. The advice we received was that there were failings in obtaining an appropriate mattress for Mrs A and that there had been some issues around wound dressings. The board had already apologised for this and for an occasion where fluids were administered more quickly than intended. The nursing adviser also noted that a fluid balance chart had not been properly completed. We made a recommendation to address this.

We found that the approach of some of the staff regarding Mrs A's family visiting her in the CCU was not reasonable. The board had identified failings in communication with Mrs A's family and apologised for these. We therefore upheld this aspect of Ms C's complaint.

Recommendations

We recommended that the board:

• ensure that fluid balance charts are appropriately completed for patients;
• make all relevant staff in the CCU aware of the nursing adviser's comments on visiting; and
• review the approach to visiting in the CCU in light of the nursing adviser's comments.

Summary

Miss C complained about the care and treatment received by her father (Mr A) during an admission to Queen Elizabeth University Hospital. Miss C said it took an unreasonable length time for Mr A to be reviewed by a doctor in the assessment unit, and that he was not treated for his urinary tract infection (UTI) for several days. Miss C was also concerned that Mr A's catheter became blocked on one occasion, and that it took several hours before this was changed. Miss C said that a doctor told her this had resulted in lasting kidney damage. Miss C also raised concerns that in their response to her complaint, the board gave an inaccurate account of what happened.

The board apologised that Mr A had waited so long to be reviewed, and for a lack of communication during the admission. However, the board said Mr A did not have a UTI on admission, but developed this a few days later (which was treated). The board also considered Mr A's blocked catheter was treated appropriately.

After taking independent medical and nursing advice, we upheld Miss C's complaints about medical care and communication. We found that there was no evidence Mr A had a UTI on admission, and that this was treated reasonably when it developed a few days later. We also found the blocked catheter was treated appropriately, and that there was no evidence that this had caused damage to Mr A's kidneys. However, we considered the delay in Mr A being reviewed was unreasonable, and we recommended the board provide more detail on how this is being addressed. We also found failings in communication, although we noted the board had already acknowledged and apologised for this, which we considered appropriate.

In relation to complaints handling, we found a factual inaccuracy in the board's response (describing the position of the blocked catheter). This appeared to be an error, and we did not consider the overall response to have been unreasonable.

Recommendations

We recommended that the board:

• provide evidence of the action being taken to reduce waiting times for patients in the assessment unit.

Summary

Miss C complained about the care and treatment her mother (Mrs A) received from the Victoria Infirmary when Mrs A attended A&E following a fall. Mrs A was found to have a fractured arm and was admitted to the orthopaedic ward. Four days later, Mrs A was noted to be suffering from hip and leg pain and was found to have a hip fracture that required surgery. Mrs A was transferred to the New Victoria Hospital for rehabilitation, but due to concerns about her condition, was transferred back.

Miss C complained about an excessive delay in transferring Mrs A from a trolley in A&E to a ward. She also complained about Mrs A's medical treatment and nursing care, and that communication with Mrs A's family was poor.

We took independent advice from an A&E consultant, an orthopaedic consultant, a consultant physician, and a nursing adviser. We found that there was an unreasonable delay in Mrs A being transferred from a trolley to the ward, which the board had accepted and apologised for. We also identified an unreasonable delay in Mrs A's hip fracture being diagnosed and that her transfer to the New Victoria Hospital for rehabilitation was unreasonable as there was a lack of evidence to show that she was fit for discharge. We therefore upheld these aspects of Miss C's complaint. However, we found that the nursing care in terms of assessing and monitoring food and fluid intake was reasonable.

Finally, we were critical that there was poor communication with Mrs A's family by both the A&E staff and orthopaedic team, for which the board had apologised. While Mrs A's consent form for the surgery indicated that she was not able to give informed consent, we found no evidence of communication with Mrs A's family in this regard.

Recommendations

We recommended that the board:

• provide information about the action taken to minimise waiting times for patients in A&E before they are admitted to a ward;
• ensure that the A&E doctor involved in Mrs A's care reflects on the adviser's findings at their next appraisal to ensure appropriate clinical assessment takes place;
• ensure that the medical staff responsible for Mrs A's transfer reflect on the adviser's findings regarding fully documenting the reasons supporting a patient's discharge or transfer;
• apologise to Miss C for the failings identified with regard to the diagnosis of Mrs A's hip fracture and the decision to transfer Mrs A;
• remind relevant staff involved in Mrs A's care in A&E and the orthopaedic ward of the importance of communicating effectively with family members and documenting in the clinical records when this has been done; and
• review their consent process for patients who are deemed to lack capacity to ensure where relevant that the views of relatives and carers are effectively taken into account.

Summary

Mrs C complained about the management of her husband (Mr A)'s cardiology care by staff at the Victoria Hospital. Mr A suffered a heart attack and later developed heart failure. Mrs C was also concerned about how staff had communicated with the family and the standard of the nursing care Mr A received. In addition, Mrs C felt that her complaint had not been dealt with appropriately.

As Mr A had a number of attendances at the emergency department, we took independent advice from a consultant in emergency care, a consultant cardiologist and a nursing adviser.

The advice we received was that the management of Mr A's cardiac problems was reasonable, although the cardiology adviser highlighted that the co-ordination of Mr A's care could have been better, an issue that the board themselves had identified during their consideration of Mrs C's complaint. We made recommendations to the board in this regard but did not uphold this part of Mrs C's complaint.

We upheld Mrs C's complaint about communication. We found that the board had already identified and apologised for some communication issues. The advice we received was that there was a lack of evidence that Mr A and his family had been provided with information about his initial signs of heart failure. We made recommendations to address the failings identified.

We upheld Mrs C's complaint about nursing care as we found that a number of failings in the care provided had already been identified. The nursing adviser was critical of an incident where there was failure to maintain Mr A's dignity. We made a number of recommendations in relation to this part of Mrs C's concerns.

Finally, we upheld Mrs C's concerns about the handling of her complaint by the board. The board acknowledged that they had not dealt with the complaint in line with their timescales and had not kept Mrs C updated. They advised that this had been addressed going forwards.

Recommendations

We recommended that the board:

• consider how this case could be used to promote learning on the importance of co-ordination of care;
• provide an update on the co-ordination of care since the time of this complaint;
• apologise for the failure to provide information on heart failure at the relevant time;
• take steps to ensure that appropriate information is provided to patients and their families about medical conditions and that this communication is clearly recorded in the notes;
• consider using this case for staff learning and development to highlight the importance of maintaining patient dignity;
• ensure that staff involved in the failure to maintain patient dignity reflect on this complaint at appraisal;
• provide evidence that action has been taken to address the issues identified during their investigation of the complaints raised in this case; and
• provide supporting evidence that steps have been taken to prevent future communication and complaints handling failings.

Summary

Mrs C complained about the care and treatment received by her husband (Mr A) at Ayr Hospital for a rare type of bladder cancer. Specifically, Mrs C was dissatisfied with surgery performed, the communication with her and Mr A, and the board's response to her complaint.

We took independent advice from a consultant urological surgeon and a consultant radiologist. We found that the surgical treatment and follow-up review were both of a reasonable standard. Whilst we did not uphold the complaint about Mr A's treatment, we identified unreasonable failings in the reporting of a scan which had shown Mr A's cancer had worsened. We found that even had the scan had been reported accurately, it would not have changed Mr A's treatment or outcome. However, Mrs C and Mr A would have known about this much sooner. We also noted that although there was no specific indication for it at the time, it would have been preferable for Mr A's particular case to have been reviewed by the urology multi-disciplinary team and we made a recommendation in relation to this.

In addition, we were critical that the board had not identified the error in the reporting of the scan after Mrs C complained about the matter.

We also considered that the communication with Mr A and Mrs C fell below a reasonable standard.

Recommendations

We recommended that the board:

• apologise to Mrs C for the inaccurate reporting of the scan;
• reflect on the reporting of the scan and take steps to identify learning and improvement;
• consider routine review by the multi-disciplinary team of follow-up imaging for those patients with bladder cancer at high risk of recurrence;
• share these findings with the staff involved in Mr A's care; and
• share these findings with the staff involved in the investigation of the complaint for shared learning.

Summary

Mr C complained that the university unreasonably failed to make him aware of an examiners' rule and that the university's consideration of his academic appeals was unreasonable.

The university acknowledged that the examiners' rule was not included in the course handbook for that academic year. Because of this failure on the university's part, which they corrected for the following year, Mr C was unable to make an informed choice about whether or not to submit a claim for mitigating circumstances. We therefore upheld this aspect of Mr C's complaint.

In relation to Mr C's appeals, we found no evidence that the university failed to follow the relevant process and we therefore did not uphold this aspect of Mr C's complaint.

Recommendations

We recommended that the university:

• provide us with evidence that they have taken steps to ensure students are notified of the examiners' rule in future.

Summary

Mr C complained that administrative errors when marking his Advanced Higher exam papers had resulted in him narrowly missing out on achieving an A grade. The Scottish Qualifications Authority (SQA) accepted that the wrong information was placed on their website in relation to the marking instructions for a particular question. However, we did not find evidence that Mr C's exam script had been assessed with these incorrect marking instructions or that he had been disadvantaged by this error. In relation to the marking of another question, it appeared that the original mark given had been amended to a lower mark. By law we cannot investigate matters of academic judgement and therefore we could not investigate why the mark was given, as it related to the academic judgement of the marker concerned. However, we were satisfied that the final mark given for this question was as stated on the exam paper.

Mr C also questioned why the same marker had both marked and reviewed his exam papers. We considered that the SQA in a communication with Mr C had given him an expectation that his scripts would be reviewed by a different individual. However, we also considered it was a matter for the SQA to decide how they operated the marking and review of examinations. We did not find evidence that the SQA's assessment processes were not followed in Mr C's case or that it was unreasonable for the same marker to have marked and reviewed Mr C's exam papers. Therefore, we did not uphold Mr C's complaints about these matters.

Mr C also complained that the SQA failed to follow their complaints handling procedures and, instead, treated his complaint correspondence as enquiries and feedback. The SQA accepted they failed to treat Mr C's concerns as a complaint and apply their complaints procedure including a referral to this office. We considered the SQA's complaints handing was poor and upheld this aspect of Mr C's complaint.

Recommendations

We recommended that SQA:

• apologise to Mr C for the failings identified in relation to complaints handling;
• ensure that appropriate training in complaints handling is being undertaken by relevant staff and that the failings in complaints handling identified during this investigation have been shared with relevant staff, and provide this office with evidence of this; and
• issue Mr C with a formal apology for the expectation given to him in relation to the reviewing of examinations.