Upheld, recommendations

Summary

Mrs C's GP referred her to St John's Hospital for a blood transfusion because she was anaemic, had chest pains and was breathless. However, Mrs C said that when she was in the hospital the blood transfusion did not happen. She was discharged and told that an urgent endoscopy (a procedure where a tube-like instrument is put into the body to look inside) and colonoscopy (an examination of the bowel with a camera on a flexible tube) would be arranged for her. Mrs C said that she did not hear anything further and that the following month she was admitted to hospital again. She had a scan which showed a large tumour and she was diagnosed with bowel cancer. Mrs C complained that she was not properly cared for and treated during her first attendance at hospital.

We took independent advice from a consultant gastroenterologist. We learned that Mrs C did not have a blood transfusion because her blood flow was not compromised and she showed no symptoms of active bleeding. While we found it was reasonable to discharge Mrs C home with plans for urgent endoscopic investigations, the board subsequently failed to deal with this as a matter of urgency. We found that this was unreasonable and we upheld Mrs C's complaint.

Recommendations

We recommended that the board:

• apologise to Mrs C for the delay;
• confirm the situation with regards to waiting times for urgent endoscopies; and
• ensure that, in the event that they cannot address the waiting times for urgent endoscopies, alternative scans, such as CT scans on the colon, are made available. This new protocol should be brought to the attention of referring clinicians.

Summary

Mr C complained that when he returned to prison having undergone surgery, he was not prescribed with appropriate pain relief.

While in hospital, Mr C had been prescribed dihydrocodeine and paracetamol (pain relief medications). However, on returning to the prison, clinicians prescribed Mr C with co-codamol (a mixture of codeine and paracetamol). The prescription was not issued until after the pharmacy cut-off time and so Mr C only received paracetamol until the following morning when he was given a one-off dose of dihydrocodeine.

We took independent medical advice. The adviser's view was that Mr C had not been provided with sufficient pain relief and that the delay was unreasonable. We accepted this advice and upheld the complaint.

We also found that the board's response to the complaint was contradictory. They had told Mr C at stage one of the complaints process that they would take action to ensure there was not a repeat of the situation. However, when we contacted the board to find out what action they had taken, they said there were no actions taken as the delay was unavoidable. We were critical of this.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for the delay in prescribing appropriate pain relief and for the contradictory response to his complaint. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/leaflets-and-guidance.

What we said should change to put things right in future:

• Patients should receive appropriate medication when returning to prison after surgery.

In relation to complaints handling, we recommended:

• The board’s decision on a complaint should be clear and, if it differs to the view reached at stage one, this should be explained in the response.

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

Mr C complained that the board had unreasonably delayed in providing treatment for his eye condition at Hairmyres Hospital.

We took independent advice from a consultant who specialises in the medical and surgical treatment of eye disease. The advice we received was that there had been no unreasonable delay in the treatment provided to Mr C, but that there had been an unreasonable delay in the following up of Mr C's eye condition. However, we found that this delay had not resulted in deterioration of Mr C's vision. Taking account of the evidence and the advice we received that Mr C should have been followed up more closely, we upheld Mr C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for the failure to follow-up his eye condition.

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

Mr C complained to us that he, his wife and daughter were removed from the practice's list. National Services Scotland (NSS) wrote to Mr C to say that his GP practice had asked NSS to remove him, his wife and their daughter from their patient list because of a breakdown in the doctor/patient relationship. Mr C said it was not clear why they had all been removed and that he had not been given a warning. Mr C believed it was because of a complaint he had made previously to us about the practice. As a result of the decision, Mr C and his family were distressed and left without the care of a GP practice while they found a new practice.

We took independent advice from a GP adviser. The advice we accepted was that there was no evidence that the practice had complied with their contractual regulations and General Medical Council guidance. We found that there had been an appointment between Mr C and practice nurses that was difficult for all concerned and that aspects of the appointment were challenging for staff. However, having reviewed in detail the witness statements and the entries in Mr C's medical records, we were not satisfied that it was reasonable for the practice to remove Mr C without first warning him that his behaviour was causing staff concern and giving him an opportunity to help restore the professional relationships.

We found that the practice had failed to give him an open and transparent response on their reasons for having him removed and that, as a result, he was concerned that he was removed because he had made a complaint. It is also of concern that the practice failed to take all reasonable steps to restore the professional relationship. We were not satisfied that the professional relationship with the practice had broken down to such an extent following the appointment with practice nurses that it affected the standard of clinical care provided, and so we found it to be unreasonable that Mr C was removed from the list. Similarly, there was no evidence that it was reasonable for the practice to remove his wife and child too. We upheld both complaints.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for unreasonably removing him, his wife and his daughter from the practice list. The apology should comply with the SPSO guidelines on making an apology, available at www.spso.org.uk/leaflets-and-guidance.

What we said should change to put things right in future:

• Staff should comply with the guidance and regulations on responding to staff concerns about patient behaviour.

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

Mr C complained about the care his wife (Mrs A) received at Aberdeen Maternity Hospital after she became unwell following delivery of their child by caesarean section. Three days after the procedure, Mrs A required emergency surgery for a perforated bowel, resulting in a temporary ileostomy (where an opening is made in the abdomen to allow waste to pass out of the body) and further surgery to reverse this, which caused her a difficult and protracted recovery period. Mr C raised concern that they had been told by a doctor that the complications had arisen because the bowel had been accidently stitched to the caesarean section wound.

We took independent advice from a consultant obstetrician and a consultant general surgeon. We found that the consent form Mrs A signed, with the assistance of a doctor, agreeing to the caesarean section was not fully completed and did not warn her of the rare but recognised risk of bowel injury, which we were critical of. We also considered that it was likely that the bowel had been caught at the time of stitching, which meant that it was unlikely an adequate check of the wound was carried out by a second doctor at the time of the procedure. We upheld the complaint and made a number of recommendations to address these failings.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs A for the failings identified in relation to the consent process and her caesarean section. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/leaflets-and-guidance.

What we said should change to put things right in future:

• Patients undergoing an elective caesarean section should be fully informed of the possible complication and risk of bowel injury and give clear, informed consent.
• All relevant sections on the consent form should be fully completed.
• The doctor who performed the surgery should reflect on the clinical incident at their appraisal to identify any training needs to ensure the matter does not recur.

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

Mrs C, who works for an advocacy and support agency, complained on behalf of her client Mr A. Mr A's late wife (Mrs A) had been diagnosed with lung cancer. Mrs A began to suffer severe neck pain which subsequently spread to her shoulder and arm. Mrs A was admitted to Dr Gray's Hospital at the request of her GP. Given that a recent scan of the shoulder had shown no problems, a further x-ray or scan was not requested by clinical staff at the acute medical assessment unit. Mrs A was discharged home the following day. Mrs A's pain continued and a few days later she was admitted to Aberdeen Royal Infirmary. X-rays and a scan were performed which showed that Mrs A's cancer had spread to two cervical vertebrae (neck bones) and to the brain. Mrs C complained that the board had failed to provide Mrs A with adequate care and treatment during her admission to Dr Gray's Hospital.

The board acknowledged that Mrs A should have been referred to the oncology team and that a neck x-ray should have been performed. They apologised for the delay in diagnosis and that they did not recognise or control the cause and nature of Mrs A's pain. The board explained that they have taken action following this complaint, including using the National Cancer Treatment Helpline, as well as considering direct referral to the oncology team. They explained that they are working to maintain the awareness of these mechanisms to prevent a recurrence through information on their intranet and documentation in induction packs. We have asked the board to provide evidence of these actions.

We took independent advice from a consultant in acute medicine. The adviser's view was that the possibility of the cancer spreading to the cervical vertebrae or the spinal cord should have been considered. The adviser said that Mrs A's pain should have been managed as a possible malignant spinal cord compression (an issue that develops when the spinal cord is compressed by bone fragments, a tumour, an abscess or other lesion. This is an issue that is usually treated as a medical emergency). The adviser's view was that there should have been a discussion with oncology and that the use of steroids and an MRI scan should have been considered. The adviser stated that they would expect doctors working in an acute medical assessment unit to recognise this and perform this role. In light of this, we upheld the complaint.

Recommendations

What we said should change to put things right in future:

• The board should have a malignant spinal cord compression protocol.
• All clinical staff within the Acute Medical Assessment Unit should be made aware of the malignant spinal cord compression protocol.
• Clinical staff within the Acute Medical Assessment Unit should learn from this case.

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

Mr C complained on behalf of his daughter (Miss A). He complained that there had been an unreasonable delay in her receiving treatment for a foot injury at Aberdeen Royal Infirmary.

We took independent advice from a consultant orthopaedic paediatric surgeon. We found that an appropriate initial referral and examination of Miss A's foot had been carried out and that an appropriate treatment plan had been instigated, which included the use of interventional radiology treatment (treatment that is used to precisely target therapy to affected areas). However, we found that due to staff shortages there was an unreasonable delay in Miss A receiving interventional radiology treatment at Aberdeen Royal Infirmary. We found that there were a series of cancellations and that it was then decided that Miss A should be referred onto another board for treatment. We found that there was also a delay in sending that referral. We upheld Mr C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Miss A for the delay in initiating treatment.

What we said should change to put things right in future:

• Patients requiring interventional radiology treatment should receive treatment in a timely manner or be referred to an alternative provider, such as another NHS board.

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

Miss C complained about the care and treatment provided to her at Victoria Hospital. Miss C complained that when she first presented at the hospital with symptoms relating to an infection in her groin area, she was discharged too early and had to be readmitted later that day. Miss C also complained that the abscess which formed in her groin area was inappropriately drained at her bedside, and that there was a delay in a diagnosis of necrotising fasciitis (a rare infection that destroys the soft tissue of the skin) being made.

We took independent advice from a general surgeon and a consultant physician. We found that Miss C was inappropriately discharged from the hospital on her first admission as she had been newly diagnosed with diabetes and had an ongoing temperature. The advice we received was that it may have been helpful for Miss C to have had input from a diabetologist and earlier surgical management of her skin infection. We also made a recommendation regarding the documentation of timings in medical records as we found this to be poor.

We further found that the drainage procedure carried out at Miss C's bedside was not reasonable as pain relief was not documented, and the signs that were present at this point, namely skin blistering and fluid filled tissues, were not reasonably acted upon.

Finally, we found that there was an unreasonable delay in the diagnosis of necrotising fasciitis as, when there were clear features of this occurring, the appropriate action was not taken in a timely manner. Additionally, the advice we received noted that there was clear indication for surgical incision and drainage at a far earlier point than was carried out and that, had surgical treatment been carried out at an earlier point, necrotising fasciitis may not have occurred. We upheld all of Miss C's complaints.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Miss C for inappropriately discharging her from hospital, inappropriately carrying out a clinical procedure at her bedside and unreasonably delaying in reaching a diagnosis of necrotising fasciitis. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/leaflets-and-guidance.

What we said should change to put things right in future:

• All entries in clinical records should be correctly dated and timed.
• The board should ensure it has clear guidelines that comply with recognised standards for how to manage skin and soft tissue infections, which include when surgical treatment should be commenced. Staff should be competent to apply them to an acceptable standard.
• In otherwise unwell patients with newly diagnosed diabetes, consideration should be given to seeking input from a diabetologist.
• Surgical staff should be familiar with signs of necrotising skin and soft tissue infections.

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

Ms C applied for, and accepted, a place on a course at the college. The price of the course was advertised on the college's website and in the course brochure as being £650. During the first unit of the course, Ms C received an invoice for £1,950 in course fees. Ms C queried this with the college but did not receive a response. When she received a further invoice, which she received after starting the second unit, she contacted the college again. The college explained that the fee was actually £650 per unit and that the course consisted of three units. They offered to reduce the fee by ten percent in light of the poor customer service, but would not reduce the fee to £650. Ms C highlighted to the college that the fee of £650 was as advertised on their website and in the course brochure. The college offered to further reduce the invoice, and stated that Ms C had five working days to accept the offer or she would be immediately withdrawn from the course. Ms C complained to us that the college acted unreasonably by charging her more than the cost of the course as advertised on their website and in the brochure. She further complained that the college acted in an unreasonable manner when they emailed her asking her to pay the amount they considered she was due the college.

We examined information from the college's brochure, which indicated that the fee for Ms C's one year course was £650. We also examined the college's website, which noted the start date, the length of the course and the cost as £650. There was no indication that the cost was £650 per unit. In their responses to Ms C, the college had accepted that the information on their website was misleading. We concluded that it was reasonable for Ms C to have interpreted the information on the college's website and brochure as meaning that the course fee was for the whole course, rather than for each individual unit. We upheld Ms C's first complaint because we considered that the college had not provided her with clear and accurate information about the course fees before the course began.

Having considered the contents of the college's email to Ms C when they asked for the outstanding amount, our view was that the college did not appropriately recognise the particular circumstances of her complaint and that the wording could be perceived to have been threatening. Therefore, we upheld Ms C's second complaint. We made a number of recommendations to the college as a result of Ms C's complaints.

Recommendations

What we asked the organisation to do in this case:

• Reimburse Ms C for the amount she paid over the advertised £650 fee, taking into account that she was entitled to some Student Awards Agency for Scotland funding towards this. The payment should be made by the date we have indicated. If payment is not made by that date, interest should be paid at the standard interest rate applied by the courts from that date to the date of payment.
• Apologise to Ms C for the content of their email to her. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/leaflets-and-guidance.

What we said should change to put things right in future:

• The college should have clear and accurate information about course fees on their website and in their course brochure.

In relation to complaints handling, we recommended:

• The particular circumstances of a complaint should be recognised when staff are responding to the complaint. Staff should be mindful of how the wording of their complaints responses could be perceived.

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

Miss C, a utilities consultant, complained about Business Stream on behalf of her clients, a trust. Miss C told us that she had recently requested that the trust's water accounts be transferred to another supplier. She said that Business Stream had initially blocked this request, as the trust had entered a contract with them until 2018.

Miss C then contacted Business Stream to ask about the contract and any exit fees and was told that there was no record of a contract, so no fees would apply. She then reapplied for the transfer and the accounts were moved to another supplier.

Business Stream contacted the trust shortly afterwards, once again confirming that a contract had been in place and requesting payment for exit fees incurred as a result of breaking the contract. Miss C then submitted a complaint about the miscommunication, requesting that the fees were written off. Business Stream accepted that they had failed in their communication and apologised. However, they refused to write off the fees as they had supplied the trust with copies of the contract before the accounts were transferred.

On investigation, we found that Business Stream had incorrectly told Miss C that there was no contract in place on more than one occasion. The reason given to Miss C for this was that staff in the customer service team were not able to access a copy of the contract, as this was stored on a part of the system reserved for account managers.

We found that all staff should still have been able to confirm the existence of the contract by referencing discounts showing on any of the trust's invoices. Despite this, we also considered that Business Stream should have done more to ensure that their systems made clear to staff when a contract was in place. For these reasons, we upheld the complaint.

However, we confirmed that Business Stream had provided the trust with copies of the contract before the contract began, and after Miss C first requested that the accounts be transferred. The contract clearly explained its term and the fees that would apply if the customer exited before this period had expired. We therefore considered that it was reasonable for Business Stream to expect the trust to pay the fees.

Recommendations

We recommended that Business Stream:

• alter their systems or procedures to ensure that the existence of any contract is clearly indicated in a way that is immediately obvious to all staff.