Some upheld, recommendations

Summary

Mr C objected to a planning application that was subsequently granted. Mr C had raised various concerns with the council and was unhappy with the council's handling of these concerns, including in relation to insulation boards and solar panels. In particular, he felt that the council had failed to properly assess non-material variation (NMV) requests; that they had failed to properly identify and address concerns about deviations from the approved plan and potential breach of planning conditions; that they had failed to correctly implement their NMV guidelines; that they had not properly fed back the outcome of his complaint to relevant staff; and that they had not posted the NMV details online, which they said they would do.

We sought independent planning advice. We noted that the council had already acknowledged and upheld some of Mr C's complaints. We upheld Mr C's complaints about the assessment of the NMVs. We also upheld Mr C's complaint in relation to the council having failed to properly identify and address appropriately concerns about deviations from the approved plan. The adviser felt that the NMV guidelines had unreasonably raised Mr C's expectations.

We noted that some of Mr C's concerns about development had not been considered and responded to by the council. We also found that the council had failed to feed back the outcome of the complaint to the relevant officers and that the NMV information had not been posted online. However, we were satisfied that the council had apologised to Mr C for this and had taken action to prevent a similar situation occurring in future.

Recommendations

We recommended that the council:

• review the NMV guidelines to ensure that it is clear to members of the public that these are guidelines only and the council has discretion to depart from them;
• consider and respond to Mr C's concerns about the change of insulation boards and omission of solar panels;
• review the circumstances giving rise to Mr C's complaint that they failed to properly identify and address appropriately concerns about deviations from the approved plan and potential breach of planning conditions and provide evidence that they have taken action to prevent a similar situation occurring in the future; and
• when reviewing the NMV guidelines, consider whether these need to make clearer that some variations can be approved through a planning condition on the original planning permission.

Summary

Mr C complained that the housing association failed to respond appropriately to his reports of problems with his boiler and then also failed to make reasonable arrangements to address water damage caused to his laminate flooring from a leak from his heating system. He was also unhappy with the way the association then dealt with his subsequent complaint.

We found that the association properly categorised Mr C's repair requests and attended within the required timeframe. We noted that any damage to Mr C's flooring was something he should raise with his insurer but that, in this case, Mr C was offered a small goodwill payment by the association's contractor, in relation to which we have made a recommendation. We were satisfied that the association acted in accordance with their procedures and we did not uphold these aspects of Mr C's complaint.

However, we did uphold Mr C's complaint about the way the association dealt with his subsequent complaint. This is because they failed to contact Mr C at an early stage to discuss his concerns with him, and also failed to provide him with a reasonable explanation for their decision.

Recommendations

We recommended that the association:

• apologise to Mr C for failing to provide a full and detailed response to his complaint; and
• contact their contractor and ask them to reaffirm their offer of a goodwill payment.

Summary

Miss C's father (Mr A) attended his medical practice with urinary problems. Tests and investigations indicated prostate cancer had spread to his bones and Mr A was admitted to Ninewells Hospital. His condition deteriorated significantly due to sepsis (a life-threatening bacterial infection of the blood) and he died two days later. Miss C complained about clinical failings in relation to investigations and treatment decisions by nursing and medical staff, including that Mr A's deteriorating condition was not recognised within a reasonable timeframe.

We took independent advice from a nursing adviser, a specialist in urology and a specialist in nephrology (the study of the kidney). In relation to the standard of nursing care provided, including communication, we found that in the main this was reasonable. We therefore did not uphold this aspect of Miss C's complaint.

With regard to the medical care and treatment provided, we found that medical staff had unreasonably failed to recognise Mr A had been suffering from sepsis and that there had been an unacceptable delay in administering antibiotics. We were also critical that medical staff failed to investigate fully Mr A's kidney injury. We therefore upheld this aspect of Miss C's complaint. However, due to Mr A's limited life expectancy as a result of his cancer, we could not say what the outcome would have been had Mr A had been investigated in a reasonable manner and treated with antibiotics earlier. However, the failings identified meant that it was possible that an opportunity to extend Mr A's life had been missed.

Miss C also complained that the board failed to respond to her complaint within a reasonable timeframe. The board acknowledged this and apologised to Miss C. We therefore upheld this aspect of Miss C's complaint.

Recommendations

We recommended that the board:

• take action to ensure the failings in aftercare and support are addressed to ensure no recurrence;
• provide us with an action plan to address the failings highlighted in this investigation and ensure no recurrence; and
• apologise for the failings identified during this investigation.

Summary

Ms C, an advocacy and support worker, complained on behalf of Ms A about the care and treatment given to Ms A after she was diagnosed with breast cancer.

Ms A was treated with surgery followed by chemotherapy and radiotherapy at the Western General Hospital, from which she appeared to be recovering well. However, part way through her course of chemotherapy, Ms A was not given a review appointment to establish how she was progressing, as per a local protocol. Ms A maintained that she had been 'lost to the system' and received inadequate care. Ms C also said that the board failed to respond reasonably to Ms A's complaint.

We took independent advice from a consultant oncologist. We found that Mrs A's treatment had been given in terms of national guidelines and had been reasonable and appropriate. While it had been intended to review her part way through her chemotherapy, Ms A was seen a few weeks later and her treatment continued. We did not uphold this aspect of Ms C's complaint.

However, we noted that the board failed to deal with Ms A's concerns about her treatment in a timely manner and we therefore upheld this aspect of Ms C's complaint.

Recommendations

We recommended that the board:

• remind the staff involved in this case of the necessity of adhering to their stated complaints procedure.

Summary

Ms C was referred to the sleep clinic at the Royal Infirmary of Edinburgh. She attended on a number of occasions over the following four years but her symptoms did not improve. She said that a consultant physician contacted her clinical psychologist but provided inaccurate and misleading information which detrimentally affected her future treatment. Ms C also complained about the way the board responded to her complaint.

We took independent advice from a consultant respiratory and general physician. We found that while Ms C's consultant physician provided her professional opinion to other health professionals, she did not provide incorrect or misleading information. We therefore did not uphold this aspect of Ms C's complaint. We noted, however, that the information could have been written more sympathetically and that the board had already spoken to the consultant physician about this. We also found that after Ms C complained, the board took too long to reply to her and their letter provided little explanation. We therefore upheld this aspect of Ms C's complaint.

Recommendations

We recommended that the board:

• emphasise to staff the necessity of providing reasoned responses to complaints made; and
• emphasise to staff the necessity of replying to complaints within the time-frames specified.

Summary

Mrs C complained about the care and treatment given to her father (Mr A) on four occasions he attended A&E at Wishaw General Hospital. She further complained that the board failed to deal with her subsequent complaint in a reasonable and timely way. The board took the view that Mr A had been treated appropriately and that they had dealt quickly and reasonably with the complaint.

We took independent advice from a nurse and from a consultant in emergency medicine. Mr A first attended A&E on three occasions over the course of a month. We found that Mr A had largely been treated appropriately but that when he unexpectedly attended on the second occasion, his case should have been discussed with a consultant and he should have undergone a scan.

On his fourth attendance around a month later, we found that while there were delays in treating Mr A, these were unavoidable as the A&E department was at full capacity. However, we found shortcomings in his triage and that he was not reviewed by the intensive care team. We found this to have been unreasonable as Mr A's diagnosis was unclear and he was seriously deteriorating. Mr A died the day after this admission. We upheld these aspects of Mrs C's complaint.

Although Mrs C also complained about the way her complaint to the board was dealt with, we found that it had been considered in a timely and appropriate way. Staff also met with her family on four occasions. We therefore did not uphold this aspect of Mrs C's complaint.

Recommendations

We recommended that the board:

• make a formal apology for the shortcomings identified;
• ensure that staff are made aware of the findings of this investigation so that they may consider these further with a view to preventing similar occurences;
• make a formal apology referencing the identified failures in dealing with Mr A's care and treatment;
• advise us of the action taken and confirm that this would prevent a similar occurrence; and
• carry out an internal review of this case which should be presented and discussed at a morbidity and mortality meeting with peer review.

Summary

Ms C, a GP, complained on behalf of her patient (Mrs B) about the care and treatment received by Mrs B's husband (Mr A) whilst he was in Queen Elizabeth University Hospital. Ms C complained that the board did not provide Mr A with a reasonable standard of medical treatment, that they did not provide a reasonable standard of nursing care, and that the board failed to communicate with Mr A's family about his condition and prognosis and provide a palliative care plan.

We took independent advice from a consultant physician and a nursing adviser. We found that whilst many aspects of Mr A's medical treatment had been reasonable, the palliative care team should have been involved in his care earlier, and that there was a lack of discharge planning. We upheld this aspect of Ms C's complaint.

We found that the nursing care provided to Mr A was of a reasonable standard and did not uphold this aspect of Ms C's complaint. However, in relation to the communication of Mr A's prognosis and condition, we found that the board did not check to ensure that Mr A's family understood his prognosis, and that a DNACPR form (do not attempt resuscitation form) and DS1500 form (an end of life benefits form) should have been completed as this may have helped the family have a better understanding of Mr A's condition. The board had accepted that the standard of communication with Mr A's family was not reasonable. We upheld this aspect of Ms C's complaint.

Recommendations

We recommended that the board:

• report to us on the action taken to review discharge planning;
• take action to ensure that, in similar cases, the palliative care team are involved at the appropriate time; and
• feed back to staff the adviser's comments in relation to completion of a DNACPR form and DS1500 form.

Summary

Mr C complained on behalf of his constituent (Mr A) about cataract surgery he had undergone in 2014. During cataract surgery on his right eye, Mr A sustained a small corneal abrasion (a scratch on the clear, front part of the eye). He was not told of this at the time of the operation. Following the operation, Mr A suffered from discomfort in his eyes and further deteriorating vision. At an appointment with an ophthalmologist more than a year after the cataract surgery, he was told about the small corneal abrasion he had sustained but was reassured that this was not the cause of his ongoing issues. Mr A complained to the board as he believed his problems with his vision were due to the corneal abrasion sustained at the cataract surgery and that he should have been told of the injury at the time of it happening.

In our investigation we took independent advice from an ophthalmologist. We found that the corneal abrasion sustained to Mr A's right eye during cataract surgery would most likely have healed up within 48 hours. We considered the cataract surgery to have been performed to a reasonable standard. However, we found that Mr A should have been informed of the corneal abrasion at or near the time of surgery. We therefore recommended that the board apologise to Mr A and draw our comments to the attention of the surgeon who performed the cataract surgery.

Recommendations

We recommended that the board:

• apologise for the failure to advise Mr A of the corneal abrasion; and
• draw the comments of the adviser to the attention of the surgeon responsible for Mr A's cataract surgery.

Summary

Mr C complained on behalf of his constituent (Mrs B). Mrs B was concerned about the care her mother (Mrs A) received from her medical practice.

Mrs A was receiving palliative care in the home from Mrs B and the district nursing service. Mrs B was concerned that the GPs at the practice did not undertake home visits to provide medical and emotional palliative care support for her and her mother. In particular, Mrs B felt that a GP should have visited in the days prior to her mother's death. We took independent advice from a GP adviser. The adviser was satisfied that the GPs visited Mrs A on a reasonable number of occasions. Similarly, they did not find evidence that the GPs unreasonably failed to visit in the days before Mrs A's death and noted that the medical records did not indicate that an urgent home visit was clinically required at this time. Furthermore, the adviser did not consider that the practice had unreasonably failed to provide a reasonable level of support and guidance to Mrs B. We therefore did not uphold this aspect of Mr C's complaint.

Mrs B also expressed concern that the practice had not responded to her complaint in a compassionate manner. We found that the practice had not followed their own complaints procedure in this instance in that they had not adopted as conciliatory and sympathetic a tone as possible when responding to the complaint. We further considered that the practice had failed to respond to the complaint in a person-centred way as required by the Scottish Government's 'Can I help you?' guidance for handling healthcare complaints. For these reasons, we upheld this aspect of Mr C's complaint.

Recommendations

We recommended that the practice:

• apologise for failing to respond reasonably to Mrs B's complaint; and
• feed back the findings of this investigation to staff in the practice responsible for responding to complaints.

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.