Upheld, no recommendations

Summary

Mr C called an ambulance after finding his wife (Mrs A) in a concerning condition. The ambulance took longer to arrive than Mr C felt was reasonable, and he made further calls to the Scottish Ambulance Service (SAS) before it arrived.

When Mr C complained to SAS about this, their investigation concluded that the call had not been handled in line with their protocol and that, had protocol been correctly followed, a higher acuity may have been given to the call and an ambulance diverted from another call to respond. SAS apologised for the delay in the ambulance arriving and took steps to prevent a similar situation recurring. Mr C was dissatisfied and raised his complaints with us.

We found that there was an unreasonable delay in the ambulance arriving but found no evidence to determine whether a higher acuity would have been given or an ambulance diverted if the protocol had been followed correctly. We upheld the complaint but made no further recommendations.

Summary

Mr C complained about the assessment and subsequent care package offered in respect of his son (Mr A). Mr C moved from another local authority area where he was in receipt of a package of care for Mr A. Following an assessment of Mr  A's needs after he moved to Edinburgh, Mr A was awarded a significantly reduced budget. Mr C disagreed with the amount of funding provided and complained that there was a lack of transparency about the assessment and decision-making process.

The council explained that different local authorities will have different eligibility criteria, therefore, it is likely that they will not receive the same level of funding. The council also acknowledged that the package of care perhaps did not meet Mr A's needs and that they could have elaborated further on the reason for their decision.

We took independent advice from a social worker. We did not find any evidence of maladministration in the fact that the council had a different eligibility criteria and threshold for funding compared to the other local authority. However, we did find that there was a lack of transparency in terms of the council's assessment and decision-making process and that this was not in line with national guidance. Therefore, we upheld Mr C's complaint. We noted that the council have taken reasonable steps to review and improve their procedures and they also reviewed Mr A's assessment, therefore, we did not make any further recommendations.

Summary

Mr C complained that the council failed to reasonably record and investigate concerns about bullying in line with their obligations. Mr C said that staff at his child's (Child A) primary school failed to apply their anti-bullying policy and guidelines, specifically that they failed to identify bullying behaviour.

The council confirmed there was evidence of bullying behaviour. They advised each allegation of bullying was investigated and the head teacher fed back findings to Mr C. The council also outlined other steps they had taken to support Child A. The council acknowledged that not all incidents of bullying had been updated on their system. They apologised to Mr C for this and advised that this matter had been addressed with all head teacher's within the local area to ensure all allegations of bullying are formally recorded regardless of the outcome of the investigation.

We found that the council's policy does not require the school to take specific actions. It requires them to take some action based on the individual circumstances of the incident(s). We considered that the school had been responsive to Mr C's concerns and explored a number of options available to them to address the bullying behaviours reported and support Child A. However, while the investigation by the school was reasonable, the recording of information was not. Therefore, we upheld Mr C's complaint but did not make any recommendations due to the action already taken by the council.

Summary

Mr C complained that NHS 24 failed to handle his call appropriately. Mr C initially phoned 999 to request an ambulance for his wife (Mrs A). However, it was deemed that an ambulance was not required and Mr C was referred to NHS 24 for a further assessment of Mrs A's symptoms to be carried out. Mr C complained to NHS 24 about the call handler's line of questioning and their refusal to send an ambulance. NHS 24 acknowledged the call could have been handled better. Mr  C was unhappy with this response and brought his complaint to us.

We took independent advice from a nursing adviser who reviewed the case records and the audio recording of the call. We found that the call handler should have been more flexible in their questioning and they could have been more empathetic and understanding of Mr C's frustration. We upheld the complaint and asked NHS 24 to provide an update on the learning and improvement they had already identified.

Summary

Mr C complained on behalf of his late wife (Mrs A) that an ambulance crew unreasonably failed to take Mrs A to hospital. Mrs A had taken a reaction to medication which had recently been prescribed for her and her blood pressure had dropped to a dangerous level. The crew felt that it was appropriate for Mrs  A to remain at home as she was due to have a visit from a specialist nurse the following day. Mrs A died a short time later.

We took independent advice from a professional adviser. We found that the crew had managed to obtain two blood pressure readings from Mrs A and they were both at critically low levels. We considered that the blood pressure readings should have indicated that Mrs A was critically unwell and required assessment and treatment at the hospital which may have prevented her death. Therefore, we upheld Mr C's complaint.

We did not make any recommendations in this case as the ambulance service have accepted these failings, apologised and taken appropriate actions to prevent future failings.

Summary

Mr C complained about the care and treatment his late father (Mr A) received when he attended the emergency department at Monklands Hospital, after having been involved in a minor road traffic accident. The board concluded that Mr A had a soft tissue injury and he was prescribed paracetamol and ibuprofen. Mr A returned to the emergency department one week later reporting worsening symptoms. A further assessment was carried out and it was noted his international normalised ratio (INR - a measurement of how long it takes blood to form a clot) levels were high and fractures to his vertebrae and ribs were identified. Mr A's condition deteriorated significantly and he developed sepsis (a  blood infection) and discitis (inflammation between the discs of the spine). Mr  A died as a result of these complications. Mr C complained that the board failed to note that his father was taking warfarin (a drug used to prevent blood clots) and he should not have been prescribed ibuprofen. Mr C also complained that the fractured vertebrae and ribs were not identified during the first assessment.

We took independent advice from a consultant in emergency medicine. We found that the assessment of Mr A's symptoms was reasonable and an x-ray to inspect for fractures was not warranted. However, we considered that the prescribing of ibuprofen was not reasonable and other forms of pain relief could have been considered. Therefore, we upheld the complaint. We did not make any recommendations as the board had already taken steps to address this failing.

Summary

Mrs C complained in her own right, and on behalf of four other parents, that a head teacher failed to follow relevant procedures after an incident involving scissors at a school, and about the council's handling of complaints about the incident.

We found that the council's Anti-Weapon/Knife Crime Policy stated that certain actions were to be taken on the day of an incident, including the weapon being confiscated and placed in a locked cabinet; the police being notified; and senior management and specific council staff being notified. The evidence showed that none of these actions were taken on the day of the incident.

We also found that the council's responses to the complaints did not reasonably reflect the findings of the council's investigation, and did not include an apology for the police not being notified on the day of the incident. In addition, the council's handling of the complaints was not completely in line with the complaints handling procedure.

We upheld Mrs C's complaints. We found that the council had already taken steps to remedy the failings identified and so we did not make any further recommendations.

Summary

Mr C was seeking a referral to children's Occupational Therapy (OT) services for an assessment. Mr C was told he was not eligible for this service as he was 17  and no longer attended school. He was asked to make a new referral for adult OT services. Mr C did this and was assessed but discharged as the OT decided that his needs would be best met by local services in a community setting. Mr C was unhappy about this and complained to the board. He made a further referral to children's OT Services at the same time as his complaint and was this time seen by the service. Mr C complained that the board failed to progress his referrals to OT in a reasonable manner.

Mr C had also highlighted that the NHS website states the children's OT service is for children aged 0-18 and, therefore, he should have been assessed by them from the outset. The board responded by initially reiterating that Mr C was 17  years old and not at school so was more suited for adult services. However, in subsequent responses to Mr C they clarified that the children's OT service only has standardised assessments from age 0-16. They also advised there is no set criteria but instead, a flexible approach is adopted depending on the patient's individual circumstances. They acknowledged that Mr C had not received a clear explanation about why he was referred to adult OT services and apologised for this failing.

We considered that there had been poor communication and mixed reasons given to Mr C for directing his referral and upheld his complaint. However, the board advised that they had taken steps to review the triage service (a process in which things are ranked in terms of importance or priority) for the OT department. This included staff phoning children or parents who made referrals to gather more information to help signpost or assess patients from the outset. Additional staff have had training to make these calls and the board advised that the data they had reviewed so far indicated this was a positive change to the process. As a result of the positive steps taken by the board, we made no further recommendations.

Summary

Mrs C has power of attorney for her son (Mr A) who has a learning difficulty and lives independently. Mr A was awarded an Individual Service Fund (ISF) under self-directed support by the board to support him to achieve his personal outcomes.

Mrs C complained that the board did not act reasonably in relation to the ISF. She said that the board unreasonably refused certain funding requests, that they failed to follow procedure and to provide clear information about their policies and procedures. The board acknowledged that their communication regarding their processes was poor, however they did not consider the funding requests sustainably supported Mr A to meet his personal outcomes.

We took independent advice from a social worker. We found that it was reasonable for the board to refuse some of the funding requests, but not all. We found the board failed to ensure the ISF agreement was completed and signed and this was not done until more than 12 months after the ISF started. We concluded that the board did not properly follow procedure and that there were failings in their communication with Mrs C. Therefore, we upheld the complaint. We noted the board had made some significant improvements since Mrs C raised her complaint, therefore we did not make any further recommendations. However, we did ask the board to provide us with evidence of these changes.

Summary

Mr C complained that the board failed to arrange his appointment for prostate surgery following a referral from another board within a reasonable time. Mr C's concerns included that the board unreasonably failed to send the letter for his appointment with the consultant at New Victoria Hospital to his correct address and that it was nearly three months until he was seen at the hospital. He also said the board failed to acknowledge the impact of the delay in arranging his appointment on the treatment of his cancer, including that he was advised by the board that he could not have the proposed surgery.

We took independent advice on the case from a consultant urologist. We found that the delay in Mr C's appointment was not acceptable. The board explained that they had Mr C's old address in their patient management system and when they received his referral, they failed to update the address. The board apologised for this and said that staff had been reminded of the importance of checking patient details on receipt of referrals and carrying out updates where necessary. They said the member of staff involved had been made aware of the considerable impact the error had on Mr C and would be given additional training, following which their performance would be closely monitored. We asked the board to provide us with evidence of their remedial action.

We found that the board correctly stated that the delay in Mr C's appointment would have been unlikely to have accounted for Mr C's cancer moving from operable to inoperable. The adviser said they did not think that there was a change in the extent of Mr C's cancer between him being referred to the board and him being seen by the consultant at the board.

We upheld Mr C's complaint. We asked the board to provide us with evidence of the steps they have taken to stop these failings occuring again in the future, however we made no further recommendations.