Upheld, recommendations

Summary

Miss C said that the housing association failed to take reasonable action when she reported nuisance and anti-social behaviour by her neighbour. Miss C also said that the association failed to provide reasonable responses to her complaints and other correspondence.

We upheld Miss C's complaints. We found that the association took steps in line with their procedures by making contact with Miss C and her neighbour. When Miss C further complained to the association, they noted that not enough had been done to investigate Miss C's concerns, and undertook to investigate further. However, we found no evidence of any further investigation having been carried out or of further action taken.

We found faults in respect of the handling and defining of Miss C's complaints, including recording these. We also found that some responses to Miss C lacked sufficient detail.

However, we noted that the association did in general communicate according to Miss C's preferences. The association found that they were unable to dedicate staff time to the detail of Miss C's replies to their communications. We found this to have been reasonable as the association was entitled to manage their own staff resources in providing a service.

Recommendations

We recommended that the association:

• apologise for a failure to adequately recognise and investigate complaints about the operation of a business, anti-social behaviour and sub-letting; and
• take steps to ensure staff are aware of the definitions of stage 1 and stage 2 complaints and the need to record and investigate these properly.

Summary

Mrs C complained about the care and treatment she received at Ninewells Hospital after having her jaw joint replaced with an artificial joint. Prior to then, Mrs C had been under the care of an oral medicine consultant who had tried a range of non-surgical methods to manage the pain she was having in her jaw joint. Mrs C was then referred to a specialist surgeon, who recommended surgical replacement of the joint. Mrs C proceeded with the surgery but suffered complications that resulted in the artificial joint being removed for several months and replaced with a different type.

Mrs C was concerned that the risks of surgery had not been properly explained to her, about the sourcing of the artificial joint, that special equipment to detect nerves was not used during the surgery, and that there was a delay in identifying problems with the replacement joint.

We took independent advice from an oral and maxillofacial (the speciality concerned with the diagnosis and treatment of diseases affecting the mouth, jaws, face and neck) surgeon. We found no failings with the standard of surgery performed or the type of artificial joint used. We also considered that Mrs C's ongoing problems were reasonably reviewed with no undue delay in providing treatment.

However, we considered it unreasonable that there was no evidence to show that a discussion took place with Mrs C at any out-patient appointment with regard to all the benefits and recognised risks associated with the surgery. The only records of such discussions were during a phone call, where not all the risks were documented, and on the day of Mrs C's surgery, where it was unclear what had been explained to her. We therefore upheld Mrs C's complaint.

Recommendations

We recommended that the board:

• apologise in relation to the failings identified in the consent process;
• review the service's process for obtaining informed consent to ensure it is in line with General Medical Council consent guidance; and
• consider providing written patient information on the jaw joint surgery.

Summary

Mr C complained that the Scottish Ambulance Service (the ambulance service) did not ensure that someone attended his home to make sure he was safe after he took an overdose of paracetamol. When the ambulance crew arrived, they could not or did not gain access and left the house without taking further action. Mr C was later helped by a neighbour to attend A&E. Mr C said he was in a vulnerable situation and that the failings by the ambulance service were potentially life-threatening.

Mr C also complained about the way the ambulance service handled his complaint, including the time it took them to respond.

We took independent advice from a specialist in the training and supervision of healthcare professionals including paramedics. We found inconsistencies in the accounts of the staff involved and it is not clear why contact was not made with Mr C. The ambulance service failed to record their findings and action taken at the time. The evidence indicated a communication breakdown between the ambulance crew and ambulance control centre. We found that the ambulance service should have escalated the situation to the police in order to gain more information and access to the property.

In relation to the handling of Mr C's complaint, we found evidence indicating confusion amongst staff about who should deal with the complaint and how it should be dealt with. We were critical that Mr C's complaint to the ambulance service was initially managed as a concern and that it took over three months for the ambulance service to start an investigation. We also found that complaint staff did not reasonably inform Mr C about the delays and the reasons for these.

Recommendations

We recommended that the ambulance service:

• raise the failings identified with relevant staff;
• confirm that the guidelines being developed for dealing with similar incidents have been implemented and communicated to all staff;
• ensure ambulance crews record adequate information on patient report forms;
• provide an update on the actions taken to improve complaints handling; and
• apologise to Mr C for the complaints handling failures.

Summary

Following a fall, Mrs C attended the A&E department at St John's Hospital with a painful and swollen left arm. X-rays were taken and Mrs C was diagnosed with a dislocated left elbow. Mrs C's elbow was moved back into position (reduced), she was given a plaster cast and further x-rays were taken. An emergency medicine consultant reviewed the x-rays and did not identify any fractures. Mrs C was discharged the same day.

Mrs C's records and x-rays were later reviewed by an orthopaedic and trauma surgeon at the hospital's virtual trauma triage clinic. The surgeon agreed there were no evident fractures. Mrs C was issued with a follow-up appointment to attend the fracture clinic.

In the interim, Mrs C returned to A&E as her cast had become loose and she was in continual pain. An x-ray was taken which showed the elbow had dislocated again and she had a displaced radial head fracture (a fracture of the bone at the top of the forearm). Mrs C was referred the same day to the Royal Infirmary of Edinburgh for surgery.

Mrs C complained that there was an avoidable delay in staff diagnosing she had suffered a fractured arm.

We took independent advice from advisers in emergency medicine and orthopaedics. We found that Mrs C's injury was managed correctly when she first attended A&E and she was appropriately referred to the virtual clinic for review. We also found that the x-rays taken before Mrs C's elbow was reduced showed a fracture which was missed on review. We noted that the x-rays taken after Mrs C's elbow was reduced were not of sufficient quality to rely upon for a diagnosis and that further x-rays should have been obtained. While the problems Mrs C experienced in terms of her outcome were due to the severity of her injury and not her treatment, if further x-rays had been ordered, it is likely the severity of the injury could have been diagnosed and the injury treated sooner. We therefore upheld Mrs C's complaint.

We accepted the advice we received that the board should give consideration to the implementation of hot reporting (where a report of an x-ray of a suspected fracture is delivered by a radiographer before the patient is discharged from the emergency department). This would be in-keeping with the National Institute for Health and Care Excellence (NICE) guidelines on the assessment and management of non-complex fractures. We also considered the board should review the relevant patient advice sheet given at discharge and the process of scheduling fracture clinic appointments to minimise the risk of administrative errors which we found had occurred in this case. We therefore made recommendations to address this.

Recommendations

We recommended that the board:

• apologise to Mrs C for the delay in diagnosing her fractured arm;
• ensure that the advisers' comments on the failure to observe the x-ray abnormalities in this case and to order further x-rays of a diagnostic quality are brought to the attention of relevant staff and report back on the action taken;
• give consideration to the implementation of hot reporting as per the NICE guideline (NG38) on the assessment and management of (non-complex) fractures;
• review the relevant patient advice sheet given at discharge to ensure it sets out the process for orthopaedic follow-up and contains appropriate contact details for any concerns the patient may have and provide us with evidence of this; and
• review the process of scheduling fracture clinic appointments to minimise the risk of administrative errors as occurred in this case.

Summary

Ms C, and advocacy and support worker, complained on behalf of Ms B about the care and treatment received by Ms B's daughter (Miss A). In particular, that there was an unreasonable delay by the board in diagnosing Miss A's genetic condition. Ms C also complained that Ms B was wrongly advised during the new-born period that Miss A, who was born at Raigmore Hospital, did not have the genetic condition. Finally, Ms C complained that the board's replies to her complaints were unreasonable.

We took independent medical advice. We found that there was an unreasonable delay in diagnosing that Miss A had the genetic condition. We also found that Miss A should have been referred for a paediatric cardiology opinion. In addition, the advice we received was that had Miss A been appropriately followed up, the genetic test that became available three years later could have been performed at that time, rather than 12 years after her birth when Miss A was referred to a consultant in clinical genetics.

The board said that they now have an IT database which enables them to identify patients who might benefit from changes in genetic testing, but that due to staffing and workload constraints, they were unable to contact all relevant patients. We found that were patients triaged and followed up appropriately, such a database should not be necessary. We therefore upheld Ms C's complaint that there had been a delay in diagnosing the genetic condition.

We also found that while Ms B was given an assurance during the new-born period that Miss A did not have the genetic condition at birth, it was not possible to exclude a diagnosis at that time. When responding to Ms C's complaints, the board explained they were unable to say why this assurance had been given. We therefore upheld this aspect of Ms C's complaint.

Finally, while the board responded to Ms C's complaints in line with the timescales detailed in their complaints process, we were concerned that they had failed to adequately address all the issues raised. In light of this we upheld this aspect of Ms C's complaint.

Recommendations

We recommended that the board:

• apologise for the delay in diagnosing that Miss A had the genetic condition;
• review their policy with respect to checking patients with suspected inherited conditions, to ensure they are appropriately reviewed by a specialist with an interest in inherited conditions;
• consider the adviser's comments regarding the current database and report back on any action taken; and
• ensure that a full response is provided to a complaint and that this addresses all the points in line with their complaints procedure.

Summary

Mrs C complained about the care and treatment provided to her father (Mr A) by staff at Ayr Hospital. She complained that full diagnostic tests had not been carried out when Mr A was in hospital on two occasions, and that signs of heart failure had been missed by staff. Mrs C also complained that Mr A had been prescribed with medication for his previously diagnosed Parkinson's disease (a progressive neurological condition in which part of the brain becomes more damaged over many years) without a full examination and consultation, and that the medication he was given caused adverse side effects. Mr A was discharged with a full care package and died shortly afterwards.

During our investigation we took independent medical advice from a consultant physician and a specialist Parkinson's disease nurse. We found that whilst the clinical treatment provided to Mr A had generally been reasonable, the board failed to consider a diagnosis of pulmonary embolism (blood clot in the lungs) and carry out the diagnostic test for this. Therefore we upheld this aspect of Mrs C's complaint.

We also found that when Mr A was prescribed with medication for Parkinson's disease, he was not appropriately assessed by the Parkinson's nurse and that there was no documented justification for the prescription. We also found that side effects were not appropriately discussed with Mr A or his family, and that prescribing guidelines were not appropriately followed. Given this, we upheld this aspect of Mrs C's complaint.

Recommendations

We recommended that the board:

• apologise to Mrs C for the failures identified by this investigation;
• draw the adviser's comments regarding the alternative diagnosis of pulmonary embolism, and the carrying out of the diagnostic test, to the attention of the relevant staff;
• apologise to Mrs C for the failings identified by this investigation;
• consider implementing in-patient guidelines for staff regarding the care of people with Parkinson's disease in an acute setting, in order to provide a framework to help with assessment and drug choice; and
• consider implementing assessment and prescribing competencies to support nurses working in this setting, to ensure they have the correct knowledge.

Summary

Mrs C complained on behalf of her son (Mr A). Mr A was admitted to A&E at University Hospital Crosshouse with a three-day history of stomach cramps, diarrhoea and vomiting. It was suspected that he had gastroenteritis and after his symptoms settled he was to be discharged. However, Mrs C said she spoke with the consultant gastroenterologist responsible for Mr A's care and told them that this had been an ongoing problem. Mr A was kept in hospital for a further six days and then discharged with plans to follow up. Prior to the follow-up, Mr A was admitted to hospital as an emergency and diagnosed with Crohn's disease (a long-term condition that causes inflammation of the lining of the digestive system). Mrs C complained that during his initial admission, Mr A was not given appropriate care and treatment.

We took independent advice from a consultant in gastroenterology. We found that on Mr A's admission to hospital, a clear history was documented in the emergency department notes of several weeks of recurrent episodes of abdominal pain associated with significant and unintentional weight loss. This history was later repeated by Mrs C. We found that in the circumstances, this should have raised suspicion of a diagnosis other than that of food poisoning, such as Crohn's disease. The adviser said they would have expected a scan of the abdomen or of the small bowel to have been undertaken during the admission or shortly afterwards. Had this happened, Mr A would have been diagnosed sooner. We therefore upheld Mrs C's complaint.

Recommendations

We recommended that the board:

• apologise to Mr A for the failures identified during this investigation;
• ensure that the consultant gastroenterologist concerned with Mr A's care during this admission is made aware of the results of this investigation and that this case is discussed at their next formal appraisal;
• satisfy themselves that the consultant gastroenterologist is made aware of the guidance relevant to this case; and
• ensure that information about Crohn's disease is readily available to patients on diagnosis.

Summary

Mr and Mrs C complained about how the Crown Office and Procurator Fiscal Service (COPFS) responded to their enquiries. Mrs C contacted COPFS a number of times over the space of two months. After receiving some initial advice from them, including information that her enquiry had been passed on to another member of staff, she found it difficult to contact them.

COPFS said Mrs C had been incorrectly advised that her enquiry was being dealt with by another member of staff. They said they had given Mrs C advice, that they could not help her with her enquiry, and when she contacted them subsequently they had ignored her calls and emails.

When Mr and Mrs C complained to COPFS, they were told they could not be helped with their enquiry and that, under the unacceptable actions part of their complaints policy, COPFS would no longer respond to contact from Mr and Mrs C about the same issue.

We found that COPFS should have had a dedicated unacceptable actions policy. We also found that their complaints policy was not compliant with the SPSO model Complaints Handling Procedure. We upheld Mr and Mrs C's complaint as COPFS had unreasonably advised them that their enquiry was being dealt with and then failed to rectify their error. It was not acceptable to ignore Mr and Mrs C's calls and emails and we therefore upheld their complaint.

Recommendations

We recommended that COPFS:

• apologise to Mr and Mrs C for the failings identified;
• put in place a dedicated unacceptable actions policy to manage situations like this in the future; and
• ensure they have a complaints procedure that is compliant with the model Complaints Handling Procedure.

Summary

Mr and Mrs C complained to us about the handling of a planning application for a wind turbine on land next to their property. They were concerned that the applicant had submitted inaccurate plans and that the application was registered under an inaccurate address. They were also concerned that the council had not fully assessed the impact of noise and that once the turbine was running, it created a noise nuisance.

We took independent advice from a planning adviser. The adviser noted the poor quality of the location plans provided with the application and the inaccurate address. They were, however, satisfied that the noise impact assessment and other information provided to the planners by the environmental health service and the energy company were reasonable.

During our investigation it became apparent that there was confusion over whether distances related to the curtilage of Mr and Mrs C's property or their house. This was not evident from the council's records, and created significant confusion as to whether the planning application had been appropriately handled. Mr and Mrs C also raised concerns that there had been a lack of enforcement action in relation to the mast that remained in place, despite conditions on its removal.

Based on the inaccuracies in plans and the lack of evidence of appropriate consideration of the distances involved, we upheld the complaint, and made recommendations to address the issues raised.

Recommendations

We recommended that the council:

• apologise to Mr and Mrs C for the failings identified in our investigation;
• share the findings of this investigation with those staff involved in validating planning applications, to ensure that the council's check-list for applications is applied consistently;
• consider whether the planning officer involved would benefit from further training in the application and use of planning conditions; and
• consider the use of the council's planning enforcement powers in relation to the current situation.

Summary

Mr C complained that the council did not acknowledge his contact when he repeatedly reported problems with street cleanliness and the condition of on-street bins. We found evidence that the council acted reasonably in response to some, but not all, of the issues raised.

The council acknowledged they failed to consistently provide the level of customer service Mr C was entitled to under their service standards. We also found Mr C was not given good information about the council's complaints process and that his many communications to the council were not always handled in an effective way. We therefore upheld Mr C's complaint.

We noted that the council had offered to meet with Mr C on more than one occasion to get a better understanding of his complaint and that Mr C did not take up this offer. In doing so he missed an opportunity to have his outstanding concerns resolved.

Recommendations

We recommended that the council:

• apologise for the failings identified;
• offer to arrange a visit to explain the standard of street cleanliness to expect going forward; and
• carry out a review of how the council manage multiple contacts with named officers about more than one council service to identify potential improvements.