Upheld, recommendations

Summary

Ms C complained about the care she received at Forth Valley Royal Hospital after she was admitted via A&E with abdominal pains. While appendicitis was initially suspected, further investigations led staff to believe that Ms C was suffering from problems with her gallbladder. On the second day following her attendance at the hospital, a scan was carried out that showed Ms C's appendix had burst causing an abscess. She was operated on that day but suffered from pleural effusion (excess fluid surrounding the lungs) that had to be treated with a chest drain. Ms C felt that an earlier diagnosis could have resulted in a better outcome.

We took independent advice from a consultant in emergency care and a consultant surgeon. In terms of emergency care, we found that Ms C had received appropriate care and investigation in A&E. However, we found that whilst it was reasonable that staff had considered Ms C was suffering from a gallbladder issue due to her symptoms, junior staff should have escalated the case when her condition worsened and alternative diagnoses should have been considered at that point. We found that there had been a delay of around 12 hours in diagnosing the cause of Ms C's condition as a result of her care not being escalated to senior staff appropriately. We upheld Ms C's complaint.

Recommendations

We recommended that the board:

• ensure that this case is included for learning purposes at the appraisal of the junior doctor;
• ensure the protocol for escalating patient care to more senior staff is highlighted during the induction of junior doctors; and
• carry out an audit of patients under the care of the surgical team with high national early warning scores to determine whether the escalation process is being appropriately followed.

Summary

Ms C, who works for an advocacy and support agency, complained on behalf of Mrs A regarding the care and treatment she received at Forth Valley Royal Hospital. A scan showed a large abscess on Mrs A's liver. She had undergone surgery to remove her gall bladder three years earlier and it was noted on the scan that one of the surgical clips had become dislodged. It was felt that this was the source of Mrs A's infection and abscess formation. The abscess was initially drained radiologically (a process in which, using radiological imaging, a thin needle is guided into the abscess and a drainage catheter placed). Following two further hospital admissions with recurrence of the abscess, surgical drainage was carried out and the clip was removed. A further admission took place following a small recurrence and the surgical incision was re-opened and the fluid drained again.

Ms C complained that the board failed to appropriately manage the complication arising from Mrs A's earlier surgery. In particular, she considered that a delay in removing the surgical clip resulted in the abscess recurrence and need for multiple admissions . We took independent medical advice from a consultant surgeon who noted that the possibility of surgical clips becoming dislodged was well recognised but rarely caused problems. They considered that it was reasonable for the board to have considered less invasive treatment than surgery in the first instance. They noted that, when this was unsuccessful, it was appropriate to proceed to surgery and remove the clip, which they noted was done within seven weeks of the first admission. They considered this reasonable.

However, the adviser did not consider that the recurrence of the abscess was due to the ongoing presence of the clip, but rather due to inadequate drainage. They noted that the drain was only left in place for four days the first time and five days the second. They considered that the drain should have been left in place for 10 to 14 days initially and that the board could also have considered flushing the abscess cavity to ensure that there was no residual fluid collection. They advised that this could potentially have avoided the need for surgery. In relation to the further small recurrence, following surgery, the adviser noted that the surgical incision had to be widened to improve drainage and they considered that this was as a result of the incision having been too small in the first instance. They considered that a wider incision was required for an abscess of the nature of Mrs A's. We concluded that the complication Mrs A experienced could have been better managed by a longer drainage period and a larger surgical incision. We therefore upheld this complaint.

Recommendations

We recommended that the board:

• apologise to Mrs A for the failings identified in this investigation; and
• feed back the findings of this investigation to relevant staff, highlighting the adviser's comments regarding the length of the abscess drainage period and the size of the surgical incision.

Summary

Mr C complained that the board failed to clearly diagnose his late mother (Mrs A's) pulmonary fibrosis (a lung condition), and failed to communicate the diagnosis and manage the condition appropriately. Mrs A's pulmonary fibrosis was first identified in a scan carried out five years prior to her death. She regularly attended her GP and hospital over the intervening years with symptoms that included breathlessness. We obtained independent medical advice from a consultant respiratory physician, a consultant general physician and a consultant in emergency medicine. We identified that there were missed opportunities to appropriately refer Mrs A to respiratory medicine. In particular, an attendance at an ageing and health clinic did not result in an onward referral despite clear evidence of progression of Mrs A's condition. We were assured, however, that the limited available treatment options for pulmonary fibrosis meant an earlier referral was unlikely to have altered Mrs A's prognosis. Nonetheless, we recognised that earlier specialist intervention would have afforded Mrs A and her family the opportunity to better understand the nature of her condition and be assured that her symptoms were being appropriately managed. We upheld this aspect of the complaint.

Mr C also complained that the board did not respond to his letters of complaint fully and within a reasonable timeframe. We noted that the board's response to Mr C's initial complaint was issued in good time and attempted to address the specific concerns raised. Mr C then wrote to the board on a further two occasions listing several additional questions and outstanding concerns. We noted that the NHS complaints procedure does not make provision for further stages of the process and complainants who remain dissatisfied should be referred to the SPSO. We, therefore, did not consider that the board were obliged to provide the additional level of detail requested by Mr C. However, having agreed to provide a further written response, we considered that the board unreasonably delayed in doing so. We noted that the board had already apologised for the delay. We also considered that they could have responded with greater clarity. We therefore upheld this aspect of the complaint.

Recommendations

We recommended that the board:

• apologise to Mr C and his family for the failure to clearly diagnose, communicate and manage Mrs A’s pulmonary fibrosis;
• carry out a review of Mrs A’s care and treatment and report the outcome back to us, ensuring that the failings this investigation has identified are fully reflected upon and account taken of the medical adviser's suggested areas for improvement;
• remind complaints handling staff of the importance of responding fully and accurately to complaints, and ensuring that the response represents the board’s definitive position in order that any subsequent disagreement can be appropriately referred to us; and
• remind complaints handling staff that, in circumstances where they choose to engage in further correspondence with a complainant, they should respond in a timely manner and keep them informed of any delays.

Summary

Mrs C underwent a hip-replacement operation at Victoria Hospital. During the operation, a suture (a stitch used to close a cut or wound) used to repair the muscles at the back of her hip caught the edge of her sciatic nerve (a nerve in the lower back area). Mrs C said that she had not been told when she consented to the operation that this was a potential risk and that it should not have occurred. Mrs C also raised concerns about the time it took medical staff to find out what happened. It was not until three days after the operation that medical staff recognised that Mrs C had sciatic nerve palsy (foot drop and numbness) and she underwent a further operation six days after the first operation.

We took independent advice from a medical adviser who specialises in surgery. We found failings in the consent process which meant that Mrs C was not in a position to give her informed consent for the procedure. We considered that Mrs C should have been warned of the potential adverse outcome in clear terms and language, even though the risk of permanent nerve damage was very rare. We also found the time it took to identify the sciatic nerve palsy and escalate it to the surgeon to be unreasonable. We therefore upheld Mrs C's complaint.

However, in relation to the standard of operation and surgical error, while we accepted this was a significant failing which had an adverse outcome, our view was that it was not evidence of poor practice or of an unreasonable failing in the surgical care provided.

Recommendations

We recommended that the board:

• review the consent process and related documentation to ensure clinicians properly obtain (and document) consent for procedures;
• bring the failings to the attention of relevant staff and ensure the failings are raised as part of their annual appraisal;
• investigate why the finding of sciatic nerve palsy was not escalated and inform us of the findings; and
• apologise to Mrs C for the failures this investigation identified.

Summary

Mrs C complained that Scottish Water unreasonably delayed in providing her with the results of a water sample taken at her home. She also complained that they failed to take reasonable steps to update her with the progress of their inspections.

We found that Scottish Water had gone beyond what they were required to do in assisting Mrs C with a leak. The leak was on the private supply and therefore not Scottish Water's responsibility.

However, in order to determine the source of the leak, Scottish Water carried out a water test. There was no evidence to show that the results were passed on to Mrs C. A later test failed as Scottish Water mislaid or mislabelled the sample, and the results of the final test were not provided until around three months after the original sample was taken. As a result of this, and because we felt that Mrs C had to regularly chase Scottish Water for updates, we upheld Mrs C's complaint.

Recommendations

We recommended that Scottish Water:

• review their sampling procedures to ensure that they have a process in place to minimise the risk of failed samples;
• review their procedures to ensure that test results are passed on to the customer promptly, and that they record this contact in their records; and
• apologise to Mrs C for the failings this decision has identified.

Summary

Miss C complained on behalf of her local residents' organisation. Her complaint concerned various issues relating to the council's waste services, including the bin crew failing to empty bins on designated days, not cleaning or picking up overspill in bin stores, not reporting tipped items to relevant services, long delays in response times for faulty bin repairs, and the bin crew not returning bins to stores after emptying them.

The council acknowledged that there had been failings in their refuse collection services, and provided evidence to show that they were taking steps to improve matters. They have also appointed a Locality Waste and Cleansing Officer.

There had also been unreasonable delays in the council responding to requests for bin repair or replacement, and unreasonable delays in responding to Miss C's complaints. We therefore upheld Miss C's complaint.

Recommendations

We recommended that the council:

• report back to us, confirming the progress that has been made in respect of the measures set out by the Locality Waste and Cleansing Officer; and
• apologise to Miss C for the delays in responding to her requests for bin repair or replacement.

Summary

Mrs C made an application for a High Hedge Notice under the High Hedges (Scotland) Act 2013 Act. The council notified Mrs C and her neighbours of consideration of the high hedge application. Approximately a month later, a site inspection was carried out. Based on the inspection, the council reached the view that the trees in question did not qualify as a high hedge, and the council refused the application on this basis.

Mrs C complained that the council unreasonably failed to process the concerns she had about planting in her neighbour's garden. She raised particular concerns about the stage in the process at which the council considered the question of whether the trees amounted to a high hedge.

We obtained independent planning advice in relation to Mrs C's complaint. We found that the council had reached a particular decision about the process for a high hedge application, based on their legal advice. However, we considered that having reached that decision, the council should have been clear about the process they were following to the complainant (who expected the council to follow the guidance), and moreover, appropriately escalated their concerns about the guidance to the Scottish Government. Therefore, we upheld the complaint.

Recommendations

We recommended that the council:

• confirm they will raise their concerns about the guidance with the Scottish Government;
• confirm they will review their process for dealing with high hedge applications following engagement with the Scottish Government, including reviewing the handling and publication of the application, and the reimbursement of associated fees; and
• apologise for the failings identified in this investigation.

Summary

Mr C raised a number of concerns relating to the planning consent for the erection of houses on a site close to his home. In particular, he complained that the council had failed to take action against the developer to ensure improvements to the state of the pathway constructed by the developer and to the area of pipework discharging into the burn. Mr C also raised concerns that the pathway had been constructed in a different location to that on the approved plans and was unlit. The location of the pathway and the requirement that it be lit was detailed in a condition attached to the planning consent.

We took independent planning advice. We found that the action taken to amend the location of the path and to decide that the path should not be lit was likely to be contrary to sections 42 and/or 64 of the Town and Country Planning (Scotland) Act 1997. We were also concerned that the council had failed to keep Mr C updated on progress at the site and that they had failed to address his concerns about the location of the path. We therefore upheld Mr C's complaint.

Recommendations

We recommended that the council:

• apologise for their handling of this matter, in particular the failure to address the issue about the location and lighting of the path; and
• in light of the adviser's comments about the likely breach of sections 42 and/or 64 of the Town and Country Planning (Scotland) Act 1997, seek to regularise the situation, ensure compliance with the Act and report back on action taken.

Summary

Mr C complained about the council's handling of a planning application submitted by his neighbours. The council had granted planning permission, with an attached condition which stipulated that the recommendations in a tree report that had been produced for the neighbours were complied with. Some of the recommendations in the tree report related to trees that were on Mr C's property. As Mr C had refused his neighbours access to his trees, the planning condition could not be met. When Mr C's neighbours wrote to the council explaining this, the council stated that they considered the condition to have been fulfilled nevertheless.

We took independent planning advice. We found that it was unreasonable for the council to attach a planning condition that was unachievable to the planning application. We also found that rather than considering the condition to be fulfilled when they discovered it to be unachievable, the council should have asked the applicants to formally apply, under section 42 of the Town and Country Planning (Scotland) Act 1997, for the condition to be varied or for the development to proceed without complying with the terms of the condition.

We noted that prior to our investigation the council had implemented new training and guidelines to reduce the possibility of a similar failing occurring again, and that they had accepted that the condition should not have been attached in the form that it was. We therefore upheld Mr C's complaint.

Recommendations

We recommended that the council:

• apologise for the failings identified by this investigation; and
• draw the comments of the adviser regarding section 42 of the Act to the attention of relevant staff.

Summary

Mrs C lived adjacent to a site on which unauthorised development had taken place. Mrs C was unhappy that the development had caused her property to flood and complained to the council that they had failed to take appropriate enforcement action to address the flooding.

We found that the council had served three enforcement notices on the developer in relation to the site, and that each of these had been appealed. We also noted that the developer had submitted a further planning application to the council, which meant that all enforcement action was on hold pending the outcome of this application.

In response to our enquiries, the council advised that they considered they had taken appropriate steps to take enforcement action against the developer. We took independent planning advice. The adviser considered that the council had taken reasonable steps in the first instance to ensure that the enforcement notices were served on the correct parties. However, the adviser was critical with the approach taken by the council in relation to the enforcement notices and did not consider that this approach would have been able to achieve the council's aim of preventing flooding to Mrs C's property.

While the adviser was critical of this aspect of the council's actions, we did not consider that this failing had altered the outcome of the case. This was because it was evident that the developer submitted a new planning application, which meant that all enforcement action would have been on hold anyway. However, we found that, in the event that the developer's latest application is refused, the council should reconsider enforcement action with the benefit of hindsight over the detail required in preparing the enforcement notices. We made a recommendation in relation to this and decided on balance to uphold Mrs C's complaint.

Recommendations

We recommended that the council:

• feed back the adviser's comments to staff in the planning service.