Upheld, no recommendations

Summary

Mrs C, who is an advice worker, complained on behalf of her client (Mrs A) about the social care provided to her late husband (Mr A) in the last days of his life. Mr A had been discharged home from hospital into the care of his GP and the district nursing service, with the support of social care officers. It was known that he was dying and there had been a meeting to discuss the support he would need at home. It was considered that Mr A should be nursed and cared for in a hospital bed. Mr and Mrs A did not want this and he was cared for in his own bed. However, there were practical difficulties with this, which compromised the support given to Mr A by council care officers. Mrs A was distressed that during the last days of her husband's life he was not afforded the dignity and respect he required and deserved.

We investigated the complaint and found that the council had acknowledged their role in the poor care provided to Mr A. Staff had not been able to manage Mr A physically because of difficulties presented by the absence of a hospital bed. They had, however, not told managers of their concerns about Mr A's care being compromised as a result of this. This was explained to Mrs A when she complained, and the council had apologised unreservedly and told her Mrs A what they had done to try to avoid this happening to someone else.

It was not in dispute that the council failed to provide Mr and Mrs A with the level of support they could have expected, so we upheld the complaint. However, the investigation also showed that the procedures the council had since put in place went far in attempting to prevent a similar situation happening. Mrs A had also received a sincere apology, so although we upheld the complaint, we did not make any recommendations.

Summary

Mr C complained that when he attended his medical practice the GP who saw him did not tell him that he could stop his diabetic medication. As a result, he had continued to take it for a year, and he wondered whether this was detrimental to his health. The practice apologised and explained that the GP recalled discussing the matter with Mr C at the time but forgot to amend the repeat prescription list. They said that by continuing with the medication, Mr C did not come to any harm.

After taking independent advice from one of our medical advisers we found that, although we could not establish exactly what the GP and Mr C discussed, it was the GP's intention to stop the medication at that time. However, human error prevented the medication from being removed from the repeat prescription list. Because of this, we upheld Mr C's complaint. However, as the practice had already apologised to Mr C and reminded staff about properly documenting conversations with patients, we did not make any recommendations.

Summary

Mr C suffers from cerebral palsy, has a history of bladder problems and is confined to a wheelchair. He was admitted to the Southern General Hospital with swollen feet, pain and discomfort. Mr C said that during his admission he was offered no practical nursing care at all and his friend, an elderly woman, had to help him on the ward and undress him for an examination. He said he was then left unwashed and unchanged throughout his two-day hospital stay and his visitors had to help with all his personal care needs. He said he asked nursing staff for assistance to shower the morning after his admission, but this was refused. Mr C complained about the standard of nursing care he received, saying that he was not treated with dignity and respect.

We took independent advice from our nursing adviser. We found that the evidence from the medical records indicated that Mr C had an assisted wash just once during admission, which was not reasonable. We also found that nursing staff failed to document what care had been given and had failed to personalise care for Mr C as a patient with specific disabilities. However, as the board had already taken action to address the complaint and ensure improvements, we made no recommendations.

Summary

Mr C, who is an MSP, complained on behalf of two housing association residents (Ms A and Mr B). The residents were unhappy that, having been told that it would not be possible to have gas central heating installed, the association had not consulted them on what they preferred instead.

Our investigation found that, due to technical and legal concerns, the association could not fit gas central heating as they had originally planned. Most of the tenants who had responded to a survey at the start of the consultation process had preferred this option. When the technical and legal issues came to light, and it was clear that gas central heating could not be installed, the system was re-designed for a wet electric system. Tenants were invited to a meeting before work on the upgrading programme began and the association considered this to be part of the consultation process. However, some tenants were unhappy as they felt that the decision had already been made and they had no opportunity to put forward their concerns or have their views considered.

We took the view that, given the very limited alternatives available when the problems came to light, the association's decision to replace the intended gas system with an electric system was reasonable. However, we were critical that they did not consult with tenants before inviting them to the meeting. We were aware that their policy on consultation with tenants promoted and encouraged consultation, but gave the association the power to make the final decisions in any cases with a financial and/or technical element. We also took on board that at the meeting the association made members of their staff available to discuss the tenants' concerns, as well as staff from the heating system designers and contractors. However, the tenants' only options at this stage were either to accept the proposed wet electric system or remain with the existing inefficient storage heater system. Several tenants, including Ms A and Mr B, in fact chose not to allow access to install the new system. We were also critical of the association's apparent assumption that because only a minority of the tenants invited to the meeting attended, those who did not attend either had no concerns about the new proposal or implicitly approved of it.

In replying at the second stage of the association's complaints process, the chief executive had written a comprehensive letter explaining the problems and the reason for the decisions taken. He acknowledged that communication could have been better in the early stages and partially upheld the tenants' complaint. The association told us that they had learned from the complaint and would in future ensure that proposed options were viable before putting these to tenants. The association also said that they would review their practice for the future. In view of the technical circumstances the association faced, and their assurance that they had learned from these events, although we upheld the complaint we made no recommendations.

Summary

Mr C was admitted to the Western Infirmary with symptoms of nausea and vertigo. He was kept in overnight and discharged the following day, with a prescription for medication to take on an 'as required' basis to relieve his symptoms. As the hospital pharmacy was closed, he was given a small amount from the ward's supply until he could get his own prescription, but was given the wrong medication. In responding to Mr C's complaint, the board acknowledged that he had been given the wrong medication in error and apologised.

Mr C complained to us because the board had not fully addressed his concerns that a nurse had advised him to take the medication three times a day for three months, instead of on an 'as required' basis, and instructed him on the use of a spray he already used. He also said that the medication might have been intended for another patient, which could have had serious consequences for them. In responding to our enquiries, the board acknowledged that they should have provided Mr C with a fuller response. They explained that they had put an action plan in place to highlight to all staff the importance of ensuring safe medication practice.

We took independent advice on this complaint from one of our medical advisers. He did not think it likely that there was a mix-up with another patient, but rather that there had been a basic dispensing error. He noted that the frequency advice appeared to relate to the incorrect drug that was provided, and confirmed that there would have been no serious consequences had Mr C taken that drug. In relation to the advice on using the spray, the adviser noted that it was common for a hospital to prescribe medication that forms part of a patient's usual prescription, and that they may just have been making sure his medication supply was complete.

As Mr C was given the wrong medication and advice, we upheld his complaint. However, as we were satisfied that in this instance the drug error was not serious in nature, and that the board had acknowledged the error, apologised and taken steps to try to prevent this happening again, we did not need to make any recommendations.

Summary

Mrs C complained about the care and treatment she received from her medical practice when she attended with clearly visible changes in her left breast. The GP told Mrs C that there was nothing wrong other than a blockage and suggested that she buy starflower oil. Mrs C's health deteriorated over the next few months and nine months later, she was diagnosed with breast cancer.

After taking independent advice from our GP medical adviser and considering the records and Mrs C's comments, we found that the GP had failed to adequately examine her breast. In view of the visible changes, Mrs C's age and the fact that she had a family history of breast cancer, we also found it unreasonable that the GP did not immediately refer her to the breast clinic. Our adviser said that the delay in referring Mrs C there was likely to have had a significant impact on the extent of the tumour and the level of treatment Mrs C required. However, the practice had carried out a significant event review, had demonstrated that they had learned lessons from the complaint and had apologised to Mrs C. In view of this, we did not need to make any recommendations.

Summary

Mr C, who is the chair of a museum, complained that Business Stream consistently invoiced the museum incorrectly for water costs. Business Stream acknowledged that this was the case and explained that they had taken steps to correct the error and adjusted the billing to ensure that the museum were not financially penalised for their mistakes.

We considered the information provided by both parties and, on the basis that Business Stream had repeatedly failed to invoice the museum correctly, we upheld the complaint. As, however, they had now corrected the billing, had acknowledged and apologised for their mistakes and had ensured that the museum had not lost out financially, we made no recommendations for further action.

Summary

Ms C, who is an advocacy worker, complained on behalf of her client, Mrs A. Mrs A went to her dentist with toothache. She was examined, but decided not to have treatment because of the complexity of the problems. Early the next month, the dentist referred Mrs A to the dental hospital. They referred her there again about two weeks later for an emergency appointment, and made a further referral some four days after that. The assessment consultation for this last referral was not until two months after the date of referral. Mrs A said that despite then going to the dental hospital a number of times, she did not receive appropriate treatment until some eight months after she first went to her dentist with toothache. Throughout this period, she made a number of calls to NHS 24 because she was in considerable pain.

Mrs A complained about the delay in treatment, and said her dentist provided all relevant information to allow treatment to proceed at the time of the third referral. She said that the delay was particularly unreasonable because she was pregnant and in pain.

We took independent advice on this case from one of our dental advisers. They said that while the board failed to meet the national 18-week target in relation to the third referral, they did tell Mrs A of the likely delays, and provided advice about what she could do to be treated more quickly. The adviser also said that Mrs A's pregnancy did not necessarily mean that she was a priority patient, and that it was the responsibility of her dentist to manage her pain while waiting for treatment. In light of the board's failure to meet the target, we upheld the complaint but we did not make any recommendations as the board have introduced a new system for appointments, with the aim of ensuring that target times are met in future.

Summary

Mr C complained that there was an unreasonable delay in the board providing care and treatment for his back pain. He told us that the board had lost a referral from his GP for orthopaedic (conditions involving the musculoskeletal system) assessment. We found that the board, in responding to Mr C's complaint, explained what went wrong, apologised for what happened, and explained that they had fixed the problem with the referral system. Given the loss of Mr C's referral and the consequent delay, however, we upheld the complaint although we did not need to make any recommendations in view of the action the board had already taken.

Mr C said that, because of the delay and his personal circumstances, he had been left with no choice but to seek private treatment, and he wanted the board to pay for this. From Mr C's description, we did not doubt that he and his family had found the situation difficult and distressing. However, because Mr C sought private treatment rather than pursuing treatment with the board, we did not know if there would have been any further significant delay in the board providing the treatment. We could not, therefore, say whether Mr C had no option but to obtain private treatment when he did. In such circumstances, we could not recommend that the board consider reimbursing Mr C for this.

Summary

Mr C and Mr D appealed to Scottish Ministers because the council had not determined their application for the removal of a planning condition on a property within the time set out for this. When the inquiry reporter did not grant consent for their application, Mr C and Mr D complained to us that the Directorate of Planning and Environmental Appeals (DPEA) had not acted reasonably in determining their appeal.

We took independent advice on this from one of our planning advisers, who said that there were procedural errors in the reporter's decision letter. These included not addressing under what section of the relevant legislation she was considering the appeal, and not warning Mr C and Mr D about an issue that had the potential to determine the case, but which had not been addressed before. The DPEA had accepted these failings when Mr C and Mr D complained to them. They had apologised, discussed the failings with the reporter concerned and also addressed these at a professional seminar with other reporters. On balance, we upheld the complaint but in view of the action the DPEA had already taken, we did not find it necessary to make any recommendations.