Some upheld, recommendations

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.

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.