Some upheld, recommendations

Summary

Mr and Mrs C complained about the steps taken by the council after they raised concerns about the bullying their daughter (Ms A) had suffered at school. They were also unhappy at the council’s handling of their complaint and the fact that Mrs C had asked to attend school trips as a parent helper but had not been selected. Mr and Mrs C also raised concerns that the school did not communicate appropriately with health professionals involved with Ms A and that, in their view, school staff had acted inappropriately by discussing Ms A’s impending school move with her.

We recognised the significance of Mr and Mrs C’s concerns about bullying and how this can affect a child and also the wider family. While we took this into account, our role was limited to considering whether the appropriate policies and procedures had been followed. The limited records available (including a playground diary and the school’s paperwork) did not support Mr and Mrs C’s correspondence. Although we recognised that the absence of a record does not automatically mean something did not happen, we did not consider the evidence available pointed to a failure to follow the relevant policy. We did not uphold this complaint but made one recommendation because of the age of the school’s policy and to ensure appropriate record-keeping in future.

We upheld Mr and Mrs C’s complaint about the council’s complaints handling. This was a particularly sensitive and distressing matter for them and the council initially failed to acknowledge their complaint and then missed their deadline for formally responding. We made one recommendation as a result, although we did not uphold Mr and Mrs C’s remaining complaints. Although we recognised that Mrs C had been very keen to assist at school trips, we saw nothing to indicate that there has been a failure to act in line with the relevant policy. In addition, the paperwork available indicated that the school had involved a series of health professionals and did not point to a failure of communication in that regard, nor did we consider the evidence indicated that school staff had inappropriately discussed the matter with Ms A.

Recommendations

We recommended that the council:

• consider reviewing the school’s policy to ensure it takes account of all relevant Scottish Government guidance, reported incidents and the need to ensure parental contact is recorded accurately; and
• apologise to Mr and Mrs C for failing to handle their complaint appropriately.

Summary

Mr C complained about the care and treatment his late wife (Mrs C) received from St John's Hospital and the Royal Infirmary of Edinburgh. Mrs C attended the emergency department at St John's Hospital where she had tests carried out that suggested that she may be suffering from a viral illness and/or a urinary infection. She was discharged home with antibiotics but remained unwell. She visited her GP four days later who arranged for her to be seen by the medical assessment unit at St John's Hospital. There were delays in Mrs C being seen by a doctor and she was found to have had a small heart attack. Further tests revealed that she had significant coronary artery disease (blockages of the arteries) and so she was transferred to the cardiology team at the Royal Infirmary of Edinburgh. It was further identified that she had an overactive thyroid. Surgery to address the blocked arteries was carried out a few days later. However, within 24 hours Mrs C's condition continued to deteriorate and further investigations were difficult to perform given her poor state of health. Mrs C was transferred to another hospital but died shortly afterwards.

We took independent advice on this case from three medical advisers who are specialists in emergency medicine, endocrinology (hormone-related diseases) and cardiology. On Mrs C's first visit to the emergency department of St John's Hospital, a junior doctor failed to refer her to a more senior doctor before discharging her. We therefore found that the care provided was unreasonable. We were also critical that, on Mrs C's second visit to St John's Hospital, there was a delay in her being admitted and seen by a doctor. The board accepted and apologised for this. We considered that the treatment given thereafter at St John's Hospital was reasonable. We concluded that the care provided by the Royal Infirmary of Edinburgh was appropriate and in accordance with national guidelines. However, we found that communication with Mr and Mrs C about Mrs C's condition was unreasonable by both hospitals.

Recommendations

We recommended that the board:

• ensure the junior doctor reflects on the failings identified at their next appraisal;
• ensure St John's Hospital reviews its policy for patients who should be reviewed by a more senior doctor before discharge from the emergency department, taking account of high-risk presenting symptoms;
• review its pathway for patients referred from their GP to the medical assessment unit at St John's Hospital to ensure that patients who should be seen urgently do not experience an excessive wait;
• share with relevant staff involved in Mrs C's care at the Royal Infirmary of Edinburgh the importance of explaining to patients and their family relevant matters related to their condition, and document that this has been done; and
• apologise to Mr C for the failings identified in relation to Mrs C's initial visit to the emergency department and for the communication failures identified.

Summary

Mr C complained about the care and treatment his late wife (Mrs C) received during an admission to the Western General Hospital. Mrs C had advanced lung cancer and her admission was arranged when it was identified that her condition was deteriorating despite treatment. She was discharged home after two weeks with a palliative care package but died in another hospital five days later. Mr C complained about the standard of nursing and physiotherapy care provided to Mrs C during her two-week admission. He also complained about the standard of communication between staff and him and his wife.

We took independent advice from a nursing adviser. The adviser identified various deficiencies in the standard of record-keeping. For instance, pain charts and records of care rounds were not fully completed. However, we were advised that, overall, there were no serious flaws or omissions in the nursing care provided. We did not, therefore, uphold this complaint but we made a recommendation regarding record-keeping. We were also advised that the level of input from physiotherapists was reasonable and we did not uphold this complaint.

We upheld the complaint about communication. The board had already acknowledged that their communication with Mr and Mrs C could have been much better. In particular, they accepted that there was a lack of continuity and consistency amongst medical staff. They also apologised for the lack of suitable private rooms in the hospital for having confidential discussions with patients and their families. We did not consider that the remedial action planned by the board would address all of the identified communication failings, and we asked them to develop a more robust action plan to tackle the issues with medical continuity and consistency.

Recommendations

We recommended that the board:

• reflect on the failings identified, alongside relevant Nursing and Midwifery Council guidance, and inform us of the steps they will take to improve record-keeping;
• develop a robust action plan to address the acknowledged failings surrounding continuity and consistency amongst staff in the medical oncology (cancer) team; and
• apologise to Mr C for the failings identified.

Summary

Ms C was concerned about the care and treatment given to her late mother (Mrs A) at Wishaw Hospital. She felt that Mrs A's symptoms were initially not properly investigated and, had they been, her chances of survival may have been improved. She complained that, other than chemotherapy, Mrs A received little treatment. Ms C also said that the information provided to Mrs A was confusing.

The complaint was investigated and we took independent advice from a consultant general surgeon. We found that Mrs A had a type of stomach cancer that was very difficult to diagnose and was very aggressive. Because of this, there was only a very small chance of any treatment curing the cancer. Although Mrs A was given appropriate tests, the results were not regarded with enough suspicion and, despite not providing an explanation for Mrs A's symptoms, no further investigations were made. Mrs A was not diagnosed until a year later when the only treatment she could be offered was palliative chemotherapy. Mrs A died the following year. In light of our findings, this aspect of Ms C's complaint was upheld.

Mrs A initially responded well to treatment, which may have led her to question her diagnosis and the information she had been given. However, our investigation showed that discussions with Mrs A explaining her diagnosis and treatment had taken place. For this reason, we did not uphold this part of the complaint.

Recommendations

We recommended that the board:

• make a full, formal apology for their failure to diagnose Mrs A sooner; and
• bring the terms of this decision to the attention of the staff involved, including the endoscopist and the junior surgical doctor concerned, for them to reflect upon and discuss at their next formal appraisals.

Summary

Mrs C complained that a trans-abdominal (TA) ultrasound scan (performed by passing the scanning device over the abdomen) she had received at Glasgow Royal Infirmary had not been properly carried out. As a result, she had been forced to seek private treatment. This had consisted of a gynaecological (relating to the female genital tract) examination and a trans-vaginal (TV) ultrasound scan (performed through the vagina, using a slim probe), as well as a TA scan. Three gynaecological problems were identified which Mrs C said the board would have identified if the scan had been done properly. Mrs C also complained that the board had failed to respond to her complaint properly.

We received independent advice from a consultant sonographer (a doctor who performs and analyses diagnostic ultrasound tests). The adviser said that the board's appointment times were too short to carry out the two separate types of scan needed in this case. The adviser noted, however, that of the problems identified during the private consultation, only one would have been apparent had Mrs C received both types of scan. We were advised that the outcome for Mrs C would not, therefore, have been different had she received both types of scan.

We found that, although there was no evidence the short appointment had caused Mrs C harm, she had not received the appropriate scans for her gynaecological condition. We found that the board had, however, responded appropriately to Mrs C's complaint.

Recommendations

We recommended that the board:

• review its standing operating procedures to ensure they provide greater clarity on when a trans-vaginal scan should be performed;
• review the time allocated for ultrasound appointments taking into account any relevant guidance; and
• apologise for the failings we identified.

Summary

Mrs C had a hysterectomy (surgery to remove the uterus (womb)) at Aberdeen Royal Infirmary. She was later discharged and made an appointment with her local hospital (which is in another NHS board area) to have her wound clips removed. A short time after the removal of the clips, once Mrs C had returned home, her wound split open and she had to be admitted to hospital for emergency surgery. Mrs C complained to the board that it was unreasonable that her wound had reopened and that the discharge arrangements were not reasonable.

We took independent advice from a medical adviser, who is a consultant gynaecologist. We did not uphold Mrs C's complaint about her wound reopening. The adviser agreed with the board's own view that this is a recognised, but rare, complication of abdominal surgery. We upheld Mrs C's second complaint regarding discharge arrangements. The adviser considered that there was evidence of leakage from the wound prior to Mrs C's discharge which was not acted on appropriately. During their own investigation, the board had identified failings with the information provided to Mrs C when she was discharged from hospital. However, the advice we received found some remaining issues with the discharge advice and the checklist that the board introduced as a result. We made three recommendations in relation to this.

Recommendations

We recommended that the board:

• issue a written apology to Mrs C, acknowledging the failings our investigation has identified;
• ensure there is feedback to relevant staff on the findings of our investigation; and
• review their checklist and discharge advice for patients who have undergone hysterectomies, in view of the adviser’s comments.

Summary

Mr C enrolled as a student on a postgraduate course at the university. He complained that a lecturer had been dismissive of an enquiry he made during a class, which caused him to feel bullied. Mr C was dissatisfied with the university’s investigation into his complaint. He said the university had unreasonably failed to consider all relevant evidence. This included a failure to interview students who were present when the alleged bullying occurred, and a failure to obtain an audio recording of the class (which was available). Mr C left the university and received a full refund of his course fees.

Our investigation found that the university had addressed Mr C's complaint about being bullied with the lecturer concerned. However, given the serious nature of the allegation, and in the interests of fairness to both Mr C and the lecturer, we considered that the university should have interviewed other students who were present. We also considered that, for the purposes of determining Mr C’s complaint, consideration should have been given to reviewing the audio recording. We found the university had unreasonably failed to consider all relevant evidence and so we upheld this part of Mr C’s complaint.

Mr C also complained that the university did not have suitable policies and procedures in place for managing his allegation of bullying. Although the university did not have a specific bullying policy for students, we were satisfied that they had a number of policies and procedures in place which dealt with allegations of bullying made by students. Therefore, we did not uphold this complaint.

As the university has a specific harassment and bullying policy and procedure in place for their employees, we recommended that they give consideration to introducing such a policy and procedure for students.

Recommendations

We recommended that the university:

• apologise to Mr C for failing to undertake a reasonable investigation of his complaint;
• ensure the findings of our investigation are fed back to relevant staff; and
• give consideration to introducing a specific harassment and bullying policy and procedure for students.

Summary

Mr C complained that his partner (Ms A) was banned from visiting him, and that after the ban was lifted Ms A would have to visit him in closed facilities for nine months. Mr C also complained that the prison did not consider his complaint properly, and that prison staff annotated part of the prison complaint form that was for his use.

We found that rule 77 of The Prisons and Young Offenders Institutions (Scotland) Rules 2011 gave the prison governor very broad discretion to ban a visitor, and did not state a time limit for a ban. Given this, we could not uphold this part of Mr C's complaint.

In most other respects, we were concerned about the prison's handling of this matter. Although rule 78 allows a governor to order that visits must be held in closed facilities, it states that such an order must be reviewed by the governor not less than once in every three months. In this case, the prison put the onus on Ms A after a nine month period, rather than on the governor not less than once in every three months as stated in the prison rules. We were of the view that the prison's letter to Ms A about the ban and the closed visits did not provide clear information about these restrictions and how they could be lifted.

Complaints that go to a prison's internal complaints committee (ICC) should be handled in line with rule 123 and the Scottish Prison Service's own complaints handling guidance. We found that the prison did not follow relevant parts of the prison rules and the guidance in relation to assistance for Mr C at the ICC hearing and calling witnesses. We were also concerned about the language used in the ICC's note of the hearing; and about the annotation of the complaint form by prison staff, as the form is the record of the complaint made and responses given at each stage of the process.

Given the process failings and issues we identified, we upheld the remaining aspects of Mr C's complaint and we made nine recommendations.

Recommendations

We recommended that Scottish Prison Service:

• apologise to Mr C in writing for the administrative failings we identified;
• apologise to Ms A in writing for the administrative failings we identified;
• remind relevant staff of the review timescale set out in Rule 78(3);
• review the imposition of closed visits on Ms A to ensure it is in line with Rule 78(3);
• consider the concerns we highlighted arising from the letter sent to Ms A about the ban and closed visits, to ensure that future letters to any person about a ban and/or closed visits are appropriate;
• write to Ms A setting out the terms of any remaining ban, explaining what supporting information she should supply to appeal the ban, setting out the terms of closed visits, explaining whether she needs to provide supporting information when writing to have closed visits lifted, and explaining what this supporting information should be;
• review the handling of the ICC in this case, and reflect on the ICC's approach and language as recorded in their note of the hearing, to ensure that the same failings are not repeated;
• remind relevant staff of Rule 123(7), GMA 36A/14 and the SPS complaints guidance in relation to assistance for prisoners and the attendance of witnesses at an ICC hearing; and
• ensure that staff do not annotate original Prisoner Complaint Forms (PCFs), and that unannotated original forms are returned to prisoners.

Summary

Ms C owns a childcare business. She initially set the business up with her daughter (Miss A) and registered the partnership with the Care Inspectorate. Miss A subsequently left the business and Ms C's son (Mr A) joined as her partner. This partnership change came to light during a routine Care Inspectorate inspection visit. Ms C was advised that the registered partnership (of her and Miss A) was no longer valid. She would have to de-register and re-register the new partnership with Mr A. It took several months for this to happen, during which time Ms C was uncertain as to the status of her business. She had been advised by her insurers that if she did not have a valid registration, her insurance would be invalid. Despite attempts to clarify the situation with the Care Inspectorate, Ms C was unable to do so and she had to close her business for two days while the re-registration was completed.

We found that Ms C was appropriately advised to de-register and re-register. However, the information she was given regarding her company's status in the meantime was unclear. Whilst the Care Inspectorate had clarified the situation internally, they advised Ms C to seek legal advice and to confer with her insurers. Whilst this advice was not unreasonable, we were disappointed with the lack of a clear answer from the Care Inspectorate as to whether or not Ms C's company was currently registered with them. As the industry regulator and the organisation responsible for registering care services, we felt this was poor. We were also critical of the Care Inspectorate's handling of Ms C's formal complaint.

Recommendations

We recommended that Care Inspectorate:

• apologise to Ms C for the poor communication in response to her enquiries;
• pay Ms C the sum of £500 for the time and trouble that she had to go to to pursue this matter; and
• review their handling of Ms C's complaint with a view to identifying opportunities for improving the process of agreeing the wording of complaints and completing investigations within the published timescales.

Summary

Mr C, a council tenant, complained about the repairs the council did to his home following water ingress. He was also unhappy that he was told he would have to pursue the council's contractor if he wanted to make a compensation claim stemming from those repairs, and also with the way that the council handled his complaint.

Mr C had reported water ingress before and the council had arranged repairs as part of an upcoming maintenance project. He reported water ingress again around a year later, in January 2012, and the council attended promptly to lay sheeting in his loft. The evidence indicated that they did work to the slates on his roof in February 2012. However, in July 2012 another repair was needed which identified a problem with their contractor's workmanship during the historic maintenance project. In assessing whether the council had acted reasonably, we found that they had responded reasonably to Mr C's reports and we did not uphold his first complaint. However, as the council neither acknowledged nor responded to Mr C's complaint within the relevant timescales, we upheld his second complaint.

In terms of Mr C being told to raise his compensation claim with the council's contractor, only a court can determine liability. Our role was limited to considering the council's administrative handling of the matter. The evidence indicated that the council investigated Mr C's claim and passed the relevant information to their claim handlers, whose advice was that the council were not legally liable. Although any compensation claim would still have had to be raised with their contractor, the council agreed a rent rebate and offered Mr C a discretionary payment for his inconvenience. We recognised that, as a council tenant, Mr C felt he should raise concerns with his landlord and we were critical that, on the basis of the paperwork available, there was no clear statement for tenants of the council's position regarding such claims (for example, an information leaflet). In light of the steps taken by the council, we could not say there had been maladministration in reaching their final position and we did not uphold this complaint. In the circumstances, however, we did make recommendations.

Recommendations

We recommended that the council:

• apologise to Mr C for the delay in responding to his complaint;
• work with Mr C to clarify whether their contractor remains in business and how he would go about raising a claim against them; and
• consider how they can improve ease of access for tenants in making such claims against contractors in future (for example, updating relevant leaflets, correspondence and / or paperwork).