Upheld, no recommendations

Summary

C complained about the care and treatment provided to their late parent (A). A had a terminal illness and was discharged from hospital to be cared for at home. A few days later, the family requested a visit from a doctor. They spoke to a doctor on the phone but it was an Advanced Nurse Practitioner that visited them at home. C was also unhappy that A was not provided with emergency medication.

We took independent advice on the complaint from a GP. We found that A should have had a named and experienced clinical lead coordinating and planning their care. We found that it would have been preferable that a GP had visited A following their discharge from hospital. However, it was not unreasonable that A was visited by an ANP. We found that A should have been provided with emergency medicine. We upheld C's complaint.

We noted that the practice had recognised potential failings and had demonstrated that they had taken reasonable learning and improvement action. Therefore, we made no further recommendations.

Summary

C complained that the council had failed to follow the correct procedures for issuing a building warrant to a neighbouring property. C had raised issues due to noise ingress to their property, which C attributed to alterations to the approved design for the neighbouring extension.

The council acknowledged that an amendment to the building warrant should have been sought and apologised for this. They noted that the original officer who dealt with the case had left the council, but a review of the works carried out had satisfied the council that the works complied with building standards and that had an amendment to the building warrant been sought, it would have been granted.

We took independent advice from an appropriately qualified building standards adviser. We found that the actions taken by the council were reasonable. The council were acting within their discretionary powers by determining that the building work carried out met the relevant standards. The council correctly identified that an amendment to the warrant should have been sought and had taken the appropriate steps to address this. Therefore, we have upheld this part of C's complaint but have made no further recommendations due to the appropriate action already taken.

Summary

C’s elderly parent (A) had recently been discharged from hospital where they had been treated with antibiotics for a urinary tract infection. However, A continued to experience nausea and vomiting along with hallucinations and A’s GP requested an ambulance be provided for A within one hour. Although the Scottish Ambulance Service (SAS) made a number of calls to A’s home to check on them, no ambulance attended. A’s condition deteriorated throughout the day and C called to request an ambulance again. However, no ambulance attended and an out of hours GP subsequently requested an urgent ambulance for A. An ambulance later arrived and A was assessed as having had a possible heart attack and received treatment from the ambulance crew before being taken to hospital.

C complained about the length of time it took for an ambulance to attend A. C considered that SAS did not recognise the severity of A’s condition or the damage to A’s heart and that they failed to appropriately prioritise an ambulance for A, unreasonably delaying their treatment.

SAS acknowledged that the delay to an ambulance being provided for A had been unreasonable, explained the particular challenges that they had faced on the specific day in relation to frontline staffing, service demand and hospital admission capacity, outlined the steps they were taking to prevent recurrence and apologised for A’s experience.

We took independent advice from a paramedic adviser. We found that there was opportunity for the board to take further steps to prevent recurrence. The information the board provided in response to this indicated that improvements are taking place. After careful consideration, we upheld the complaint given the delay that the board have already accepted and apologised for. The steps that the board had taken and are taking since are reasonable and we made no further recommendations.

Due to a technical error, only half of the intended decision summary was published on the 24 May 2023.  The paragraph in italics below was added on 8 January 2024 once the error was identified.

Summary

C complained about the care and treatment provided to their late parent (A). A felt unwell whilst residing in a care home. They were coughing up blood associated with green phlegm and had chest and abdominal pain. Staff at the care home contacted NHS 24 and were advised that a home visit would be conducted. However, the GP subsequently carried out a telephone consultation due to concerns around the transmission of COVID-19. They diagnosed A with a chest infection. A second GP visited 48 hours later and suspected A had pulmonary embolism (a blocked blood vessel in the lungs) and deep vein thrombosis (a blood clot in a vein). A was admitted to hospital where this was confirmed. A died a few months later and C said that pulmonary embolism was described as a contributing factor on their death certificate. C was concerned that the GP did not conduct a home visit and subsequently failed to correctly diagnose A's condition and instead focused on the transmission of COVID-19 and associated risks. C believes that if a home visit had been conducted, A would have been correctly diagnosed 48 hours earlier and could have received treatment.

The board responded and identified some issues in the medical history and documentation taken. C remained dissatisfied with the board's response and brought their complaint to us.

We took independent advice from a GP. We found that it was reasonable that no home visit was offered in the context of COVID-19. However, the medical history and particularly the documentation taken by the GP was unreasonable. In particular, there was no documentation to support the consideration of respiratory rate/breathlessness, leg pain/swelling and pulmonary embolism. In view of these failings, we upheld C's complaint that the board failed to provide A with reasonable care and treatment. The board had already apologised for the failings and had highlighted them to relevant staff as a learning point. However, we  provided some further feedback to the board.

Summary

C attended A&E following problems they had had with their elbow. Their doctor had advised them to go to A&E if it worsened. C complained that they were not properly triaged as they were not triaged in a private area and their pain score was not noted.

We took independent advice from a nurse. We found that the triage process had not been appropriate. The board had also accepted this and put in place measures to improve the triage process. Therefore, we upheld C's complaint but did not make any recommendations in light of the actions already taken by the board.

Summary

C complained that the practice failed to provide a face to face appointment to their late spouse (A) which contributed to a delay in onward referral, and ultimately delayed diagnosis of amyloidosis (a condition in which amyloid proteins build up on organs like heart, kidney and liver).

A had multiple telephone consultations with their GP over the year, presenting with varying symptoms. C complained that the frequency with which A presented should have prompted a face to face appointment. The practice response stated that it was not common practice to offer face to face assessment during the COVID-19 pandemic and that A had not requested a face to face appointment

We took independent medical advice from a GP adviser. We found that the practice’s failure to offer a face to face appointment was not reasonable. The frequency with which A presented and the symptoms that they described should have been identified as ‘red flags’ which triggered a face to face appointment and onward referral for specialist investigation, regardless of COVID-19 restrictions in place at the time. Therefore, we upheld this complaint.

We noted that the practice had already reflected extensively on their management of A, demonstrated learning and things that they would do differently in future, and offered apology to C. As such, we made no further recommendations.

Summary

C complained about Scottish Ambulance Service (SAS) on behalf of A for whom they hold welfare Power of Attorney. A waited for an ambulance for nearly 21 hours. A has multiple sclerosis (a disease that affects central nervous system), lives in a care home and usually has a catheter (a thin tube used to drain and collect urine from the bladder). The catheter was not working and there was concern that A had an infection.

C was unhappy with the delay as A had a known history of sepsis (blood infection) as a result of urinary infections. C also said that A’s case had been incorrectly prioritised, that they had received only two calls from SAS during the wait, and that the overall time waiting for the ambulance had been unreasonable.

We found that A’s case had been correctly triaged and prioritised by SAS clinical support desk paramedics, however, we noted that SAS did not meet their own standards for the frequency of welfare calls but recognised that the service was under extreme pressure at the time. We upheld the complaint that the ambulance response time was unreasonable as it had taken nearly 21 hours to attend the patient, which significantly breached the 60-minute target for cases like A’s.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

Summary

C complained that the board failed to provide their child (A) with orthognathic treatment (orthognathics is a specialist subset of dentistry which involves surgical correction of growth issues with the jaw and lower face) within a reasonable timescale.

A's teeth were overcrowded to the extent that they caused pain in their head and jaw and difficulties with eating and speech. Following referral to an orthodontist, A was placed on the waiting list for orthognathic treatment. However, despite it being identified that A would require surgery, their treatment was not progressed. The board explained to C that this was due to a shortage of orthognathic specialists in their area and that an agreement with neighbouring health boards for them to provide treatment had come to an end. C complained that the board had failed A by not providing the required treatment within their area, or making arrangements for the treatment to be provided in another area, or privately.

The board were open and honest about the fact that they struggled to provide specialist orthodontic and orthognathic appointments over a number of years due to staff recruitment issues and the loss of arrangements with neighbouring health boards. They acknowledged and apologised for the fact that this led to substantial delays for A. We commended the board for their transparency in this respect and acknowledged that there were a number of factors beyond their control that limited the provision of these services and contributed to a long waiting list for all patients in the area.

We took independent advice from an orthodontic specialist. We found that, whilst it was recognised at an early stage that A would benefit from orthognathic surgery, this treatment would not have been available to A for a number of years. Surgery was first discussed when they were 11 years of age. We noted that, prior to surgery, there would be 12 to 36 months of preparatory orthodontic treatment and this would not normally start until the patient was 15 or 16 due to their bones needing to develop. Once this preparatory treatment had been completed, a multidisciplinary discussion would be undertaken to assess the nature of the surgery that would be required. The available evidence showed that the board followed this approach for A.

Whilst we were satisfied with the overall treatment plan for A, we found that there was an unreasonable delay of around 18 months to A being seen by a consultant following their referral to the orthognathic service. Although this did not delay A's treatment, we recognised that the long wait for a consultation and details as to what treatment options were available would have added to C and A's distress. Therefore, we upheld this complaint. We did not make any recommendations due to the appropriate action already taken by the board.

Summary

C complained that Castle Water Ltd did not reasonably handle matters related to a water leak. C operated a bed and breakfast business from their home (the premises). Castle Water Ltd were appointed as the Licensed Provider for water and waste water services at the premises.

Scottish Water fitted a water meter to the pipework supplying the premises so that water usage could be measured for commercial water charges. C subsequently received water bills that were disproportionately high for the number of residents and guests in the premises. Following a number of attempts to speak to someone at Castle Water Ltd, C was eventually able to raise their concerns around four months after the meter was fitted.

A representative of Castle Water Ltd attended the premises and it was established that there was likely a leak on the pipework between the meter and the premises. C was advised that this pipework was their responsibility and that they would need to appoint a contractor to locate and repair the leak. Ultimately, C’s contractor replaced the full length of pipe from the premises to the meter at a cost of over £10,000.00. Whilst no leak was found, the water usage dropped to an acceptable level following the works.

In replacing the pipework, the contractor found that a length of narrower pipe had been used to connect the meter to the premises’ pipework. C said that, had Scottish Water made them aware that the narrower pipework had been used, the contractor could have passed a similarly narrow pipe through the existing supply pipe, negating the need to excavate the ground and saving C a substantial amount of money.

C attempted to recover the cost of the excavation works from Scottish Water through Castle Water Ltd. C complained that Castle Water Ltd failed to reasonably assist them to do so. C also complained that the staff failed to adequately communicate with them regarding their water account and the issues relating to the leak.

We found that Castle Water Ltd took reasonable steps to assist C to resolve the leak problem and represented C’s side of the matter appropriately when dealing with Scottish Water. We found that their actions in relation to the leak and C’s account were entirely reasonable once the presence of a leak was identified. However, we found that C faced unreasonable delays initially when attempting to query their high water bills with Castle Water Ltd and that this contributed to an overall delay in the leak being fixed. Whilst we were critical of this, we recognised that Castle Water Ltd had already acknowledged and apologised for the poor service C received in this regard and had taken reasonable action to put matters right. We upheld C's complaint but made no further recommendations.

Summary

C complained to the council but did not receive a response until two years later.

We found that the council failed to acknowledge the complaint within the timeline as set out by the Model Complaints Handling Procedure. The council failed to update C while they were waiting for the council’s response, and the length of time it took for the council to provide a response was excessive and unreasonable.

As such, we upheld this complaint. Due to the learning and actions taken by the council after they issued their response we did not make recommendations as appropriate action had already been taken.