Some upheld, recommendations

Summary

Mrs C complained on behalf of her mother (Mrs A) about the care and treatment she received at Monklands Hospital in 2013 and 2014 for liver-related disease. Specifically, she complained that a specialist procedure was not performed in 2013 and the aftercare arrangements were poor; that during a second admission in 2014 Mrs A's condition continued to deteriorate until she was transferred to a different hospital where a liver transplant was performed; and that she was malnourished prior to the transplant.

In their complaint response, the board did not identify failings in the care and treatment but acknowledged that communication with the family could have been better.

We took independent advice from two of our medical advisers, a consultant gastroenterologist (who specialises in the treatment of conditions affecting the liver, intestine and pancreas) and a consultant gastroenterologist and hepatologist (who specialises in liver disease). We found that the treatment given in 2013 was in line with national guidance and, whilst there were records to show that there was an appropriate discharge plan in place, there was no evidence to demonstrate that this had been explained to either Mrs A or her family. Furthermore, given that Mrs A had abnormal blood tests, we were critical that the consultant who discharged her failed to reasonably monitor her. Therefore, we upheld this aspect of the complaint and made three recommendations. We considered that the care given in 2014 was appropriate and, having also taken independent advice from our nursing adviser, we found that there were factors that impacted on Mrs A's ability to take oral nutrition and we did not uphold this aspect.

Recommendations

We recommended that the board:

• apologise to Mrs A for the lack of communication surrounding her discharge plan;
• review their procedures for arranging follow-up clinic appointments and for reviewing abnormal blood results, specific to this case, to identify any learning; and
• share the failings identified with relevant staff.

Summary

Mrs C complained about the treatment her father (Mr A) received from the board. In 2013 Mr A began to experience difficulties with his mobility and memory. Mr A was referred to the board's Falls, Stroke and Memory clinic at Coathill Hospital where he was seen by a consultant. A CT scan (computerised tomography scan) was arranged, which showed some shrinkage of the brain. The consultant referred Mr A for an MRI scan (magnetic resonance imaging scan - a more detailed scan than the CT scan). However, the radiologists questioned whether the scan was required, as they did not feel that an MRI would provide any additional useful information. They suggested a discussion with the referring consultant, however, Mrs C said that this did not take place.

Mr A was disappointed that the MRI scan did not go ahead and arranged for the scan privately. This resulted in a diagnosis of vascular Parkinsonism (a form of Parkinson's disease, a progressive neurological condition in which part of the brain becomes more damaged over many years). Mrs C complained that the radiologists inappropriately rejected a test that had been identified as necessary by Mr A’s consultant.

We took independent medical advice from one of our advisers. We accepted the advice that the consultant's decision to request an MRI scan was reasonable but that it is a radiologist’s duty to ensure that patients are not subjected to unnecessary imaging. When a radiologist believes imaging might be unnecessary, they should get clarification on the need for it. We were satisfied that a discussion did take place between the referring consultant and radiology, and that it was agreed that the MRI would not necessarily add anything to the diagnosis that had already been made. Whilst we found that Mr A’s treatment may have differed slightly had the MRI been carried out, we did not consider there to be a significant impact on his treatment.

We were critical of the board’s handling of Mrs C’s formal complaint and made a recommendation to address this.

Recommendations

We recommended that the board:

• apologise to Mrs C for the failings in complaints handling which have been identified in this report.

Summary

Ms C complained that when she first registered with her new GP she had difficulty in getting an appointment. When she first saw a GP, two weeks after joining the medical practice, she was refused a prescription for regular medication for various conditions as her medical notes had not yet been transferred from her old practice. Ms C also complained that she was removed from the practice list for alleged abusive behaviour, and that the practice failed to deal with her subsequent complaints.

We took independent advice from one of our GP advisers. They told us that records can sometimes take up to 12 weeks to be transferred between NHS practices when a patient changes GP. Therefore, it is common practice for basic information, including details of repeat medications, to be faxed over to the new practice to prevent any delays in prescriptions being issued. The adviser was particularly concerned that Ms C was on medication that can have serious withdrawal symptoms if stopped suddenly. We upheld this aspect of Ms C's complaint.

On the issue of Ms C being removed from the practice list, there was evidence that the staff at the practice found Ms C's behaviour, at times, to be unacceptable. While there does not have to be any intention to behave in an unacceptable way by the patient, where a GP considers that a patient's behaviour is unacceptable, they have the right to ask for that patient to be removed from their list. We did not uphold this aspect of Ms C's complaint.

In relation to the handling of the complaint, Ms C said that she had hand-delivered four letters of complaint between October and December 2014 but the practice said they had no record of the letters being received by any staff member. Following contact with our office, the letters were copied to the practice and were dealt with within the timescales laid down by the NHS guidance on complaints handling. We did not uphold this aspect of Ms C's complaint.

Recommendations

We recommended that the practice:

• issue a written apology for the failings identified; and
• implement a system for contacting the previous practice of NHS patients transferring to them to obtain basic details of previous medical history and regular medications.

Summary

Ms C, who is an advice worker, complained on behalf of Mrs A's family about the care and treatment provided to Mrs A by Southern General Hospital when her life-support machine was switched off. Mrs A was admitted to hospital after sustaining a severe injury at home, and put on a life-support machine. After being told by hospital staff that she could not survive, the family agreed to switch off the life-support machine. However, unexpectedly, Mrs A continued to live for a further 20 days. During this period, the family said there were communication failures; they did not know what was being done and what to expect in terms of care. They were also concerned that staff failed to provide appropriate care, particularly in relation to pain relief, fluids and nutrition. At the end of Mrs A's life, she was transferred to another hospital (Glasgow Royal Infirmary). The family said that her medical records were not transferred with her which meant that appropriate care could not be provided within a reasonable time at the second hospital. Finally, the family complained about the way the board had handled the complaint.

We took independent advice from one of our medical advisers. We found that the standard of care provided in relation to medication, nutrition and fluids was reasonable, and that sufficient information accompanied Mrs A when she was transferred to the second hospital. We were also satisfied that the evidence indicated that the family were kept fully informed of Mrs A's condition and prognosis. However, we found that the language the board used in their response to the complaint was inappropriate and insensitive, and that the response was overly technical and difficult for a layperson to understand.

Recommendations

We recommended that the board:

• take steps to ensure that Glasgow Royal Infirmary are complying with Records Management: NHS Code of Practice (Scotland);
• ensure that appropriate and sensitive language is used in complaint responses; and
• apologise for the failures this investigation identified.

Summary

Mrs C complained about the care and treatment her husband (Mr C) had received from the board in relation to brain tumours. We took independent advice on this part of her complaint from one of our medical advisers, who is a consultant neurosurgeon. We found that it had been reasonable not to give Mr C radiotherapy after a tumour had been removed at the Western Infirmary. However, Mr C had also been receiving other treatment that would have increased the risk of early or more rapid progression of a recurrent tumour. We found that it had been unreasonable for the board to wait eleven months before carrying out a follow-up scan. In view of this, we upheld this part of Mrs C's complaint. When the follow-up scan was then carried out, it showed a large recurrent tumour.

Mrs C also complained about the nursing care provided to Mr C whilst he was in the Southern General and Beatson Hospital. We took independent advice on this from a nursing adviser and we found that the care provided had been reasonable so we did not uphold this aspect of her complaint. Mrs C also said that the board had failed to adequately explain Mr C's condition and prognosis. Whilst the evidence in relation to this was not conclusive, the comments made by the consultant about the information given to the family were somewhat vague, and Mr and Mrs C had not fully understood what the consultant was trying to say. We found that, on balance, the information had not been satisfactorily communicated to Mr and Mrs C and so we upheld this aspect of the complaint. Finally, Mrs C complained about the board's handling of her complaint. We found that the board's response had been difficult to understand. It contained too much medical terminology and jargon that was not adequately explained. We upheld this part of her complaint for this reason.

Recommendations

We recommended that the board:

• issue a written apology to Mrs C for the failings we identified;
• make the relevant staff involved in Mr C's care and treatment aware of our findings; and
• remind the staff involved in the handling of Mrs C's complaint that responses to complaints should be clear and easy to understand.

Summary

Ms C complained that the board failed to adequately manage her Von Willebrand Disease (VWD – an inherited bleeding disorder) when she was admitted to Aberdeen Royal Infirmary for gall bladder surgery. She said she had previously been given medication for her VWD before dental treatment and treatment for cancer, but said this did not happen for her gall bladder surgery. Ms C also complained that the board failed to communicate properly with her about her VWD when she was in hospital.

We obtained independent medical advice on Ms C’s case from a consultant haematologist with specific expertise in blood clotting disorders. Our adviser said that Ms C’s VWF levels (levels of a blood protein which helps blood to clot) were checked on the day of her surgery and found to be within the normal range. As a result, the board decided not to treat Ms C with a concentrated form of the clotting agent, but to have it ready in case any problems arose. Our adviser said that this approach was reasonable.

The board apologised for the lack of communication with Ms C about her VWD and said that staff should have explained and discussed her condition with her. Our adviser said that communication could have been improved by checking Ms C’s VWF levels the day before surgery, rather than on the day of her surgery, and making a decision on whether she required treatment with the concentrated form of the clotting agent at that time. This would have allowed more time for discussion with Ms C about VWD and the proposed treatment, and at a less stressful time than on the day of her operation. This would have increased the chances of Ms C understanding and accepting the apparently conflicting advice about the management of her condition. We were critical of the board in this regard.

Recommendations

We recommended that the board:

• feed back our decision on the complaint about the board's communication regarding VWD to the staff involved.

Summary

Mr C had treatment to extract two teeth. Immediately after the treatment, he complained about the treatment received and that the dentist had failed to take reasonable account of his hearing condition. He complained that his dentist took too long to carry out the extractions and that he did not appear able to carry out the extractions. He also said that he had advised his dentist of his need to lip read in order to fully understand what was being said to him. However, during the procedure, the dentist had continued to speak to him with a mask on.

We took independent advice from our dental adviser, who said that the treatment Mr C received was reasonable and appropriate and that, while the extractions had taken some time, this was reasonable in this case. Our adviser explained that guidance issued by Health Protection Scotland requires dentists to wear full personal protection equipment (PPE), including a mask, during any operative procedure. As such, he considered that it would not have been reasonable to expect the dentist to repeatedly stop the procedure and remove his mask to speak to the patient. This would have required the dentist to remove his PPE, undertake hand hygiene and put on new PPE on each occasion that he stopped to speak to the patient. However, we were mindful of Fife NHS Board's advice that requires staff to respect disabilities. We considered that, in the circumstances, consideration should have been given to offering Mr C the services of an advocate/translator/interpreter or similar. This would have ensured that he fully understood what was being said to him during the procedure.

Recommendations

We recommended that the dentist:

• reflect on this case to guide future practice to ensure that a patient's communication needs are being met. In particular, that in a similar situation consideration should be given to offering a patient the services of an advocate/translator/interpreter or similar who could speak to the patient without wearing a mask.

Summary

Mr C complained that his university unreasonably required him to re-attend for a whole academic year, after he failed to submit a piece of coursework for a module. Mr C was also unhappy with the university's handling of his complaint.

We found that Mr C assumed he could re-sit the coursework at the end of the academic year. However, university regulations said that, in the circumstances, Mr C was required to re-attend. Mr C, as an enrolled student, was bound by university regulations and had confirmed his acceptance of them. Therefore, he had to re-attend. We did not uphold this part of Mr C's complaint.

We found some failings in the adminstration of Mr C's complaint, where the university had not followed their complaints procedure in respect of stage one of the process. We upheld this part of Mr C's complaint.

Recommendations

We recommended that the university:

• remind relevant staff of the stage one process in their complaints handling procedure.

Summary

Mr C passed the first part of his course, but his grades were not high enough for automatic progression to honours. The university invited Mr C to a Progress Committee Meeting (PCM) to determine whether he would be granted conditional entry to honours. Mr C did not attend the PCM. The university offered to reschedule it but in the meantime they became concerned that Mr C was not well enough to attend the PCM and/or classes. They arranged a meeting to discuss this, and a referral to occupational health for assessment. Occupational health confirmed Mr C was fit to study. The PCM was held soon after this and did not grant conditional entry to honours. Mr C appealed against this decision, but the university did not uphold his appeal. Mr C also asked to be allowed to attend lectures while the appeal was being considered, but the university did not allow this. Mr C complained about the university’s handling of the PCM and appeal process, and also that the university failed to take into account his disabilities and mitigating circumstances. He also complained about the university’s handling of his complaints.

The university said Mr C had been given ample opportunity to present his case for the PCM and appeal, including multiple extensions to enable him to request documents under freedom of information (FOI) legislation. The university said Mr C’s mitigating circumstances were taken into account, but Mr C did not notify them of a disability until after the PCM. He had also still not provided any medical evidence for this, although the disabilities adviser contacted him to request this. The university considered that they responded to Mr C’s fourteen complaints in accordance with their procedures.

After investigating Mr C’s complaints, we found he was given a reasonable opportunity to present his case to the PCM and appeal. Although Mr C did not receive all the documents he requested under the FOI process, the university did grant significant extensions, and we considered that he had a reasonable opportunity to make his case. We also found Mr C had no automatic entitlement to attend lectures while his appeal was being considered, and there was no evidence the university acted improperly in deciding not to allow this. We found Mr C did not comply with the university’s requirements for registering a disability, and so the university did not act unreasonably by not taking this into account in the PCM and appeal. However, we found that the university should have explained more clearly to Mr C when they decided not to investigate part of one of his complaints (which was being considered in the appeal process instead). We were also critical that the university did not follow the relevant procedure for managing unacceptable behaviour when deciding not to respond to further complaints from Mr C (in particular, failing to give Mr C a formal warning, and failing to make arrangements to review this decision, or for Mr C to appeal it).

Recommendations

We recommended that the university:

• issue a written apology to Mr C for the failings our investigation found;
• remind complaints handling staff of the need to provide a full and proportionate response to complaints, including explaining the reasons for the decision; and
• revise the procedure for managing unacceptable behaviour in line with the model Complaints Handling Procedure.

Summary

Miss C complained that the council failed to properly investigate when she complained to them that she had been knocked off her bicycle by a council employee who opened his van door directly into her path. She complained that the driver did not stop to make sure she was unhurt. She said he said that she should have rung her bell and he then left in his van. She also complained to our office about the significant length of time it had taken the council to respond to her complaint. The council eventually wrote to Miss C to advise that they were unable to trace the van or driver from the details Miss C had provided and could not, therefore, accept any liability for the incident.

Although the issue of liability in an accident like this can only be determined by the courts, we did look into the background of the case in order to establish whether or not the council's investigations into the incident were reasonable, and whether they had dealt with Miss C's complaint appropriately.

We found that the council did conduct an investigation to identify the van and driver involved but, on the basis of the limited information provided by Miss C, they were unable to identify the vehicle or driver. We found their investigations to be reasonable. However, we noted that the council initially failed completely to respond to Miss C's complaint and, when they did contact her, this was through the claims process rather than the complaints process. We noted that the council did not respond to the questions Miss C raised in her complaint even after prompting by our office. It was not until we had begun our investigation that the council finally wrote to Miss C to answer her questions and to provide information about how to complain to our office. As a result of these failings, and the significant delay in responding to her complaint (around 15 months), we upheld this aspect of the complaint. We recommended to the council that they review their procedures, in light of our findings, in order to ensure that complaints are directed to the relevant team for response.

Recommendations

We recommended that the council:

• review the process they follow, in light of the circumstances of this case, when identifying and acknowledging complaints to ensure that in future, complaints such as these are passed to the appropriate service for response in line with their complaints procedure, and let us know when this review is complete.