Upheld, recommendations

Summary

Mr C complained about the housing association after they failed to carry out adjustments to improve soundproofing in his property. As Mr C has a disability which heightens his sensitivity to noise, he stated that normal living noise from his neighbour below was causing him a great deal of stress. He felt that as he was at a substantial disadvantage compared to someone without his disability, this meant the association had a duty to make reasonable adjustments under the Equality Act 2010 and suggested the installation of soundproof matting. However, the association refused his request.

On investigation, we found that the association had failed to explain their decision to refuse his request. Instead, they had made reference to a previous response they made to an unrelated request for a reasonable adjustment. They also failed to fully explain their decision in response to our enquiries. As such, we upheld this element of the complaint.

Mr C also complained that, throughout the four years of his tenancy, the association had failed to provide him with sufficient tenancy management support.

On investigation, we found that an early offer of support had been made to Mr C, but that this had not been repeated despite clear indications that Mr C was struggling to manage various aspects of his tenancy. We also found no evidence that the association had carried out a detailed assessment of Mr C's support needs to ensure that they were meeting their responsibility to provide suitable support, either internally or through external agencies. Finally, we found that the association had no policies directly relating to the provision of tenancy support, and despite making a number of enquiries on the subject, we were not clear on the extent of the support they aimed to provide to their tenants, either internally or externally, or how and when referrals to these services were triggered. For these reasons, we upheld this aspect of Mr C's complaint as well.

Recommendations

We recommended that the association:

• apologise to Mr C for the failings identified;
• reconsider Mr C's request for reasonable adjustments in the form of auxiliary aids to reduce noise disturbances in his home and provide clear explanation of a robust, evidenced decision;
• share the findings of this investigation with all staff responsible for responding to requests for reasonable adjustments;
• carry out a full assessment of Mr C's current support needs and take reasonable steps to ensure suitable support is made available going forward;
• consider implementing a policy/procedure that clearly defines: the extent of the support the association aim to provide internally; which external agencies are available to provide any additional support required; and how and when referrals to both internal and external services will be triggered; and
• provide training to relevant staff on how to identify and assess support needs.

Summary

Mrs C complained on behalf of her husband (Mr A) about the way a consultant at Ninewells Hospital managed his care and treatment following the discovery of a nodule (a growth of abnormal tissue) in his lung. Mr A was reviewed over three years and then received a letter discharging him from the clinic because the nodule appeared stable. At Mrs C's persistence, the consultant reviewed Mr A again and further investigation identified that the nodule was a slow growth tumour.

We took independent medical advice and found that Mr A had been appropriately managed up until being discharged from the clinic. However, we considered that Mr A's latest scan results should have been discussed at a multi-disciplinary team meeting prior to taking the decision to discharge him as it showed other lung changes. We also found it unreasonable that the consultant had referred to these lung changes in the discharge letter rather than discussing them in person with Mr A.

Recommendations

We recommended that the board:

• apologise to Mr A for unreasonably discharging him from the service; and
• draw these findings to the attention of the consultant to discuss at their next appraisal.

Summary

Mrs C complained to us about the medical care and treatment provided to her late father (Mr A) at the Western General Hospital before his death. Mr A had previously been diagnosed with rheumatoid arthritis associated interstitial lung disease (a group of disorders characterized by inflammation and scarring of the lung tissue). He was admitted to hospital and a CT scan showed that he had inflammation and a possible infection in his chest. He was given steroids and antibiotics to treat this and was then discharged. Mr A was then admitted to hospital again with increased breathlessness. He was again treated with antibiotics and discharged after physiotherapy. Mr A was subsequently admitted to hospital again with increased shortness of breath. A chest x-ray showed that this was most likely pneumonia. His condition deteriorated in the hospital and Mr A died there several days later.

We took independent medical advice from a consultant in respiratory medicine. We found that the care and treatment provided to Mr A had been reasonable. However, when he was discharged from hospital on the second occasion it was decided that he could be reassessed for portable home oxygen at his respiratory clinic appointment which the staff thought was two or three weeks later. However, they did not check the date of the clinic appointment and it was in fact nearly six weeks after Mr A was discharged. We found that this was too long to wait to assess Mr A and for this reason we upheld this aspect of Mrs C's complaint.

Mrs C also complained about the nursing care Mr A received. We took independent nursing advice. We found that there had been a number of failings but we were satisfied that the board had apologised and had taken action to try to prevent similar problems recurring.

In addition, Mrs C complained about the communication with Mr A and her family. We found that this had been inadequate and upheld this aspect of the complaint.

Recommendations

We recommended that the board:

• confirm that relevant staff are now working in line with the NHS quality standard on assessment for oxygen therapy.

Summary

Mrs C complained that her mother (Mrs A) was left sitting in a chair for nine hours without access to a bed, whilst waiting to be moved to a new ward. Mrs C said that Mrs A had asked to go to bed during this time. The board told us that Mrs A had chosen to sit in her chair and was offered access to a bed in a side room if she wanted to lie down. We found that nursing records had not been kept on the day in question and we upheld the complaint because there was a lack of evidence of proper nursing care on the day in question.

Recommendations

We recommended that the board:

• offer an apology to Mrs A which recognises that she has a different account of what happened to that of the staff nurse, and which acknowledges the failure to keep reliable nursing records, and outline the steps taken to address the issues with ward staff.

Summary

Mr C complained about a lack of measures taken by the mental health team based within the prison after he reported thoughts of harming himself or others. Several days later, Mr C caused damage to his arm and hand requiring surgical treatment at hospital.

We took independent advice from a mental health adviser. We found that a team approach should have been taken towards assessing and making a joint decision on Mr C's risk of harming in light of historic factors which do not appear to have been considered after he reported concerning thoughts.

We concluded that Mr C should have been managed under ACT 2 Care arrangements (a strategy for the care of individuals assessed to be at risk of self-harm or suicide) until such time that a multi-disciplinary team decided that his level of risk no longer needed such measures to be in place.

Recommendations

We recommended that the board:

• issue a written apology to Mr C for the failings identified;
• ensure all relevant staff in the health centre team at the prison are aware of the ACT 2 Care approach to self-harm where 'at risk' prisoners should be subject to the individualised risk management arrangements; and
• share these findings with the staff involved in Mr C's care.

Summary

Mr C complained to us about the medical care and treatment provided to his late mother (Mrs A) in the Southern General Hospital before her death. We took independent advice on Mr C's complaint from a consultant in general and elderly medicine. We found that there had been a number of failings in the medical care provided to Mrs A. There were delays by medical staff in attending when her condition deteriorated. She should also have been seen by a more experienced doctor when nursing staff raised concerns about her condition. In addition, there were failings in relation to communication with Mrs A's family. Although we upheld this complaint, we were satisfied that the board had acknowledged that aspects of Mrs A's care were not adequate and had apologised for this. The board had also carried out a significant incident review and had made recommendations to address the failings.

Mr C also complained that Mrs A did not receive a reasonable standard of nursing care. We took independent advice on this aspect of Mr C's complaint from a nursing adviser. We also found that there had been a number of failings in relation to the nursing care provided and upheld this complaint. However, these failings had been identified by the board and they had made recommendations to ensure there was learning and improvement. They had also apologised to the family for the failings.

Finally, Mr C complained that there had been a delay in moving Mrs A to a critical care unit. We upheld this complaint as we found that Mrs A should have been moved to the critical care unit at an earlier stage and that the delay in doing so had been unreasonable. Although the board had introduced new criteria for medical referrals to the critical care unit, they did not have a written policy in relation to this.

Recommendations

We recommended that the board:

• provide evidence that the recommendations from their significant incident review have been implemented;
• provide evidence that they have considered what the role of a first year trainee doctor should be in cases where there has been a serious deterioration in a patient;
• formalise the criteria now in place for medical referrals to the critical care unit in a written policy; and
• issue a written apology to Mr C for the delay in transferring Mrs A to the critical care unit.

Summary

Mr C, who works for an advice and support agency, complained on behalf Mrs A. Mrs A's husband (Mr A) was suffering from neck pain and had also experienced some episodes of blood in his urine. He attended at the A&E department of Inverclyde Royal Hospital and was also attending the urology out-patient clinic following a referral from his GP. Mr A was diagnosed with a muscular neck condition at two emergency department attendances. The blood in his urine was considered to be connected to a medicine he was taking to help prevent blood clots. Mr A was later admitted to the hospital via the A&E department and was subsequently diagnosed with lung cancer which had spread to the vertebrae in his neck.

Mr C complained about the care and treatment that Mr A had received as Mrs A felt that his condition could have been diagnosed earlier if appropriate tests had taken place.

After taking independent advice from a consultant in A&E care, a respiratory consultant and a urology consultant, we upheld this complaint. Whilst no failings were identified in relation to the urology investigations or the care that Mr A received following his admission and diagnosis with lung cancer, we found that there had been issues in the two attendances at the A&E department. The advice we received was that the diagnosis that Mr A had received was not reasonable and that other issues had not been appropriately considered. The A&E adviser highlighted that after Mr A's second attendance, it would have been reasonable to discuss his case with more senior doctors.

Recommendations

We recommended that the board:

• apologise for the failings in care provided by the A&E department during Mr A's two attendances;
• ensure that the findings of this investigation are discussed at the next appraisals of the relevant clinicians; and
• review the procedure for escalation to senior staff for patients presenting at emergency departments with progressive symptoms or signs.

Summary

Mr C attended his medical practice with a recurrence of back pain and sciatica (back and leg pain caused by irritation or compression of the sciatic nerve) and it was agreed he would be referred to neurosurgery. Mr C complained about a subsequent delay in the referral being sent and about the practice's response to his complaint to them.

We took independent advice from a GP, who confirmed that routine referrals should normally be sent within one week. Mr C's referral was not sent for almost six weeks. We were critical of the practice for not having clearly explained the reason for the delay to Mr C. In their response to Mr C they had blamed general delays across the NHS system and had not accepted any specific fault on their part. However, the practice told us that the delay was caused by a delay in dictating and typing the referral letter. They informed us of the process they have in place to avoid a similar future occurrence.

The adviser also noted that Mr C attended the practice on a further three occasions in the interim period. They considered that his reported symptoms should have prompted the upgrading of the referral to urgent. They noted that urgent referrals should be sent within 24 hours. The adviser saw no evidence of Mr C having been asked questions to rule out further warning signs that may have necessitated an emergency hospital admission. We therefore found that there was an unreasonable delay in sending the routine referral and an unreasonable failure to upgrade this to urgent. We upheld this aspect of Mr C's complaint.

With regard to the practice's handling of Mr C's complaint, we noted in particular that Mr C did not receive a response to his initial complaint letter and that he was not referred to the SPSO at the end of the process. We were also critical of the practice for including details of Mr C's medical history in their correspondence to us that was not relevant to his complaint. We upheld this aspect of Mr C's complaint.

Recommendations

We recommended that the practice:

• confirm that the management of back pain, and red flag signs, will be included as a learning need in the annual performance appraisals of the doctors in the practice;
• apologise to Mr C for the failures identified in the handling of his referral to neurosurgery;
• review their complaints handling procedure to ensure that both staff and patient guidance are consistent with each other and with NHS 'Can I help you?' guidance. In particular, they should ensure that complaints are appropriately acknowledged, timescales for response are clearly communicated to complainants, complaints are responded to in full, with any learning points clearly identified, and complainants are appropriately signposted to the SPSO;
• advise complaint handling staff to ensure that they refrain from including confidential patient information in complaint correspondence, where it is not relevant to the complaint issues that have been raised; and
• apologise to Mr C for the failures identified in their handling of his complaint.

Summary

Mr C complained that he was being required to work in the prison work-sheds despite it being a source of anxiety for him and causing him to suffer panic attacks. He considered that the prison health centre should have supported him in being excused from work on health grounds. He noted that a mental health nurse had briefly declared him unfit for work but that this decision was reversed following a multi-disciplinary review of his case.

The board told us that the decision to declare Mr C unfit for work had been reversed on the basis that it was considered his anxieties were being managed appropriately. They noted that a care plan had been devised to reflect this.

We took independent advice from a senior mental health nurse. They noted that the clinical reasoning behind the initial decision to declare Mr C unfit for work, and the content and conclusions reached at the subsequent meeting, were not documented. They were critical of this and the lack of evidence of a comprehensive and structured assessment of Mr C's mental health needs having been carried out. They did not, therefore, consider that Mr C's mental health and fitness to work were adequately assessed prior to the meeting and on this basis we upheld Mr C's complaint.

However, the adviser noted that the care plan that was subsequently put in place took a reasonable approach in seeking to support Mr C's continued attendance at work.

Recommendations

We recommended that the board:

• provide evidence of the steps taken to ensure that, where appropriate, structured mental health assessments are carried out by prison healthcare staff;
• provide evidence of the steps taken to ensure that nurse record-keeping within the prison health centre complies with the Nursing and Midwifery Council standards; and
• apologise to Mr C for the failings this investigation has identified.

Summary

Mr C complained about the care and treatment received by his late brother (Mr A) in relation to Mr A's lung cancer and his admission to Forth Valley Royal Hospital following a cardiac arrest.

During our investigation we took independent advice from two advisers, a consultant in respiratory medicine and a consultant in anaesthesia and critical care medicine.

The board accepted that there had been unnecessary delays in Mr A's cancer care pathway, for which they apologised and outlined the action taken. The consultant in respiratory medicine said that while some delays had been unavoidable, others were unexplained and unreasonable, in particular the delays relating to the referral from primary care to secondary care. They also noted poor communication. We therefore upheld this aspect of Mr C's complaint. However, the advice we received from the consultant in anaesthesia and critical care medicine was that the decisions taken following Mr A's admittance to the hospital and the care and treatment he received were reasonable.

Recommendations

We recommended that the board:

• consider the adviser's comments in relation to the delays experienced by Mr C's brother, in particular the referral from primary care to secondary care and poor communication, to see what further lessons can be learned.