Upheld, recommendations

Summary

Mr C complained about the council's handling of a planning application at a business park where he owns property. Mr C was concerned that the neighbour notification process had not been correctly followed as he had not received any information on the proposed development. He also complained that the council did not have sufficient information about the nature of the business that was to operate from the new development before approving the application, and that his subsequent reports of noise and pollution had not been acted on appropriately.

We took independent advice from a planning adviser and upheld Mr C's complaint. We found that while Mr C's property was not within the neighbour notification area, the council had already acknowledged that the process had not been correctly followed as the description of the development provided in the notification and local press advertisements was inaccurate. The council accepted that updating the description amounted to a substantial change which should have been re-notified and re-advertised. The advice that we received was that a change of this type should have necessitated a new planning application. The council explained that they had reviewed their planning processes and steps were in now in place to prevent a recurrence of errors like this in future.

In relation to the information available to the council in reaching a decision on the planning application, the advice we received was that not all material considerations had been taken into account. The adviser considered there was no evidence that pollution and contamination had been considered. The adviser explained that any decision on whether the planning consent was valid would be a matter for the courts if a legal challenge was made.

We noted that Mr C had continued to report difficulties in respect of pollution. We found that following initial reports, there had been a failure to promptly advise Mr C of the outcome of environmental investigations and that planning action on this issue had been somewhat delayed. We made a number of recommendations to address the issues highlighted by this investigation.

Recommendations

We recommended that the council:

• provide evidence of all the steps taken, including training, to prevent such errors recurring in future;
• apologise for the failings identified in this investigation;
• make the relevant staff aware of the adviser's comments and guidance on material considerations;
• establish whether noise and pollution continues to be a concern for Mr C; and
• consider further environmental health investigation on the basis of the current position.

Summary

Ms C, who works for an advocacy and support agency, complained on behalf of her client (Miss A). Ms C complained about the failure of GPs to follow up Miss A's abnormal blood results when she registered with the practice. Miss A had abnormal blood results when tested at her previous GP practice and as a result, she was diagnosed with hepatitis C (a virus that can infect and damage the liver, and can be transmitted to others through contact with infected blood) a number of years later. Miss A believed that had the practice kept the blood results under review when she moved into their area, the diagnosis of hepatitis C would have been made earlier and she would therefore not have suffered from other medical conditions.

The practice said that due to the passage of time, it was difficult to comment and that the GP who had seen Miss A had retired a number of years ago. The practice explained that there was a note that Miss A had had abnormal blood results at her previous practice but that the clinical picture was improving. However, they accepted that follow-up tests were not arranged. A GP had diagnosed that Miss A had Gilbert's syndrome (a genetic disorder where higher than normal levels of bilirubin, a substance found naturally in the blood, build up in the bloodstream causing jaundice).

We took independent advice and found that although there was an improvement in Miss A's condition initially, her blood results were still abnormal and that further tests should have been arranged by the practice. This had contributed to the delayed diagnosis of hepatitis C. We also found that although Miss A had abnormal blood results, her bilirubin level was not abnormal and as such the diagnosis of Gilbert's syndrome was not accurate.

Recommendations

We recommended that the practice:

• apologise to Miss A for the failings identified in this investigation.

Summary

Ms C, who works for an advocacy and support agency, complained on behalf of her client (Miss A). Ms C said that Miss A's medical practice failed to follow up her abnormal blood results, and that as a result she was subsequently diagnosed with hepatitis C (a virus that can infect and damage the liver, and can be transmitted to others through contact with infected blood) a number of years later. Miss A believed that had the practice kept the blood results under review, the diagnosis of hepatitis C would have been made earlier and that she would therefore not have suffered from other medical conditions.

We took independent medical advice and found that although there was an improvement in Miss A's condition initially, her blood results were still abnormal and further tests should have been arranged. As a result, this had contributed to the delayed diagnosis of hepatitis C. We therefore upheld Ms C's complaint. We also found that the practice procedure for the reporting of blood results had subsequently been updated and that the current process is appropriate and would highlight that action is required when abnormal results are identified.

Recommendations

We recommended that the practice:

• apologise to Miss A for the failure to arrange follow-up blood tests.

Summary

Mr C complained that the board failed to provide the results of a scan that he underwent at the Western General Hospital. He said that his GP had not been given the results of the scan, and that when he called the board he was given results over the phone by a secretary who had not been able to explain the results in full. He also complained about the board's handling of his complaint.

We took independent advice from a hospital consultant. We found that it was the responsibility of the consultant who ordered the scan to report the results back to Mr C, and that this was not done. Whilst there was some limited evidence that the consultant had notified the GP of the results, there was no evidence of what form this notification took. We found that when the results were viewed by the requesting consultant, a letter should have been sent to both Mr C and his GP. We therefore upheld this aspect of Mr C's complaint.

In addition, we found that the board's response to Mr C's complaint contained several inaccuracies and upheld Mr C's complaint in this regard.

Recommendations

We recommended that the board:

• ensure that this case is brought to the consultant's attention at their next annual appraisal for them to reflect on;
• reflect on this case and consider whether this was an isolated error or whether steps should be taken to ensure scan results are being communicated to patients in a timely manner;
• bring the findings of this investigation regarding the communication of test results to the relevant secretarial staff's attention;
• apologise for the failings identified with regards to their complaints response; and
• remind complaints handling staff of the necessity of providing factually accurate and non-contradictory responses.

Summary

Ms C, who works for an advocacy and support agency, complained on behalf of her client (Mrs A) that there had been an unreasonable delay in diagnosing that Mrs A's husband (Mr A) had cancer. Mr A had been admitted to the Southern General Hospital with breathlessness and swelling in his right leg. His condition deteriorated over the next few weeks and a number of tests were carried out. One month after he was admitted to hospital, it was confirmed that Mr A had metastatic cancer (cancer that spreads to other parts of the body).

We took independent advice from a consultant respiratory physician. We found that although the speed of investigation was timely during the first three days of Mr A's admission, there was then an unreasonable delay in carrying out further investigations and medical staff had not acted in line with the relevant guidance. An earlier diagnosis would have meant that Mr A and his family would have known the prognosis and likely outcome earlier. Palliative care could also have been considered at an earlier stage, although we found that curative systemic treatment (treatment such as chemotherapy that reaches cells throughout the body by travelling through the bloodstream) would not have been appropriate for Mr A. We upheld this aspect of Ms C's complaint.

Ms C also complained that staff had failed to ensure that Mr A had appropriate pain management. We found that although there was a good record of pain assessment within the nursing notes, there were numerous inconsistencies between the nursing and prescription records. We found that the pain management and escalation of pain relief treatment had not been in line with the relevant guidance and, in view of this, we also upheld this aspect of Ms C's complaint.

Recommendations

We recommended that the board:

• provide this office with an action plan detailing the steps that will be taken to prevent similar failings in future cases and to ensure that staff act in line with the relevant guidance;
• provide evidence that steps have been taken to ensure the involvement of palliative care specialist services at the appropriate stage in cases of this nature; and
• issue a written apology to Mrs A for the failings identified.

Summary

Mrs C complained about a delay in receiving surgery. She said that she had waited longer than the 12-week treatment time guarantee (TTG) to be given a surgery date, and that this affected her quality of life as she could not work and had distressing ongoing symptoms. Mrs C also raised concerns about the board's handling of her complaint.

During the investigation of Mrs C's complaint, she was given a surgery date with the surgery taking place about 18 weeks after she agreed to the treatment. The board said the time-frame was due to the complexity of the surgery which meant that two different specialists had to be involved.

The board also said that Mrs C requested a named consultant, which Mrs C disputed. When we asked for evidence, the board acknowledged that this was incorrect and explained that staff had misunderstood the process and created a letter stating that Mrs C wished to have a named consultant, instead of the letter explaining that the TTG would not be met.

After taking independent medical advice, we upheld Mrs C's complaint about the delay. Although there was evidence that individual clinicians were aware of delays with this kind of surgery and were taking appropriate action, we were critical that the board did not deliver the TTG in Mrs C's case. We were also critical that the board did not contact Mrs C to explain the delay due to the administrative error. During our investigation we also found that a referral for further investigations had been missed due to the wrong name being given on the letter. Although the medical adviser said it was reasonable in this case for the surgery to go ahead despite these investigations not being done, we were critical that the referral was missed.

We were also critical of the board's handling of Mrs C's complaint as it appeared that the initial complaint, which was made by her mother, was missed by complaints handling staff which lead to a delay in it being investigated. However, instead of acknowledging this error, the board incorrectly said the delay was due to waiting for Mrs C to consent to the complaint.

Recommendations

We recommended that the board:

• feed back the findings of this report on the misdirected referral to the medical staff involved;
• review the arrangements for referrals of this kind to reduce the risk of referrals being misdirected in future;
• demonstrate to this office that a long-term solution has now been put in place to progress waiting lists for this kind of surgery;
• apologise to Mrs C for the failings identified; and
• discuss the findings of this report with relevant complaints handling staff for reflection and learning.

Summary

Ms C, who works for an advocacy and support agency, complained on behalf of Ms A that during a surgical procedure at Aberdeen Royal Infirmary to address a condition affecting her spine, Ms A's spinal-cord was injured which led to a significant deterioration of her condition. Ms C complained that staff failed to investigate her new symptoms following the procedure and that they failed to recognise that they were a result of an injury from the surgery.

We took independent medical advice from a specialist in neurosurgery. We found that while the evidence indicated the operation itself was carried out to a reasonable standard and that the cord injury Ms A suffered from was a recognised complication (and one which she had been made aware of prior to the operation), there were shortcomings. Firstly, there was no evidence that clinicians had discussed all treatment options with Ms A during the consent process. Secondly, clinicians unreasonably failed to investigate Ms A's new symptoms before discharge home. Therefore, we upheld Ms C's complaint.

Recommendations

We recommended that the board:

• take steps to ensure clinicians discuss all relevant treatment options with patients during the consent process and document this;
• bring the failings identified in this investigation to the attention of relevant staff; and
• apologise for the failings identified in this investigation.

Summary

Miss C complained that she was excluded from South Lanarkshire Leisure and Culture (SLLC)'s library premises and placed on their violent marker system following a verbal exchange with staff. She complained that her exclusion was unreasonable. Our investigation focused on whether the relevant process and procedures were followed in taking the decision to exclude Miss C.

We noted that SLLC's management rules and founding legislation states that an exclusion order can be issued where someone has persistently contravened management rules and is considered likely to do so again. However, SLLC confirmed that their decision to issue the exclusion order in Miss C's case was based on a single contravention. We also noted that Miss C should have been formally informed of her right to make representations against the exclusion and this did not happen. In addition, we noted that a phone call and a meeting between senior staff and Miss C, which were cited by SLLC as features of the exclusion process, were not documented.

While we identified that Miss C was notified in writing of her placement on the violent marker system, SLLC advised us that this letter was sent in error and that the template had since been removed. We therefore did not consider that they had provision in place to meet their future obligations in this regard. However, we noted that they were still in the process of reviewing their procedures. We considered that it was appropriate for this review to be completed, taking account of the failings our investigation identified, and that it would be beneficial for the relationship between the exclusion and violent marker procedures to be clarified. We noted that Miss C had subsequently been informed that her exclusion had been lifted following review, but she did not receive any confirmation of the outcome of a review of her position as it relates to the violent marker system. In light of the identified failings, we upheld this complaint.

Recommendations

We recommended that SLLC:

• complete a review of their management rules and violent marker procedure (and the relationship between the two) and inform this office of the steps taken to ensure future compliance with their statutory and procedural obligations;
• remind staff of the importance of documenting the content of meetings and phone calls, particularly where they will be relied upon to support future actions;
• apologise to Miss C for their failure to follow the appropriate procedure when taking action to exclude her from using their facilities; and
• write to Miss C to confirm the position as it relates to information held about her on their violent marker system.

Summary

Mr C complained that the prison health centre unreasonably opened mail that was addressed to him.

The board were unable to identify who opened Mr C's mail, but they acknowledged that it appeared to have arrived at the health centre unopened. They accepted that the item should not have been opened by staff and that an apology should have been issued to Mr C as soon as it was identified that it had been opened in error. We therefore upheld Mr C's complaint.

Recommendations

We recommended that the board:

• issue appropriate staff guidance on the handling of prisoner mail by healthcare staff.

Summary

Ms C, who works for an advocacy and support agency, complained on behalf of Mrs B about the care and treatment given to Mrs B's husband (Mr A) after he had two wisdom teeth extracted under general anaesthetic at Raigmore Hospital. Ms C said that on his return home after discharge, Mr A became very unwell. Mrs B twice phoned the hospital for advice but it was only after her second call that he was asked to return. When Mr A returned to the hospital, no record was found of the calls made.

After examination and a scan, Mr A was diagnosed with sepsis and was admitted to intensive care where he stayed for about a week. Ms C said that information about Mr A's discharge failed to reach his GP and dentist in a timely way. Mrs B made a formal complaint to the board about these matters. Ms C complained that they failed to properly address Mrs B's concerns.

The board were of the view that they had treated Mr A reasonably although they recognised a number of shortcomings (namely that records of phone calls to the hospital were not properly recorded and that letters and discharge information were delayed).

We took independent advice from a consultant in oral and maxillofacial surgery and found that there was no record of phone conversations prior to Mr A's admission. However, after his re-admission Mr A's care had been reasonable. We also found that there had been delays in issuing discharge letters and that addresses had been omitted. Furthermore, Mrs B's complaint had not been properly addressed in that although these shortcomings had already been identified by the board, they had put no plan in place to prevent the same thing happening again. We therefore upheld Ms C's complaint.

Recommendations

We recommended that the board:

• advise of the action taken in the interim to prevent the same thing happening again (in relation to information not being recorded in the clinical notes) and if no action has been taken, they should advise of their proposals;
• advise what they have done to address communications concerns since they were brought to their attention and failing any action, they should undertake an audit of the clinics and ward concerned to establish the extent of any continuing problem and provide their solution should problems remain; and
• make a formal apology for their oversights to Mr A and Mrs B.