Some upheld, recommendations

Summary

Miss C, an advocacy and support worker, complained on behalf of Mr A about the care and treatment he received at Dumfries and Galloway Royal Infirmary for the surgical removal of haemorrhoids. Mr A developed a wound infection (a recognised complication of surgery) and he had to have a permanent colostomy. Miss C complained that Mr A had not been fully informed about the risks of the surgery, that his operation was not performed properly, and that care of his wound was poor.

We took independent advice from a general and colorectal surgeon. We found evidence to support that the surgery carried out was to a reasonable standard. However, Mr A reattended the hospital by ambulance with post-operation wound-related problems and we considered that the registrar doctor who reviewed Mr A at this point should have contacted the surgeon who had carried out the surgery or the consultant surgeon responsible for admissions that day. We therefore upheld this aspect of Miss C's complaint.

We also took independent advice from a nursing adviser and found evidence of appropriate care of Mr A's wound following surgery. We were critical that a full nursing assessment was not carried out at the time Mr A re-attended hospital. However, we did not consider this to have been a failing by the nurses, due to Mr A having been discharged.

We found insufficient evidence to show which risks and complications of surgery had been discussed with Mr A prior to him consenting to the operation. We were also critical that the consent form did not include all of the known risks and complications of the surgery. We therefore upheld this aspect of Miss C's complaint.

Recommendations

We recommended that the board:

• apologise to Mr A for the failings identified;
• demonstrate there is an effective process in place to ensure review takes place with the operating consultant or, if unavailable, the consultant surgeon with responsibility for acute surgical receiving when post-operative patients re-present to the emergency department;
• ensure the speciality doctor reflects on the findings of this investigation at their annual appraisal as part of shared learning and improvement;
• review their consent process to ensure that all risks and complications relevant to surgery are fully documented, that they have been discussed with the patient and that written patient information has been provided where relevant; and
• draw these findings to the attention of the consultant surgeon and the trainee doctor who completed the consent form.

Summary

Mr C complained about the process and timing for appointing the examining committee for his PhD oral examination (viva). We found that the university did not follow the correct administrative process for appointing one of the examiners. Although there was no evidence this had affected the examination, we upheld this aspect of Mr C's complaint. We also found there was a delay in appointing the committee, which led to one of the examiners becoming unavailable. This meant that Mr C's viva took place six months after he submitted his thesis, rather than six weeks.

Mr C also complained about the conduct of the viva and that he did not have time to properly defend part of his thesis (study three). After considering the evidence available, we found it was likely there was at least some discussion of study three at the viva and that the viva was reasonably detailed overall. We found that there was not sufficient evidence to conclude that the conduct of the viva was unreasonable, therefore we did not uphold this aspect of Mr C's complaint. However, we suggested the university might wish to introduce a requirement for notes to be taken at the viva, to ensure there is a record of the timing and topics discussed at future examinations.

Finally, Mr C complained that the university did not consult his supervisors during his initial appeal, or take into account the written statements they provided. We did not uphold this complaint as we found there was no requirement for the supervisors to be consulted, and it was reasonable for staff to rely on the written statements rather than seeking further comments from them. We also found that the supervisors' statements were included in the evidence considered at the initial appeal stage, although the appeals committee did not agree with the supervisors' arguments. However, we found the response to Mr C's appeal at the next stage (the senate appeal) contained some factual inaccuracies. We therefore made a recommendation to address this.

Recommendations

We recommended that the university:

• apologise to Mr C for failing to follow their procedures in approving the examining committee, and for the delay in identifying this error;
• put in place processes to ensure that the availability of a fully approved examining committee is checked promptly when a thesis is submitted, to avoid delays in identifying any problems; and
• review their response to Mr C's senate appeal in light of the inaccuracies identified, to ensure that the overall decision not to hear the appeal was appropriate.

Summary

Mr C suffered from a long-term illness of which he had made the university aware when he began his studies. After his final exams, Mr C made a request for the university to take into account special circumstances of illness when determining his grades (known as S-coding). Mr C complained to us that the university unreasonably rejected this request. He also complained that they did not communicate this outcome directly to him until five months after the decision was made.

Mr C appealed this decision, providing evidence that he was suffering from another illness alongside his long-term illness while taking exams. The university rejected this appeal on the grounds that Mr C should have made his additional illness known to them at the time of exams and Mr C complained to us about this. Mr C appealed this decision again, stating that the reason he had not disclosed his additional illness was because he did not want to discuss his long-term illness with staff. The appeal was again rejected and Mr C complained to us about this also. The university said they had carefully considered all aspects of Mr C's circumstances and found that there was no compelling evidence to suggest that Mr C's additional illness could not have been disclosed to them at the time of the exams.

During our investigation, we found that the university's policies on special circumstances affecting exams are clear, and that the university had followed these policies. We did consider that the university should have made their decision on the original request known to Mr C earlier. However, during the course of our investigation the university changed their policy to ensure students are notified of the outcomes of such decisions within ten working days of the decision being made.

We also found that the university had reasonably considered Mr C's reasons for not disclosing his additional illness at the time of his examinations and that they had reasonably considered the medical evidence he provided.

Recommendations

We recommended that the university:

• offer an apology for the unreasonable delay in communicating the outcome of Mr C's request for retroactive S-coding.

Summary

Mr C complained about Business Stream on behalf of the owner of the company he works for. Mr C complained that the company's property had experienced flooding a number of times and that Business Stream had failed to investigate. Mr C consequently felt that it was unreasonable that the company should pay for surface water drainage when he did not receive an effective drainage service. We found evidence that Business Stream had informed Scottish Water (who manage the drainage network) of the flooding, and we noted that Scottish Water had missed opportunities to investigate. We noted that the company received an effective drainage service for a large proportion of the time and we accordingly considered that it was reasonable for Business Stream to charge the company for surface water drainage. While we did not uphold the complaint, we considered that Business Stream and Scottish Water had failed to investigate the flooding issue in accordance with their policies. This meant that Scottish Water had not considered whether the company was eligible for a payment under their guaranteed service standards, or eligible for compensation for increased insurance premiums as a result of the flooding.

Mr C also complained that Business Stream failed to handle his complaint reasonably. Business Stream acknowledged that they had failed to call Mr C back on an occasion. We considered that Business Stream could have made enquiries to Scottish Water in relation to the complaint much earlier. We also found evidence that Business Stream delayed in issuing their written response to Mr C's complaint. We were critical that Business Stream did not provide an update to Mr C about the delay and we upheld this aspect of the complaint.

Recommendations

We recommended that Business Stream:

• take reasonable steps (along with Scottish Water) to investigate the flooding the company experienced with a view to considering payment(s) under service standard 7;
• consider (along with Scottish Water) any claim from the company in respect of increased insurance premiums as a result of the alleged flooding;
• issue a written apology for the failings identified in this investigation; and
• feed back the findings of this investigation to relevant staff with a view to ensuring that complaints are handled in accordance with the relevant procedures.

Summary

Mr C complained that Business Stream applied excessive water charges to his account as a result of his business suffering a water leak in a bathroom. He was concerned that they only provided a limited leak allowance and failed to address his concerns and refer him to the SPSO within a reasonable period of time.

We found that there had been failings in the way this case was dealt with and we noted that Mr C's original complaint was not identified as a complaint at the time and as a result, Business Stream delayed in providing him with details of the SPSO. We upheld these aspects of the complaint.

However, we were satisfied that the charges applied by Business Stream were reasonable, that they notified Mr C of the changes to his water usage promptly and that he was responsible for dealing with leaks within his premises. We also noted that Mr C did not qualify for a leak allowance. As a result, we did not uphold these aspects of the complaint.

Recommendations

We recommended that Business Stream:

• write to Mr C to apologise for the failings identified; and
• write to Mr C to apologise for failing to record his original contact as a complaint.

Summary

Mr C complained about the council regarding a statutory notice served for roof works affecting a property owned by him. He complained that he had not received a notice served notifying owners that the works would be executed. He also complained that the council had failed to provide a 20-year guarantee on materials and labour for works to a flat roof on the building which had been agreed before works commenced.

On investigation, the council provided copies of all notices served in connection with the works and we found no evidence that the council had failed to properly serve any notice. As such, we did not uphold this complaint.

However, it was clear from their correspondence with owners that a guarantee was agreed but never provided. We found that the council had failed to take reasonable steps to secure the guarantee from the contractor on completion of works. As such, we upheld this complaint. Following our enquiry the council were able to secure the guarantee from the contractor and provided copies of this to all affected owners.

Recommendations

We recommended that the council:

• apologise to Mr C for the failings identified.

Summary

Mr C complained that the council failed to resolve flooding in his house which appeared to be coming from a nearby culverted burn (a burn that is diverted through a pipe). Although the council undertook some investigations including a camera survey which found that the pipe did not follow the expected route, they were not able to survey the full length of the pipe due to an inaccessible manhole. They told Mr C they were not responsible for repairs as the problem appeared to be on private land.

Mr C disagreed and contacted his councillor. After a meeting with all parties the council agreed to undertake a dowser survey (a test used to detect the presence of water) to trace the route of the pipe. The survey was undertaken but the council did not contact Mr C after this or respond to his email asking about next steps.

After investigating these issues we upheld Mr C's complaint about communication. We found it was unreasonable that the council did not share the results of the dowser survey with Mr C or respond to his email about this. We also found the council did not give Mr C clear and consistent information about what he could expect from them as they told him the repairs were not their responsibility but also continued to indicate that future work was anticipated.

We did not uphold Mr C's complaint about the repairs as we found the council had taken reasonable steps to check that the repairs were not their responsibility.

Recommendations

We recommended that the council:

• apologise to Mr C for the failure in communication;
• remind relevant staff of the importance of documenting meetings, in particular agreed outcomes; and
• consider and address relevant staff training needs in relation to clear communication and managing expectations.

Summary

Mrs C complained about the council's handling of her complaint about a letter written to her husband which contained comments about her. In particular, she was concerned that the council had not contacted her during their investigation of her complaint. She also complained about a number of issues relating to the council's handling of a request to defer her son's entry to primary school. In particular, she was dissatisfied with the accuracy of the information provided and the handling of her complaint.

While we had some concerns about aspects of the council's handling of Mrs C's complaint to them, we were satisfied that the council had explained why they had written to Mrs C's husband. However, we did not consider that the council's position on not considering information during an investigation which was covertly obtained was reasonable. We were also satisfied that the council had provided a reasonable explanation for the information provided and saw no evidence of fault in the handling of Mrs C's complaint about this matter.

Recommendations

We recommended that the council:

• apologise for the handling of this complaint; and
• in view of the legal advice detailed in this case, reconsider their position for future cases on the admissibility of material presented in a complaint which has been obtained covertly.

Summary

Ms C, an advocacy and support worker, complained on behalf of Mr A about the care and treatment he received from the orthopaedic and physiotherapy departments at Ninewells Hospital after he fractured his fibula (shin bone). Mr A was unhappy that he was not given surgery at this time and that he was only discharged with crutches and pain relief with no follow-up appointment. Mr A continued to experience pain and self-referred to physiotherapy, which did not help his pain. He was dissatisfied that the physiotherapist did not query why his leg was not improving and he felt there was a missed opportunity to identify the lack of healing.

We took independent advice from two clinical advisers on the care and treatment Mr A received. We found that the orthopaedic care was reasonable and in keeping with this type of fracture. In addition, there was evidence that appropriate advice was given at the time Mr A was discharged from hospital. Although a follow-up appointment was not felt to be necessary, Mr A was informed at the time of discharge that he could contact the fracture clinic if he experienced any problems, which he did. We found that he was reviewed further and that the decision to continue conservative (non-surgical) management was appropriate. However, we were critical that there was poor communication between the orthopaedic ward staff and physiotherapy department prior to Mr A's discharge from hospital which meant that he was not reviewed by a physiotherapist. The board had apologised to Mr A but we made a further recommendation to ensure the matter does not recur.

We were also critical that the physiotherapy care Mr A received as an out-patient failed to document relevant factors in order to properly assess his calf pain. Therefore we upheld this complaint.

Recommendations

We recommended that the board:

• inform us of the mechanisms in place to ensure effective communication between orthopaedic ward staff and the physiotherapy departments;
• ensure the physiotherapists involved in Mr A's care clearly record a patient's primary problem, a full subjective and objective patient history and the measurable outcomes; and
• apologise to Mr A for the failings identified in relation to the outpatient care he received for his calf pain.

Summary

Mrs C complained that her husband (Mr A) had received inadequate nursing care and treatment when he was a patient at Perth Royal Infirmary. Mr A had a number of health problems including diabetes and had previously had a toe amputated. He then had a major stroke and was transferred to the hospital for rehabilitation.

We took independent nursing advice on the complaint. We upheld Mrs C's complaint as we found that staff had initially failed to dress Mr A's toe amputation wound when he was admitted to the hospital. They had also failed to ensure that his feeding tube (a tube passed through the abdominal wall) was regularly flushed. In addition, nursing staff had failed to inform both Mrs C and the vascular nurse of a wound on one of Mr A's other toes. However, we were satisfied that the board had apologised to Mrs C for the failings in Mr A's care.

Mrs C also complained to us that staff had failed to ensure that suitable arrangements were in place when Mr A was discharged. We found that the discharge planning had been reasonable and we did not uphold this aspect of her complaint.

We upheld Mrs C's complaint that staff had failed to respond appropriately to her verbal complaints. The board had already accepted that complaints she made to staff in the hospital could have been dealt with more effectively and appropriately at the time. They had told Mrs C that they would review the complaints awareness training needs of frontline staff and had apologised to her for the events she had described.

Recommendations

We recommended that the board:

• take steps to ensure that education and training on wound care has been provided to support workers in the hospital; and
• consider reviewing their policy on the care and management of tube feeding.