Some upheld, recommendations

Summary

Mr C complained to us about the care and treatment his wife (Mrs A) had received from the board. Mrs A had been diagnosed with functional disease (where the functioning of the body is disturbed in the absence of any disease). Her condition deteriorated significantly and she died. A post mortem was carried out and it was found that she had motor neurone disease (a rare condition that progressively damages parts of the nervous system). Mr C complained to us about the care and treatment provided to Mrs A and about the failure to diagnose motor neurone disease.

We took independent advice from a consultant neurologist and a general medical adviser. We found that the initial diagnosis of functional disease had been reasonable and the care and treatment Mrs A had received in relation to this had been excellent. However, when Mrs A then displayed other symptoms that were not typical of functional weakness, staff failed to reasonably investigate these symptoms. It was likely the further tests would have led to a diagnosis of motor neurone disease, although this could not be proved. In view of this, we upheld Mr C's complaints that the board did not provide reasonable care and treatment to his wife and that they failed to diagnose motor neurone disease.

Mr C also complained that the board failed to arrange a package of home care for Mrs A. We found that the actions of staff had been reasonable given Mrs A's initial diagnosis. The correspondence from the board had set out the type of support she would require in the future. We could not say definitively that a diagnosis of motor neurone disease would have been made had the relevant tests been carried out. On balance we did not uphold this aspect of the complaint.

Finally, Mr C complained about the board's handling of his complaint. We did not find failings by the board in relation to the issues Mr C had raised and we did not uphold this aspect of his complaint.

Recommendations

We recommended that the board:

• issue a written apology to Mr C for the failings identified;
• ensure that relevant staff are aware of the latest National Institute for Health and Care Excellence guidance, 'Motor neurone disease: assessment and management', which was published in 2016; and
• ensure that relevant staff are aware of the motor neurone disease red flag diagnosis tool.

Summary

Mrs A and her daughters were removed from the GP list following an incident at the practice involving her husband, who was not registered at the practice.

Mrs A's father (Mr C) complained that the decision to remove Mrs A and her daughters from the list was unreasonably severe and lacked transparency and that the removal letter was vague. He also complained that previous problems experienced with a particular receptionist had not been addressed and that the complaints process was lengthy and unclear.

We found that while the decision to remove Mrs A and her daughters from the list was reasonable, the practice did not follow NHS guidance which states that where no warning about the patient's or their representative's behaviour is given within the preceding 12 months, patients can only be removed if the police or the procurator fiscal had been informed of the incident which led to the removal. This did not happen in Mrs A's case. Although we did not uphold this part of Mr C's complaint, we made a recommendation to the practice.

The letter informing Mrs A of her removal reached her on a Saturday and she had an appointment booked at the practice for the following Monday. The letter did not make it clear that this appointment could still go ahead and repeat prescriptions could be issued until Mrs A was registered with a new GP. The practice has now changed the wording of such letters to make the transition arrangements clear. Therefore while we upheld Mr C's complaint in relation to this, we made no further recommendations.

We reviewed the actions taken to address the previous problems that the family had experienced with a particular receptionist and found that these had been appropriately addressed. We did not uphold this part of the complaint.

In relation to the handling of the complaint, we found evidence of delays. Although the delays were not a result of inaction by the practice, Mr C was not kept informed of the reasons or given a timescale by which he could expect their response. We upheld this part of the complaint.

Recommendations

We recommended that the practice:

• remind all relevant staff of the requirements of the NHS guidance on the removal of patients from a GP list;
• ensure that copies of their complaints procedure are readily available to patients and are provided on request;
• remind all staff involved in complaints handling about the timescales set by the NHS complaints handling guidance and provide training if necessary, and that where timescales cannot be adhered to, patients and/or complainants should be provided with meaningful updates;
• reflect upon our view that it was not appropriate to address complaints correspondence to Mrs A when the complaint was being made by Mr C on her behalf and with her consent; and,
• issue a written apology for the failings identified by this investigation.

Summary

Ms C, who works for an advocacy and support agency, complained on behalf of Mrs A about the care and treatment given to Mrs A's husband (Mr A), who had been diagnosed with chronic liver disease. Ms C said that despite regular testing since his diagnosis, there had been a failure to pick up Mr A's deteriorating condition and she was concerned that he had not been offered a liver transplant. Mr A died following discharge from hospital. Ms C also complained about a delay in receiving a response from the board.

We took independent advice from a consultant gastroenterologist (a doctor who specialises in the treatment of conditions affecting the liver, intestine and pancreas). Mr A had been regularly monitored and checked but the nature of his disease was unpredictable and his diagnosis had not always been clear. We also found that Mr A's case had not been appropriate for liver transplant as the severity of his illness (based on an established scoring system) had not been high enough to justify it. We therefore did not uphold this aspect of Ms C's complaint. However, the adviser said that the board should have involved the Macmillan palliative care team at an earlier stage to provide symptomatic help for Mr A and support for his family.

We found that there was an unreasonable delay on the part of the board in responding to Ms C's complaints and in addressing her concerns.

Recommendations

We recommended that the board:

• ensure that the medical staff involved in Mr A's care are informed of the outcome of this complaint;
• review the advice they provide to patients and their families about the hepatocellular carcinoma (liver cancer) surveillance programme and consider providing a relevant leaflet;
• make a formal apology and provide full information of how they intend to address the concerns identified;
• ensure that staff involved in Mr A's care are reminded of the necessity of adhering to the stated complaints policy; and
• confirm to us that they are satisfied that the Macmillan referral process used is fit for purpose.

Summary

Mrs C complained that when the board decided to change follow-up appointments for some cancer patients from face-to-face appointments to phone appointments, the decision was notified to her in an inappropriate way, that the decision was unreasonable and that there was an unreasonable delay in providing a copy of the discharge letter sent to her GP.

Mrs C received treatment for cancer which was thought to be of low risk of recurrence. She was told she would be followed up for a period of three years at six-monthly clinic appointments. However, before the sixth appointment she was sent a letter informing her that the appointment had been changed to a phone appointment. The letter was undated, on plain notepaper and had no signature or indication of the author.

Our investigation found that the decision to move to phone appointments was reasonable and in line with guidance from the Department of Health. However, the manner in which Mrs C had been notified of this change was unacceptable. The board explained that the consultant in charge of Mrs C's care had drafted a letter to inform patients of the change. It was then circulated to the multi-disciplinary team for review and once approved was sent to Mrs C without being transferred to headed notepaper and having the date, the name of the consultant and their signature added. Since Mrs C's complaint the letter had been amended.

Mrs C did not receive a copy of the GP letter until several weeks after her phone appointment. We considered this and other administrative failures which occurred during the complaints process to be unacceptable.

Recommendations

We recommended that the board:

• issue a written apology for the failings identified during this investigation; and
• review the way complaints correspondence is dealt with to ensure that relevant enclosures are provided and standard letter templates are amended to reflect the situation with the complainant at that time.

Summary

Miss C complained that staff at the Assisted Conception Service at Glasgow Royal Infirmary failed to provide her with appropriate in vitro fertilisation treatment (IVF) and failed to communicate appropriately with her. IVF is where an egg is removed from the woman's ovaries and fertilised with sperm in a laboratory. The fertilised egg is then returned to the woman's womb to grow and develop.

Miss C's concerns included that during four referrals she was not once told that she was ineligible for treatment because she was a smoker. Miss C said she also attended various appointments at the service with an egg donor, only to be told at the last appointment that the donor was unsuitable because she was also a smoker.

We obtained independent medical advice from a consultant in reproductive medicine and surgery. The adviser said the IVF treatment provided to Miss C by the board was reasonable. However, the new Scottish Government Access Criteria for NHS-funded treatment for all NHS boards had already been introduced and this set out that smokers were no longer eligible for treatment. Miss C and her partner attended three appointments at the service over a nine-month period before they were finally advised that they were ineligible for treatment because they were both smokers. We were critical of the board in this regard.

The evidence also suggested that Miss C and her partner attended an appointment at the service in which a proposed donor was put forward but the eligibility of the donor under the new access criteria was not discussed.

Recommendations

We recommended that the board:

• take steps to ensure that relevant staff and patients attending the clinic are fully aware of the new Access Criteria;
• provide us with a copy of their revised patient leaflet on egg donor treatment which includes information on the Access Criteria; and
• provide Miss C and her partner with a written apology for failing to advise them of the new Access Criteria at a specific appointment.

Summary

Mr C complained about the care and treatment he received for abdominal symptoms. He said that he did not receive treatment until he was admitted as an emergency for an operation to remove his gallbladder, over a year after first experiencing symptoms.

We took independent medical advice. We found that Mr C's symptoms of lower abdominal pain were different to those he later developed (upper abdominal pain), and in each case appropriate tests were carried out, with further follow-up planned. We therefore did not uphold this aspect of Mr C's complaint.

We concluded that the overall treatment pathway was reasonable, although we were concerned that there was a six-month waiting period for one of Mr C's non-urgent follow-up appointments and made a recommendation to address this.

Mr C also complained that, when he called out-of-hours with severe pain, the board's operator gave him an appointment at a hospital that was not the closest to his house and that this cost him about £100 in taxi fares. Mr C was also concerned that at this appointment he was reviewed by a nurse and discharged, before being admitted to hospital as an emergency the next day.

After taking independent nursing advice, we did not uphold this complaint. The recording of the out-of-hours call showed the operator offered Mr C a closer appointment first, but that he chose to travel to the more distant hospital for a slightly earlier appointment. We found the nurse practitioner carried out a reasonable assessment of Mr C's symptoms and consulted with the GP, and that it was reasonable for the board to have discharged Mr C in the circumstances.

Mr C also complained that the board failed to the take action they had agreed with him in response to an earlier complaint. In particular, the board agreed to put a note on his medical records to alert staff to a childhood trauma, so that he would not have to keep explaining this at medical appointments. While the board put a written note on Mr C's physical health records, we found this was unlikely to be effective as clinicians would not normally look at his entire record prior to an appointment. We upheld this complaint. However, the board explained that they are currently updating their electronic system and would be willing to discuss the possibility of an electronic update with Mr C.

Recommendations

We recommended that the board:

• review their waiting times for routine or repeat general surgery out-patients and take action to address any significant delays;
• apologise to Mr C for failing to adequately implement the complaint outcome discussed (or explain why this would not be possible);
• explain to Mr C what steps they have taken to ensure that patients are not issued appointments with a clinician they have asked not to see; and
• discuss with Mr C the possibility of including a general case alert on his electronic health records (once this facility becomes available).

Summary

Mrs C said her son (Mr A) had bilateral gynaecomastia (swelling of male breast tissue) and was to have surgery at Dumfries and Galloway Royal Infirmary to remove the excess tissue from both breasts. Mrs C complained that on the day of the operation, the board changed the procedure Mr A was to have by operating on one breast instead of both and failed to communicate this to Mr A appropriately. She also said that the operation was not carried out to a reasonable standard and that the board did not reasonably respond to her complaint about the surgery.

We obtained independent advice from a consultant breast surgeon. The adviser said it was unreasonable that the decision to operate on Mr A's right breast only was made immediately pre-operatively. We were also concerned that the board did not obtain Mr A's signed consent for the revised procedure and that Mr A did not appear to have been shown photographs of other patients who had had the procedure carried out by the board or been provided with written information on the procedure for him to consider in advance of surgery. Therefore, we upheld this part of Mrs C's complaint.

The adviser said it was not possible for them to determine whether Mr A's surgery had been carried out to a reasonable standard or whether the decision to change the surgery had been reasonable as there were no photographs of Mr A's chest before and after surgery and no notes of the surgeon's rationale for making this decision. We therefore did not uphold this part of Mrs C's complaint.

The evidence showed that it took the board nearly 11 months to successfully make contact with the surgeon, who had since left their employment, and that when Mrs C first raised issues about Mr A's surgery, the board logged this as a concern rather than a complaint. We upheld this part of Mrs C's complaint.

Recommendations

We recommended that the board:

• feed back the failings identified to the staff involved, including the surgeon, for future learning;
• ensure that in future cases of this type patients are provided with appropriate written and photographic information in advance of surgery and photographic records are made of patients pre- and post-surgery;
• provide Mrs C and Mr A with a written apology for the failings identified;
• provide this office with a copy of their process for ensuring complaints are shared with staff who have left employment with the board;
• remind relevant staff of the need to properly record complaints when they are received; and
• provide Mrs C with a written apology for failing to respond reasonably to her complaint.

Summary

Mr and Mrs C complained on behalf of their son (Mr A) who is a former student at Edinburgh College. They complained that although Mr A had been diagnosed as dyslexic, the college delayed in organising the agreed support he needed. They also said that specific agreed support had not been available to him on the day of an exam and that after he received his results, he received inadequate feedback. They complained about the way the college dealt with their formal complaint about these matters.

We investigated the complaint and found no evidence of a delay in the college's processing of Mr A's request for support. However, other agencies were also involved in this, over which the college had no control.

In the meantime, the college updated Mr A's lecturers about his level of support but on the day of an assessment, although a computer was available it did not have a spellcheck facility. A separate room for Mr A's use was also not made available. As these things were part of Mr A's support plan, we upheld this part of the complaint. However, we found no evidence that the college had provided inadequate feedback on his assessment. Like other students, Mr A's papers were returned to him annotated with the marker's comments.

When Mr and Mrs C complained, the college explored details of their concerns with them but took too long in terms of their stated complaints policy to deal with the matter. We upheld this aspect of the complaint.

Recommendations

We recommended that the college:

• apologise for the delay in responding to the complaint.

Summary

Ms C runs a business from premises that she rents from her landlord who occupies the neighbouring premises. These units formed a larger premises until they were subdivided by the landlord. Ms C had an arrangement where she paid water charges through her rent.

After a number of years, Business Stream contacted Ms C and confirmed that she was operating from the premises. Although water and waste water charges were being accounted for through her landlord's metered water bill, it was established that property and roads drainage charges were not covered for her premises. Business Stream issued a bill for this. Ms C complained that this was unfair as her landlord had informed Business Stream that they were sub-letting the premises previously and that they had been aware of her business. Ms C felt she should have been issued with a letter advising that she could change water supplier and that Business Stream staff had provided poor customer service.

We found that a welcome pack had been issued to Ms C which made reference to the open water market. With therefore did not uphold this aspect of Ms C's complaint. We also did not uphold her complaint about customer service as we found no evidence that this was poor.

However, we found that her landlord had contacted Business Stream a number of years earlier and told them that the premises were subdivided and let out, although no specific information had been provided about the tenant. We accepted that the drainage costs were due for payment but recommended that Business Stream provide Ms C with a long-term payment plan. During our investigation, Business Stream acknowledged a delay that had occurred in confirming that water and waste water charges were being billed through her landlord's account. We therefore upheld this aspect of Ms C's complaint.

Recommendations

We recommended that Business Stream:

• provide Ms C with a long-term payment plan to pay off the backdated balance alongside the continuing drainage costs; and
• apologise to Ms C for the delay identified.

Summary

Ms C's late mother (Mrs A) had a history of bladder cancer and following surgery, self-catheterised through a stoma (a surgically-made opening from the inside of an organ to the outside) in her stomach. She was admitted to Monklands Hospital in February 2014 complaining of severe abdominal pain and a number of tests were carried out. Mrs A was discharged and continued to see hospital specialists as an out-patient but was readmitted several months later for an operation to remove her right kidney. When the operation was carried out, recurrent bladder cancer was found. Ms C said that following this operation Mrs A's dementia worsensed. After several weeks, Mrs A was discharged again. She was readmitted the following month when she continued to deteriorate and she died several weeks later. Ms C raised concerns about the standard of medical care and treatment during Mrs A's three admissions to hospital and, in particular, said that the decision to carry out the operation was not reasonable and that medical staff failed to manage her pain and dementia in a reasonable way. Ms C also said that nursing staff failed to properly care for Mrs A's catheter and ensure that she had sufficient food and fluids and that the family had to provide personal care. Finally, Ms C raised concerns about the standard of communication.

We took independent advice from an urology adviser and a nursing adviser. We found that the medical care and treatment was reasonable including the decision to operate (although there was a record-keeping shortcoming). However, we also found that there were failings in relation to the standard of nursing care and treatment provided and communication. The overall assessment and care concerning Mrs A's dementia was below a reasonable standard and nursing staff failed to assess her capacity during two of her admissions to hospital. There were further shortcomings in relation to monitoring and recording fluid and nutritional intake. However, we were satisfied that clinicians did assist with Mrs A's catheter. In relation to communication, there was evidence that communication was challenging at times and no evidence that the family was as involved as they should have been in the wider care planning process.

Recommendations

We recommended that the board:

• ensure patients' capacity to consent to treatment on the ward is assessed and recorded in line with relevant guidelines and legislation and provide evidence of this;
• bring the nursing adviser's comments about shortcomings in communication to the attention of relevant staff and carry out audits to ensure compliance;
• bring the nursing adviser's comments about shortcomings in implementing the relevant standards in relation to dementia and nutrition, and the related record-keeping failings, to the attention of relevant staff and carry out audits to ensure compliance;
• apologise for the failings we identified; and
• ensure that sedation and/or analgesia prescribed in the ward before being taken for procedures out with the ward is fully and properly recorded in the medical records.