Upheld, no recommendations

Summary

Mr C complained that he was not receiving the time off from his prison work party that the prison rules state prisoners should receive. The prison advised that there was a historic arrangement in place whereby prisoners agreed to work extra hours. However, they acknowledged that this was not in line with the relevant prison rules and confirmed that steps had been taken to provide sufficient cover so prisoners would receive the required time off work in future. We upheld the complaint but as appropriate steps had already been taken to remedy the identified failing, we did not make any recommendations.

Summary

Mr C complained that the board delayed in giving him his cardiac medication after he was admitted to prison. Mr C had a heart attack two days later and required surgical treatment. He was unhappy that the board withheld the medication he had in his possession at the time of admission to prison.

The board accepted that it had taken 24 hours longer than it should have done to verify and prescribe Mr C's medication. They apologised to Mr C and advised him of the steps they had taken as a result of the incident to reduce the likelihood of it recurring.

We took independent advice from one of our GP advisers and found that it was appropriate for the board to confirm Mr C's prescribed medication in line with General Medical Council guidance. However, we were critical that there was an unreasonable delay in this being done, although it was unlikely to have caused Mr C's heart attack.

Whilst we upheld the complaint, we made no recommendations as the board had taken reasonable action as a result of the incident to identify learning and improve their practice to ensure the matter would not recur.

Summary

Mrs C attended an out-of-hours GP service with sinus congestion and ear pain. Mrs C complained that medication was unreasonably prescribed without proper checks being carried out into allergies.

Mrs C was asked about known allergies by a nurse practitioner and declared the one she knew about. The nurse practitioner did not check her electronic care summary. Mrs C was then prescribed a drug she had previously suffered an adverse reaction to. The drug made her feel unwell. Mrs C only discovered she had a recorded allergy to the drug prescribed when she went to hospital for unrelated treatment.

We took independent medical advice. We found that the nurse practitioner should have checked the electronic care summary. We therefore upheld Mrs C's complaint. However, we were satisfied that the failure to check the electronic care summary was one of human error rather than evidence of a deficit in the training or clinical ability of the nurse practitioner. We found evidence that the practitioner and the out-of-hours service had reflected appropriately on the sequence of events and had apologised to Mrs C.

Summary

Ms C, an advice worker, complained to the board about immunisations given to the child of her client (Ms A) by the community nursing team. The child had been given additional vaccinations on two occasions and the staff had failed to keep accurate records. Although the board upheld the complaints, Ms A felt they had not taken her concerns seriously.

We took independent nursing advice. The adviser found that vaccination errors had occurred but that the board had carried out a detailed investigation into the causes and that appropriate action had been taken to prevent a repeat occurrence. We upheld Ms C's complaints but made no additional recommendations.

Summary

Miss C complained to us about the nursing care provided to her mother (Ms A) at Stobhill Hospital. Ms A had been transferred to a rehabilitation unit in the hospital after suffering a stroke. Her condition deteriorated and Ms A died.

Miss C complained in particular that her mother was not monitored properly, that her pain was not controlled appropriately, that staff had failed to prevent falls, that staff failed to maintain Ms A's dignity and that Ms A was unreasonably moved into a side room. Miss C also complained that Ms A's belongings were not dealt with appropriately.

We took independent advice from a nursing adviser. We found that Ms A's pain had been reasonably managed, that it was reasonable to put Ms A in a side room and that a care plan in relation to falls prevention was in place. However, we found failings in the nursing care provided to Ms A in relation to maintaining Ms A's dignity and the treatment of her belongings, therefore we upheld Miss C's complaint in view of these specific failings. We did not make recommendations, however, as we were satisfied that the board had apologised for the failings and had taken reasonable action to try to prevent similar problems occurring in the future.

Summary

Miss C complained to us about the failure of a GP at the out-of-hours service at Wishaw General Hospital to provide her with appropriate treatment when she attended with symptoms of severe abdominal pain. Miss C explained that she had told the GP that she had also fainted and that she had had a contraceptive coil removed five days previously. The GP felt that Miss C had either an ovarian cyst or menstrual pain and gave Miss C an anti-sickness injection and told Miss C to go home and see her own GP in the morning. Miss C's pain became unbearable and she re-attended the hospital and was admitted with a diagnosis of an ectopic pregnancy (when the egg implants itself outside the womb). Miss C believed that the GP was wrong to have discharged her home earlier.

We took independent advice from a GP adviser and concluded that although the GP had carried out an appropriate examination, they should have carried out a pregnancy test when Miss C first attended the hospital. We felt that it was unreasonable for the GP to have assumed that Miss C could not have been pregnant because she had only recently had the contraceptive coil removed. We noted that the GP had subsequently realised that they should have carried out a pregnancy test and that they would ensure that they would, in future, carry out a pregnancy test in women of child bearing age who presented with similar symptoms. We upheld Miss C's complaint. However, we did not make any recommendations as the board had already apologised for the failure to perform the pregnancy test and the GP had conducted a significant event analysis of this case.

Summary

Mr C complained that an agency that provides custody escorting services on behalf of the Scottish Prison Service failed to take reasonable steps to ensure that he could attend his brother's funeral. Mr C missed the funeral service and he complained to us about the agency's failure, and about the failure to fully explain what had gone wrong. During our investigation, the agency explained there was a delay in collecting an additional member of staff required for the special escort. The agency accepted that they could have done a number of things differently on the day in question. They said that they recognised the understandable upset caused to Mr C in missing his brother's funeral and had taken immediate steps to learn from the incident. The agency apologised to Mr C for their error.

We upheld Mr C's complaint. However, we considered that there was nothing further we could recommend that would undo what happened to Mr C. Given that the agency had provided a more comprehensive explanation of what had gone wrong, had taken steps to learn from the complaint and had apologised to Mr C, we made no further recommendations.

Summary

Mrs C complained about the way the council administered a statutory notice served on her and her husband (Mr C)'s property. In particular, she was concerned about the tendering process followed by the council, by their failure to seek listed building consent for the works, and their failure to apply for a grant for the works. Additionally, Mrs C was concerned that they had failed to take into account her husband's comments about the need for the works at the time of the initial inspection. Finally, she was concerned about the time it took for the council to issue the final invoice.

We found that the council did follow the required process when appointing contractors to carry out the work. We noted that listed building consent would not be required for these works and that the council had, indeed, applied for grants to contribute to the costs of the work. The grant application was refused by the funder. We had no documented records of Mr C's comments on the works required but, notwithstanding this, any dissatisfaction with the level of works included in the notice is a matter which should be appealed to the sheriff.

A significant level of works were, however, carried out to the property which were not included in the statutory notice. As part of a review of the statutory notice process, this significant additional work was noted and was deducted from the final invoice. As this review took a considerable amount of time, there was a very significant delay in issuing the final invoice. As a result of the mistakes in the invoicing, the inclusion of works not contained in the statutory notice and the significant delay in issuing the invoice, we upheld Mrs C's complaint. However, we did not make any recommendations to the council as they arranged for this matter to be independently reviewed and suitable remedial action was taken.

Summary

Mr C, who is a landlord, asked the council to pay his tenant's housing benefit directly to himself. The council failed to do this and the tenant did not pass on the payment to Mr C.

The council explained that when Mr C requested the housing benefit be paid to him, the tenant had not yet been granted housing benefit. They made a note on the file. The council acknowledged they had failed to ensure the payment, when authorised, was paid to Mr C. For this reason we upheld the complaint.

We noted that the council had apologised for the error and spoken to the relevant staff about the matter. Therefore we did not make any recommendations about this.

As the investigation progressed, it became clear that the tenant had not been entitled to housing benefit. Therefore, even if payment had been made to the landlord correctly, the council would have been within their powers to pursue the landlord for the overpayment. It is for the landlord and not the council to pursue their tenant for any outstanding rent they are due.

Summary

Mrs C complained that the practice cancelled an important appointment with the practice nurse without giving her notice. Mrs C moved to a different practice, and she complained there was delay in sending her medical records to the new practice.

We found that the practice could have told Mrs C sooner that the appointment had been cancelled, and there was no record that they had tried to contact her before she arrived for the appointment. We also found that the practice should have tried to re-arrange the appointment for Mrs C, or arrange an alternative appointment nearby. In addition, we found that there was an unexplained delay of several weeks in the practice sending Mrs C's medical records to her new practice. We upheld Mrs C's complaints.

Shortly after Mrs C complained to the practice, it changed management from GPs to the local health board, as the GPs had left the area. Given these specific circumstances, we did not make recommendations to the health board, as they were not responsible for running the practice at the time of the events complained about. However, we asked the board to confirm whether any relevant staff currently working at the practice were there at the time of the events complained about and, if so, to share our findings with them so they could learn lessons from what happened, to try to ensure that similar problems do not arise again.