Some upheld, recommendations

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.

Summary

[When this report was first published on 19 October 2016, the Southern General Hospital was incorrectly named as the hospital being complained about. This should have said Victoria Infirmary.  This was due to an administrative error for which we apologise.]

Mrs C complained about the care and treatment her late mother (Mrs A) received at the Southern General Hospital. Mrs A died following an endoscopy (a medical procedure where a tube-like instrument is put into the body to look inside). During the procedure biopsies (tissue samples) were taken, which later led to a bleed.

Following Mrs A's death, the Crown Office and Procurator Fiscal (COPFS) investigated and concluded that they would not refer the death to a Fatal Accident Inquiry.

Mrs C complained to the board at this point, saying she was advised to do this once the COPFS had finished their investigation. The NHS complaints procedure places a 12-month time-limit for considering complaints. The board said that as they had fully cooperated with the COPFS inquiry, there would be no further information to offer and they would not extend the timescale.

We used our discretion to investigate the complaint. We took independent advice from three clinical advisers. The nursing adviser noted that a SEWS (Scottish Early Warning System - a set of patient observations to assist in the early detection and treatment of serious cases and support staff in making clinical assessments) chart was missing. The gastroenterology adviser noted the recording on some of the drug charts was inadequate. The third adviser was a physician and while they noted these omissions in the medical notes, they did not find evidence that the care Mrs A received was unreasonable. While we noted some clinicians would not have biopsied Mrs A, considering her other health conditions, we found this was a degree of professional judgement and the decision to biopsy Mrs A was not unreasonable.

We did, however, uphold Mrs C's complaint about the board's response to her complaint to them and made recommendations to address the failings. We found that, given the serious nature of Mrs C's concerns and the fact that the board were not previously aware of the content of the COPFS report, it would have been good practice for the board to investigate Mrs C's concerns to identify potential learning and give her the opportunity to discuss her concerns. Additionally, the board have a duty to advise complainants that if they will not extend their timescales, the complainant has the right to come to SPSO. This did not happen in this case.

Recommendations

We recommended that the board:

• apologise to Mrs C for the fact that a SEWS sheet was missing from the clinical records;
• apologise to Mrs C for the fact that drug charts were incomplete and ensure all relevant staff are aware of the necessary record-keeping flowing from the guidelines on anti-coagulation in endoscopy;
• apologise to Mrs C for not advising her of her right to refer her complaint to the SPSO for consideration;
• share the learning from this complaint with relevant staff; and
• reflect on the impact on Mrs C of their refusal to consider investigating her complaint and advise us of the outcome of their reflection.

Summary

Miss C complained about care provided by her GP practice. She attended the practice a number of times over a period of six months with various symptoms which were ascribed to depression and treated as such.

When Miss C began displaying slurred speech, her GP urgently referred her to hospital where she was diagnosed with a brain tumour.

We sought independent advice from a medical adviser. Their view was that Miss C's symptoms were reasonably ascribed to other causes and it was not until the symptom of slurred speech occurred that it became clear there might be another cause for Miss C's condition. The adviser said the GP then took appropriate action by urgently referring Miss C. For this reason we did not uphold this complaint.

We did however uphold the complaint about post-operative care as the practice had acknowledged that their normal practice is to contact patients once they have been discharged from hospital and this did not happen in this case. The practice said they intended to carry out an Enhanced Significant Adverse Event (ESAE), and we made a recommendation in relation to this.

Recommendations

We recommended that the practice:

• apologise to Miss C for the failings they identified; and
• share with Miss C any learning from the ESAE.

Summary

Mr C complained about how a prison investigated and responded to his complaint and the time taken to do so.

Mr C had submitted a Complaint about Confidential Matters using a PCF2 form. Scottish Prison Service (SPS) guidance states that on receiving a PCF2 form a response should be given within seven days. We found that the prison failed to investigate Mr C's complaint within the required timescale and did so without giving Mr C a reason for the delay and a revised timescale. We upheld this aspect of Mr C's complaint.

We were satisfied that apart from the unreasonable delay, the prison's investigation and their response to Mr C's complaint were adequate. We did not uphold this aspect of Mr C's complaint.

Recommendations

We recommended that SPS:

• ensure staff involved in the investigation of PCF2 complaints at the prison are aware of the relevant sections of the SPS guidance; and
• apologise to Mr C for a failure to adhere to the relevant timescales set out in the SPS guidance.

Summary

Mr C has a diagnosed personality disorder and post-traumatic stress disorder (PTSD). He complained that the practice had refused to come to his home for a house call in relation to physical symptoms he was experiencing including a cough. When the practice initially declined the house call request, Mr C said that his PTSD had rendered him housebound. He later asked for a mental health referral. The practice advised that they needed to see him at a consultation at the surgery before this could be made and Mr C also complained about this decision. In addition, Mr C complained that his complaint to the practice had not been handled properly.

After taking independent advice from a GP, we did not uphold either of Mr C's complaints about his care. We found that Mr C had been seen recently at the practice and that it was reasonable to ask him to attend for an assessment of his physical symptoms. The GP adviser also considered that it was reasonable to require a face-to-face consultation before making a mental health referral. We also took independent advice from a mental health adviser. The mental health adviser said that the practice's approach was reasonable but highlighted the fluctuating symptoms of PTSD and considered that their approach may need to change in future. These comments were drawn to the practice's attention.

However, we found no evidence that Mr C had been provided with information about the Patient Advice and Support Service and the final response to Mr C's complaint did not include information on how to progress his concerns if he remained dissatisfied. We upheld this aspect of Mr C's complaint.

Recommendations

We recommended that the practice:

• review their complaints handling procedure to ensure that it reflects the requirements of the Scottish Government's 'Can I help you?' guidance.

Summary

Mr C complained that following surgery for a hernia repair at Stracathro Hospital, he suffered severe and continuing pain. Mr C complained to the board about the surgery and the reasons for his continuing pain, which he said had an adverse effect on his daily life. Mr C was dissatisfied with the response he received from the board.

We took independent advice from a consultant surgeon experienced in performing hernia repairs and related complications. They advised that the treatment Mr C received was appropriate. The adviser did not identify failings in either the surgical procedure or in Mr C's post-operative care. The adviser said that Mr C was one of the small percentage of patients who develop pain following this procedure. The steps taken by the board to address Mr C's ongoing pain had been appropriate and reasonable. We accepted this advice and did not uphold Mr C's complaint.

Mr C also complained that the board had failed to respond appropriately to his complaint. The board had accepted they had not dealt with Mr C's complaint in a timely and reasonable manner and that the delay in responding to the complaint was unacceptable. The board had apologised and mentioned action taken to improve their complaints handling.

It was clear to us that the board had failed to deal with Mr C's complaint in a timely manner and in accordance with their complaints procedure. We also considered in particular that their communication with Mr C about the reasons for the delay was poor. We therefore upheld this complaint.

Recommendations

We recommended that the board:

• issue Mr C with a formal apology for their failure to handle his complaint in a timely manner and in their communication with him; and
• provide evidence of the action taken to review and improve their complaints handling.