Some upheld, recommendations

Summary

Ms C complained about the care and treatment provided to her father (Mr A) following two admissions to Glasgow Royal infirmary. Mr A, who resided in a nursing home, had vascular dementia and visual impairment. Ms C also complained about the time taken by the board to investigate and respond to her complaint.

During our investigation, we obtained independent medical and nursing advice.

Mr A was admitted to hospital after sustaining a fractured hip in a fall. He had surgery the following day and was discharged back to his nursing home several days later. The board accepted there were failings in Mr A's nursing care which had resulted in a failure to identify the infection(s) which Mr A was developing and had led to his premature discharge. The advice we received was that Mr A's surgical treatment was reasonable and he was not able to undertake rehabilitation due to his mental state.

However, we identified a number of failings in Mr A's medical care, nursing care, and in communication with his family. These included failure by staff to ensure they had the relevant information to make an informed decision about Mr A's discharge, as well as failures in record-keeping and nutritional care. We also found that during the assessment, planning and delivery of Mr A's care, there was a failure to fully comply with the Adults With Incapacity Act and the Standards of Care for Dementia in Scotland. We therefore upheld this aspect of Ms C's complaint. The board had apologised for the failings in communication during this admission and said they had introduced a new relatives communication sheet, in relation to which the nursing adviser said there were advantages and disadvantages.

Mr A was readmitted to hospital the following day. While Ms C considered the quality of care Mr A received was generally satisfactory and often good, she was critical of certain aspects of his care and about his subsequent transfer to Lightburn Hospital.

We did not find evidence that the medical treatment Mr A received during this admission was of an unreasonable standard and so did not uphold this aspect of Ms C's complaint. Although we considered that aspects of Mr A's nursing care were carried out to a reasonable standard, we found staff failed to ensure that it was appropriately person-centred. We found failures in complying with the Adults with Incapacity Act and the Standards of Care for Dementia in Scotland and also in the communication with Mr A's family. We therefore upheld Ms C's complaint in this regard.

The board also accepted that the time taken to investigate and respond to Ms C's complaint was unreasonable, and so we upheld this aspect of Ms C's complaint. We considered that the board had provided Ms C with an appropriate apology for this and taken steps to address what had occurred.

Recommendations

We recommended that the board:

• apologise to Ms C for the failings in Mr A's care and treatment;
• feed back the comments of the advisers and the findings of this complaint to the staff involved for reflection and learning;
• report to us on the steps taken to address the failings identified by this investigation in relation to complying with the Standards of Care for Dementia in Scotland, both in relation to patient care and treatment and in communication with relatives/carers;
• feed back to relevant staff the comments of the nursing adviser concerning the use of a relatives communication sheet;
• report to us on the steps taken to address the failings identified by this investigation in relation to complying with the Adults With Incapacity Act (2000), with particular regard to capacity to consent to treatment;
• carry out an audit of early readmissions following discharge from the ward concerned so as to identify any further avoidable failures; and
• provide evidence that the issues identified in relation to complaints handling have been fed back to their complaints lead and shared with complaints staff.

Summary

Mr C complained about the board's management of healthcare appointments for his child, who suffers from allergies and diabetes. In particular, Mr C was concerned that the board cancelled an out-of-area appointment for a joint allergy and gastroenterology clinic, on the basis that equivalent local services were available. However, the board did not provide a gastroenterology appointment until about six months later.

The board acknowledged that some of the appointments were outwith the

12-week waiting time target for new out-patient appointments, including a clinical genetics appointment (delayed due to a missed referral), an allergy appointment (provided out-of-area as the child's GP had requested this), and a gastroenterology appointment (which took longer to arrange as it was a joint appointment with gastroenterology and the head of the local allergy service, and was further delayed by a consultant gastroenterologist leaving the board).

After taking independent medical advice, we found that it was reasonable for the board to take the position that an out-of-area referral for allergy and gastroenterology was not required, as there were equivalent services available within Scotland. We found that the delay in the clinical genetics appointment was unreasonable, and while the board had already acknowledged this and addressed the problem, we considered they should also apologise to Mr C. However, we were not critical of the timeframes for the gastroenterology and allergy appointments. While we acknowledged these were outwith the 12-week target, we noted that the target is for 95 percent of cases to meet these timeframes, and in this case we considered the timeframes were reasonable in view of the specific circumstances.

Mr C also said the board gave inaccurate information in their complaint response about what kind of support it was agreed at a clinical meeting the health visitor should provide. We found there were conflicting accounts about exactly what was said at the meeting, but the board's description of this was consistent with the health visitor's role and in keeping with the support actually provided, and we therefore did not uphold this aspect of Mr C's complaint.

Recommendations

We recommended that the board:

• apologise to Mr C for failing to meet the waiting time target for his child's clinical genetics appointment.

Summary

Ms C, a council tenant, complained about the time it took the council to deal with a problem she was having with pigeons on her balcony. Although we found the council's communication could have been better, we were satisfied that the works, which had been assessed as non-emergency, were carried out within a reasonable timescale. We therefore did no uphold this aspect of Ms C's complaint.

Ms C also told us there was a delay in progressing a claim she made for compensation. This delay had already been acknowledged by the council. Ms C also said that the council did not respond reasonably to points of complaint she raised by email. We found that there were shortcomings in the council's response and that some issues were not addressed either at all or as fully as possible. We therefore upheld these aspects of Ms C's complaint.

Recommendations

We recommended that the council:

• apologise for the unnecessary delay in progressing Ms C's claim for compensation.

Summary

Mrs C raised a number of concerns relating to the planning situation at an adjoining farm. In particular, she complained that the council had failed to ensure all planning conditions attached to planning consent for the erection of four houses were enforceable. She also complained that the council failed to follow planning procedures in relation to a planning application for a replacement shed on land owned by the farm and that incorrect information was contained in the officer's report for another planning application for the same site.

We took independent advice from a planning adviser, whose advice that the planning condition did not meet the standards of precision and reasonableness we accepted. We upheld this part of Mrs C's complaint and recommended that a full and unreserved apology be issued to Mrs C.

We also found that while the officer's report lacked detail, there was no evidence that the council had failed to follow planning procedure, and we did not uphold this part of Mrs C's complaint. The council also accepted that the officer's report had contained some drafting errors, and while we were mindful that a site visit had been carried out during which the planning officer would have seen the actual position when assessing the planning application, we found that the errors should have been corrected prior to determination of the planning application. We upheld this part of Mrs C's complaint.

Recommendations

We recommended that the council:

• feed back our findings to staff responsible for drafting or approving planning conditions, as a learning tool; and
• demonstrate how quality checking is being used to improve the accuracy and quality of planning reports (both in relation to the accuracy of calculations, and to ensuring reports are sufficiently detailed to explain and support the planning decision).

Summary

Mr C complained about a property he rented from the council and about their handling of his complaint.

Two days after signing his tenancy agreement, Mr C reported that the heating was not working. He also raised a number of additional concerns about the property including problems with a fuse box, windows and insulation, and about how the council conducted repairs.

Based on the evidence available, we found the council acted in accordance with their allocation policy when letting the property. The council provided evidence that the heating system had been in working order after installation. The council also provided a property survey report evidencing that they conducted a reasonable assessment of the property. We also found that the council acted in accordance with their repairs policy in relation to the property. The council's records indicated that repairs were attended to within the council's time-frames. We therefore did not uphold this aspect of Mr C's complaint.

However, we found that the council did not respond to Mr C's complaints within a reasonable time-frame. In particular, we considered the council should have recognised his complaint at an early stage and provided a response accordingly. We therefore upheld this aspect of Mr C's complaint.

Recommendations

We recommended that the council:

• apologise for the failings identified in the report regarding complaints handling; and
• feed back the findings of this investigation to the relevant staff.

Summary

Mrs C complained about the length of time it took the council to inspect and make safe a damaged wall in the cul-de-sac where she lived, as she was concerned about the health and safety of children who play there. She was also unhappy with the council's communication concerning the planned works on the wall, and their handling of the complaint that she raised with them.

We found that the timescale for inspection of the wall was at the discretion of the council. We therefore did not uphold this aspect of Mrs C's complaint.

However, we found a number of failings by the council with regard to their communication and the handling of Mrs C's complaint. We found that there was a delay in the council responding to Mrs C's complaint. The council did not inform Mrs C that they had undertaken an inspection visit or that their decision that the damaged wall did not constitute a hazard for the public. We found that they did not provide regular updates and that when Mrs C did receive information, it was often confusing and contradictory. We therefore upheld these aspects of Mrs C's complaint.

The council apologised for some of these failings and have since repaired the wall.

Mrs C also raised concerns about a faulty fence and we made a recommendation relating to this.

Recommendations

We recommended that the council:

• apologise to Mrs C for the failings identified in this case;
• reflect on the failings identified during this investigation and advise this office of the steps they will take to improve their communication in similar circumstances in the future; and
• advise this office when the planned works on the fence have been completed

Summary

Ms C complained about the housing association's handling of her concerns about her neighbour's dog. Ms C said there was excessive noise from her neighbour's dog and remained dissatisfied with the action taken to date by the association to resolve the situation. Ms C was also unhappy with the association's handling of her complaint.

The association provided evidence of the action taken to try to resolve the situation, which included discussions with a number of agencies. These discussions were ongoing in an effort to try to resolve the situation. We were satisfied that, based on the evidence provided, the association had taken action in line with the relevant policy. We did, however, identify faults in the handling of the complaint under their process.

Recommendations

We recommended that the association:

• ensure a further assessment has been undertaken and independent evidence of the situation is obtained, and provide evidence of this to this office and Ms C; and
• remind staff of the need to follow the complaints procedure, in particular, in relation to an extension to the timeline and a referral to this office.

Summary

Mr C complained to us about the care and treatment provided to his wife (Mrs A) by the medical practice. He complained that the practice failed to provide Mrs A with appropriate treatment when she presented with lower back pain, and that they failed to appropriately examine her at her consultations. Mr C felt that the back pain was a symptom of the cancer Mrs A was later found to have and which led to her death. Mr C further complained that Mrs A had been provided with inappropriate inhalers for a number of years.

In investigating this complaint, we took independent advice from a GP adviser. We found that whilst Mrs A had presented with lower back pain for a number of months, there were no symptoms at that time which would have alerted her GP to the possibility of her having cancer. When Mrs A reported new symptoms, these were found to be due to abdominal cancer. We found that the management of Mrs A's original symptoms, which was primarily with painkillers, was reasonable. We also found that Mrs A was reasonably examined by GPs at the practice based on her reported symptoms. We therefore did not uphold this aspect of Mr C's complaint.

With regard to the inhalers Mrs A had been prescribed, we found that as Mrs A had never been formally diagnosed with an illness that would require regular use of inhalers, it was not reasonable that she had been prescribed these on a long-term basis. Whilst we did not find there to have been adverse effects as a result of this failing, we upheld Mr C's complaint. The practice acknowledged that the monitoring of Mrs A's inhaler use could have been better and told us they had undertaken a review of their system regarding this.

Recommendations

We recommended that the practice:

• apologise for the failings identified in this investigation;
• draw the comments of the adviser regarding prescription of inhalers to the attention of the relevant staff; and
• update this office on the action taken following the practice's review of their systems for recalling patients who are on regular inhalers.

Summary

Mrs C complained to us about the care and treatment provided to her late father (Mr A) in Western General Hospital and St John's Hospital.

We took independent advice from a consultant physician and a nurse. Though we found Mr A's medical treatment reasonable, we identified a number of other concerns. In particular, we found that communication of Mr A's prognosis was not carried out reasonably with Mr A or his family. We also had concerns about the adequacy of record-keeping by nursing staff in relation to Mr A's stay in St John's Hospital. We were also concerned that no arrangements had been put in place for a member of Mr A's family to travel with him in the ambulance when he was transferred from St John's Hospital to hospice care.

Recommendations

We recommended that the board:

• apologise for the failure to properly communicate with Mr A and his family with regards to his prognosis and who his consultant was;
• take steps to ensure communication between staff and families is properly documented;
• ensure that relevant staff are made aware of our comments in relation to communication of prognosis;
• take steps to ensure complete daily nursing records are properly kept at all times;
• apologise for the failure to properly document nursing care provided to Mr A; and
• consider putting in place specific guidelines for allowing family members to travel alongside patients in ambulances.

Summary

Mrs C's father (Mr A) was treated with radiotherapy for cancer of the tongue. Following his treatment, Mr A was cared for in the community with regular reviews at a joint cancer clinic and input from dieticians in another health board. He also received speech and language therapy (SALT) as part of the cancer clinic for about six months, and was then referred back to the other board for ongoing SALT care.

In the 18 months following his treatment, Mr A had increasing difficulty swallowing and suffered from recurrent mouth ulcers and pain. He also had several short hospital admissions with bleeding from the mouth. He was subsequently admitted to hospital (in another health board) in June 2014 with weight loss, decreased ability to swallow and stridor (noisy breathing caused by a narrowed or obstructed airway). He underwent endo-tracheal intubation (insertion of a tube to maintain an open airway to the lungs) and was transferred to St John's Hospital (for intensive care and ear, nose and throat (ENT) investigations), and then to the Royal Infirmary of Edinburgh (for gastrointestinal investigations). Mr A suffered a major haemorrhage (bleeding) from the throat and died in hospital.

Mrs C complained about Mr A's care during this period, and raised concerns that clinicians failed to adequately respond to Mr A's mouth pain, malnutrition and weight loss, as well as infections in his mouth. Mrs C also raised concerns about care and communication during the hospital admissions in June 2014.

After taking independent advice from an oncologist, a consultant in general medicine, an ENT surgeon and a SALT therapist, we upheld three of Mrs C's four complaints. We found that, although Mr A had regular reviews and involvement of appropriate clinicians in his care, there was a lack of integration and cohesion in the team's approach, which meant that Mr A's symptoms were not adequately addressed. We also found failings in relation to communication during Mr A's final admissions, although we found that the medical care during these admissions was reasonable.

Recommendations

We recommended that the board:

• feed back our findings to the staff involved for reflection and learning;
• use Mr A's experience as a learning tool to promote patient-centred care and provide us with evidence of this;
• review their processes for ensuring joined-up post-treatment care for patients with head and neck cancer;
• apologise to Mrs C and her family for the failings identified in our investigation;
• feed back our findings on communication to the nursing and medical staff involved for reflection and learning; and
• demonstrate that the incident of the missing Royal Infirmary of Edinburgh records has been investigated and reported, and provide details of any resulting action.