Some upheld, recommendations

Summary

Miss C complained about her son (Mr A)'s admission to the Langhill Clinic at Inverclyde Royal Hospital. Mr A was admitted with suicidal thoughts and diagnosed with personality disorder, but requested a second opinion. This was provided by a different psychiatrist about a week later, and supported the clinical team's view that Mr A did not suffer from a major psychiatric illness, with his presentation relating to personality traits and recent trauma and bereavement. The following day, Mr A was found to have taken illicit drugs while absent from the hospital on a day pass. In view of this and increasing incidents of aggression towards staff, the doctor decided to discharge Mr A the following morning. Mr A then became aggressive and staff called the police to escort him from the hospital. Miss C was concerned that Mr A was not appropriately assessed and felt he should not have been discharged so early. She also raised concerns about the board's handling of her complaint.

After taking independent psychiatric advice, we did not uphold Miss C's complaints. We found that Mr A received reasonable assessments which appropriately took into account his risk of self-harm. He was also given a second opinion when he requested this. We also found the discharge was reasonable and in line with the board's policy on the management of violence and aggression. In particular, we noted that Mr A's admission was intended to be short and there were numerous documented instances of aggressive behaviour not caused by a major psychotic illness. However, we found the board failed to handle Miss C's complaint in line with Scottish Government guidance as they did not accept her complaint at first because it was not in writing, there were significant delays in the investigation and there was no evidence that staff contacted Miss C to explain the delay.

Recommendations

We recommended that the board:

• apologise to Mrs C for failing to handle her complaint in a timely manner;
• feed back findings to the staff involved for reflection and learning;
• take action to ensure that all complaints to the clinic are appropriately recognised and acknowledged, including verbal complaints made to clinic staff; and
• put in place clear procedures to ensure that complaints are investigated within 20 days where possible, and that complainants are updated when the investigation is expected to exceed 20 days.

Summary

Miss C's mother (Mrs A) had cancer and was receiving care at home. During an admission to Glasgow Royal Infirmary for a review of her care, Mrs A suffered a fall. After her fall, Mrs A underwent a scan and was discharged two days later.

The scan report was issued six days after the scan took place and showed a fracture to Mrs A's L1 vertebra (a bone in the base of her spine). Miss C said that on Mrs A's discharge from hospital, Mrs A's family had been told that the scan was clear.

Mrs A's family continued to care for her at home but were concerned about her continuing back pain. They asked her GP to check the results of the scan with the hospital. Miss C said that the family was told that Mrs A had suffered a fracture to her L3 vertebra (a different bone in the base of the spine). Mrs A died the next day. Miss C was concerned that Mrs A had been cared for without her family being aware of her fracture.

Miss C complained to us that the family had not been reasonably informed about the results of the scan. We took independent advice from a consultant in general medicine and a radiologist. They noted that the fracture was clearly visible on the scan, but although the hospital's computerised audit trail showed staff had reviewed the scan, this was not documented in the medical records and there was no evidence that the results had been communicated to Mrs A or her family. While we did not find evidence that staff had given incorrect information to Mrs A or her GP, we were critical that staff did not identify the fracture and share this information. We therefore upheld this complaint.

Miss C also complained about the provision of Mrs A's pain relief during her admission. The advisers noted that staff had assessed and monitored Mrs A's pain appropriately and provided pain relief when required. We therefore did not uphold this aspect of Miss C's complaint.

Recommendations

We recommended that the board:

• apologise to Miss C's family for the failings found during our investigation;
• feed back our findings about the lack of documentation and communication of the scan results to the medical staff involved; and
• review and address any training needs for the staff involved, in relation to interpreting scans of this kind.

Summary

Ms C brought this complaint to us on behalf of her late grandfather (Mr A) in relation to the care and treatment he received from the board during investigations into urology symptoms, and subsequently, during an admission to the Jubilee Hospital.

Mr A was referred to urology in 2013 with symptoms indicating potential prostate cancer though treatment was not considered necessary. He was admitted to hospital following the identification of suspected metastatic cancer and a fall at home. He was cared for in a GP-led ward and received palliative treatment for his cancer symptoms. During his time in hospital he missed a consultant appointment because he was not informed of it. While the urology consultant was in contact with the GPs involved in Mr A's care, Mr A did not see a consultant after his diagnosis with metastatic disease until his death around four months later.

During our investigation of this complaint, we obtained independent advice from a urology adviser and a GP adviser. The urology adviser did not raise any concerns about the care and treatment Mr A received in relation to his prostate cancer. They noted that the timescales for Mr A's clinical review were not appropriate but that these timescales were overtaken by events. The adviser noted that the urology consultant had written to the GP on several occasions setting out his opinion of Mr A's condition and treatment decisions, though it was not recorded as to whether this had been explained to Mr A. Once he was in hospital, Mr A's care and treatment had been discussed at case conferences which included family members. When Mr A was first admitted to hospital, doctors completed a form to instruct that he should not be resuscitated in the event of a heart attack (a DNACPR form). This form was subsequently overturned following discussions with Mr A's family. This was noted on his medical records. Though Ms C said she saw Mr A's name on a list on the ward, there was no evidence of inaccurate records held by the board.

When Mr A was discharged to a nursing home, the family thought he was going to have rehabilitation so he could return home. Records passed between the board and the nursing home indicated he was being transferred for management of cancer symptoms. The GP adviser explained that Mr A was receiving palliative care, and it was possible that if his condition had stabilised he would have been able to return home. His condition deteriorated more rapidly than had been expected, and this could not have been foreseen. We accepted the advice provided by the advisers in relation to Mr A's care and treatment.

Ms C also raised concerns about the way her complaint was handled. She said that her grandmother (Mrs A) was contacted directly to gain consent, and that this was not appropriate. She also raised concerns that the board used the wrong name for Mrs A and that they did not provide a response within the appropriate timescales. We noted these issues and considered that the board failed to follow their complaints handling procedure.

Recommendations

We recommended that the board:

• feed back findings to the staff involved for reflection and learning;
• apologise to the family for the failings identified in our investigation;
• review their processes to ensure that complainants are contacted when consent is needed from a patient or next of kin; and
• review their processes to ensure that, where an investigation cannot be completed within 20 days, they contact the complainant to explain this.

Summary

Mrs C complained about a decision taken by the board to cancel her heart surgery and the lack of communication to her about this decision. She was also concerned that her complaint had not been dealt with appropriately because members of the complaints team had been involved with the decision to cancel her surgery.

We took independent advice from a consultant cardiologist. We found that there were appropriate reasons for the surgery to have been postponed until an independent review was sought to endorse Mrs C's management plan.

However, we found the communication in relation to the postponement of the surgery to be unreasonable. The board apologised to Mrs C that she was not informed beforehand that a further clinical meeting would be held. We also considered that the board should have sought Mrs C's input in relation to the independent review and informed her that there was a possibility it would delay her surgery.

We did not find that there had been a conflict of interest in the complaints staff handling of Mrs C's complaint about the cancellation of her surgery. The decision to cancel the surgery was taken by relevant clinical staff involved in her care. We therefore concluded that her complaint was investigated appropriately.

Recommendations

We recommended that the board:

• draw our findings abut the failure to adequately communicate the decision to postpone the surgery to the attention of the multi-disciplinary team involved in Mrs C's care; and
• apologise for failing to seek Mrs C's input in relation to the decision to obtain an independent review.

Summary

Mr C complained that the board had failed to provide compression stockings for his varicose vein surgery at University Hospital Ayr. Mr C said he was unusually large and already received custom-made support stockings from the hospital. On the day of his surgery, however, the stockings he required needed to provide a greater degree of compression than his day-to-day pair. None had been ordered by Mr C's doctor and none of the standard sizes fitted him. As a result, Mr C's surgery was delayed. Mr C said he felt this was unacceptable and that staff had failed to recognise the serious inconvenience this had caused him.

We took independent advice from a consultant vascular surgeon and consultant physician. They found that it was unreasonable for the board to have not ensured the correct size of stocking was available. We therefore upheld this aspect of Mr C's complaint.

Mr C said that staff had made fun of his unusual size, which he considered unprofessional. We were unable to investigate this aspect of Mr C's complaint as it was not possible to confirm what had been said.

Mr C also complained that he had not been provided with an appropriate level of information about the planned surgical procedure and that he had subsequently found out there were possible serious side effects. Mr C said he would not have consented to the procedure had he been aware of these.

We found, however, that the decision not to proceed with surgery due to the correct size of stockings not being available was appropriate given Mr C's medical history.

With regard to the information provided to Mr C about his surgical options, the advisers found that this was adequate and set out clearly the possible risks of surgery. We therefore did not uphold this aspect of Mr C's complaint.

Recommendations

We recommended that the board:

• remind the doctor concerned of the importance of confirming prior to surgery whether custom-made stockings are required and ensuring these are available on the day of surgery.

Summary

Mr C complained that his university withdrew him from a course due to lack of engagement and about the handling of his appeal.

We found the university's process for withdrawing Mr C was not applied in line with their policy and there was an issue with the accuracy of records that it was the university's responsibility to make and keep. We upheld this aspect of the complaint.

We found that the university followed the process for appeals appropriately. We did not uphold this aspect of the complaint.

Recommendations

We recommended that the university:

• apologise to Mr C for failing to ensure accurate attendance records were maintained and for not giving consideration to his improved attendance following receipt of the emails from the university;
• remind relevant staff of the importance of maintaining accurate attendance records; and
• reflect on the findings in this case and ensure the student engagement policy reflects the need for appropriate exercise of discretion as part of due process.

Summary

Mr C raised concerns about Business Stream's handling of his water charges. In particular, he complained that he was paying for a neighbouring business's water consumption. He was also unhappy with the charges for drainage and road drainage and the manner in which Business Stream responded to his complaints.

During our investigation, Business Stream accepted that Mr C was paying for another firm's water services and agreed to install a sub meter to that property to ensure that going forward Mr C would not be liable for their water services. We therefore upheld this aspect of Mr C's complaint. Business Stream also accepted that the matter had taken a considerable length of time to resolve and agreed, as a gesture of goodwill, to clear his outstanding balance.

We were satisfied that Business Stream had considered Mr C's position that he was not liable for waste and drainage charges, and following investigation, had confirmed that, as Mr C enjoyed the benefit of a connection to the public sewerage network, he was liable for property drainage charges and roads drainage charges. We did not uphold this aspect of Mr C's complaint.

Recommendations

We recommended that Business Stream:

• apologise to Mr C for their handling of this matter; and
• ensure that complainants receive a robust response which contains adequate information on the reasons for the decision reached on their complaint.

Summary

Ms C complained that when the Scottish Prison Service (SPS) were assessing evidence at a disciplinary hearing for fighting, they had not considered all relevant CCTV of the incident before reaching their decision. Ms C believed that there was further CCTV camera footage which had not been shown. Ms C was also unhappy that, when she complained about this, the Internal Complaints Committee (ICC) did not say whether all the CCTV footage had been reviewed and there was no attempt to allow her to attend the ICC as she had been transferred to another prison.

We found that the additional cameras that Ms C wished to be shown as evidence did not exist. Therefore, we were satisfied that all relevant CCTV evidence was considered prior to reaching a decision on her disciplinary hearing and we did not uphold this aspect of her complaint.

In relation to Ms C's complaint about the ICC, we found that, while we were satisfied that the ICC had considered the available evidence, the ICC decision to Ms C merely stated that they had reviewed 'all evidence presented' without responding to her specific request that other footage be considered. Our view was that they should have noted the lack of additional footage and expressed this to Ms C in a way that allowed her to be satisfied that the points she had raised had been taken on board. The prison had already acknowledged, in response to our enquiries, that they did not consider options to allow Ms C to take part in the ICC. They have now put in place a process to ensure that if a prisoner transfers to another establishment prior to an ICC, video conferencing will be available to enable them to take part in the ICC. We upheld this aspect of Ms C's complaint.

Recommendations

We recommended that SPS:

• remind staff involved in ICC decision-making of the need to adequately record all evidence considered and communicate decisions and the reason(s) for those decisions clearly to the complainant; and
• apologise to Ms C for the failings identified in the handling of her complaint.

Summary

Mr C complained that the council had failed to take reasonable action to protect him and other residents from what he said were excessive levels of noise from a scrap processing yard next to his home. Mr C considered the noise levels were a statutory nuisance and the council had failed to take appropriate action to address this.

We obtained independent advice from an environmental health adviser. The complaints concerning noise levels had been long-standing and ongoing. We accepted that the council had carried out noise monitoring as a result of complaints received about the level of noise coming from the scrap yard since 2011. We were satisfied that the council had determined that a statutory noise nuisance was established firstly in 2011, and then again in 2012 and 2013.

However, the council did not take enforcement action and serve an abatement notice until late 2013. The abatement notice was then suspended. We considered the council could and should have taken earlier action. We were critical of the council's failure to do so and of the significant delay in serving the abatement notice from the time when nuisance was first established in 2011.

The council said that since the abatement notice was suspended they have continued to assess complaints received and have not found there to be any situation which warranted further enforcement action. However, we found it concerning that since the suspension a significant number of complaints about noise have been made. Although the council have said the noise levels were found to be excessive on only two of these occasions, it was unclear why the council have not taken further enforcement action. We considered the council failed to act reasonably in respect of noise nuisance that Mr C experienced at his home and made a number of recommendations to address this.

Mr C also complained about the council's handling of concerns he raised about alleged soil contamination in his garden and at a nearby play park, which he considered had originated from the operations carried out at the scrap yard. We found that the council had carried out sampling which included taking samples of soil and fruit from Mr C's garden. The advice we received from the adviser was that the council had carried out appropriate monitoring and sampling and in respect of the most recent sampling results had taken appropriate advice from public health authorities about these results and in evaluating the risk to human health. These results had found there was not a significant risk to human health and that further investigation was not required. We therefore did not uphold this part of his complaint.

Recommendations

We recommended that the council:

• apologise for their failure to act reasonably and earlier in respect of noise nuisance Mr C experienced at his home;
• undertake a review of their policies and procedures in relation to noise nuisance, having due regard to the current guidance and best practice, and to ensure that staff have the requisite competencies in assessing acoustics and noise control;
• ensure our investigation findings are brought to the attention of the relevant staff involved; and
• provide evidence of what action they are taking to continue to monitor noise levels from the scrap yard.

Summary

Miss C complained about care provided to her father (Mr A) by the council on a specific day, and about the council's handling of her complaint.

We looked at information provided by Miss C and the council about what happened on the day. Both accounts agreed there was an incident with Mr A, but they did not agree about the reason for it. There was no conclusive evidence of the reason for the incident, which could have helped to prove whether the care provided was adequate in the circumstances. In the absence of this evidence, or any independent evidence of what actually happened, we could not uphold this aspect of Miss C's complaint. However, although we did not uphold the complaint, we had concerns about specific actions of the staff member involved, and we made recommendations to address these concerns.

The council's responses to Miss C's complaint focused on the days before and after the day she complained about. The council told us this was to assess whether what happened on the specific day could have been predicted, or if the care provided could have had an effect on Mr A. The council should have explained this to Miss C.

It appears that no action was taken when Miss C first reported her complaint to the council, and there were delays when they did deal with her complaint. We found the council did not, as they should have, interrogate evidence provided by their staff thoroughly, in order to resolve a lack of clarity in the evidence given by staff. Our main concern was that the council failed to tell Miss C that she had the right to refer her complaint to a social work complaints review committee, which meant she was denied the opportunity to have her complaint heard fully through the correct process. We upheld this aspect of Miss C's complaint.

Recommendations

We recommended that the council:

• discuss the timing of a phone call with the staff member, to ensure that in future cases they prioritise the patient they are with;
• ensure that points for improvement arising from a discussion between a manager and Miss C's parents are fed back to the staff member, so this general approach can be applied in future;
• ensure that home care staff and management know how to deal with complaints about their service, and how to signpost them to the correct formal process when necessary;
• feed back to staff involved in this complaint the need for them to interrogate evidence thoroughly; and
• ensure that where they handle complaints through the social work complaints process, complainants are always signposted to the complaints review committee.