Upheld, recommendations

Summary

Mrs C complained about the treatment provided by her dentist. Mrs C said the treatment she received was unsatisfactory and as a result she had been left with problems with her teeth for which she held the practice responsible. Mrs C had attended an emergency appointment with the dentist complaining of tenderness and food trapping in the upper right quadrant of her mouth. The dentist said that Mrs C had an established problem with an upper right crown and provided Mrs C with temporary treatment and advice regarding her upper anterior teeth. The dentist placed a temporary filling in the palatal deficiency (the roof of the mouth) to prevent food trapping. The dentist also prescribed Mrs C antibiotics for an infection in an upper right tooth.

We took independent dental advice who said there was evidence the treatment the dentist provided was of an unreasonable standard. The adviser said that the symptoms experienced by Mrs C were suggestive of an infection. Therefore, the dentist should have carried out some form of investigation to determine its cause, specifically, they should have taken an x-ray of the tooth, in order to make an accurate diagnosis. The adviser also said that the prescription for antibiotics had been issued without a clear diagnosis being established or recorded in Mrs C's dental records. We accepted that advice and upheld Mrs C's complaint.

The adviser also commented that because Mrs C saw the first dentist with an available appointment whenever she contacted the practice, she was seen and treated by six different dentists in the practice over several months. The adviser said this may have resulted in a failure in communication in that Mrs C was not provided with consistent messages and advice about her treatment.

Recommendations

4, A Dentist in the Lothian NHS Board area
Sector:

• health
• Subject: clinical treatment / diagnosis
• Outcome: upheld, recommendations
• Summary
• Mrs C complained about the treatment provided by her dentist. Mrs C said the treatment she received was unsatisfactory and as a result she had been left with problems with her teeth for which she held the practice responsible. Mrs C had attended an emergency appointment with the dentist complaining of tenderness and food trapping in the upper right quadrant of her mouth. The dentist said that Mrs C had an established problem with an upper right crown and provided Mrs C with temporary treatment and advice regarding her upper anterior teeth. The dentist placed a temporary filling in the palatal deficiency (the roof of the mouth) to prevent food trapping. The dentist also prescribed Mrs C antibiotics for an infection in an upper right tooth.
• We took independent dental advice who said there was evidence the treatment the dentist provided was of an unreasonable standard. The adviser said that the symptoms experienced by Mrs C were suggestive of an infection. Therefore, the dentist should have carried out some form of investigation to determine its cause, specifically, they should have taken an x-ray of the tooth, in order to make an accurate diagnosis. The adviser also said that the prescription for antibiotics had been issued without a clear diagnosis being established or recorded in Mrs C's dental records. We accepted that advice and upheld Mrs C's complaint.
• The adviser also commented that because Mrs C saw the first dentist with an available appointment whenever she contacted the practice, she was seen and treated by six different dentists in the practice over several months. The adviser said this may have resulted in a failure in communication in that Mrs C was not provided with consistent messages and advice about her treatment.
• Recommendations
• We recommended that the dentist:
• issue Mrs C with an apology for the failings identified in the treatment they provided;
• reflect on the comments of the adviser in relation to ensuring that they confirm any clinical findings with an accurate diagnosis before providing advice and treatment or issuing a prescription to a patient; and
• work with other dentists in the practice to give consideration to ensuring that, where a patient is seen and treated by more than one dentist, appropriate processes are in place so that the patient is given consistent messages and advice about their dental treatment.

Summary

Mrs C's elderly mother (Mrs A), who suffered from dementia, was a patient in the Royal Alexandra Hospital. During her admission, members of Mrs C's family visited to find Mrs A naked and lying in a wet bed. Her pyjama top had been removed and her drip displaced, soaking the bed. The family complained and were advised that on two occasions in the hours before the incident, Mrs A was noted to be settled. They concluded that she had removed her top herself. Mrs C was unhappy with this as she believed that given her illness and debility, Mrs A could not have done this. She complained to us because she felt that the board had failed to investigate her concerns appropriately. She was also unhappy about the way they communicated with her.

We took independent nursing advice and we found that the board's investigations had been poor. There was no documentation in Mrs A's medical records to confirm that she had been settled, the incident had not been noted in the file and no statements had been taken from staff who were present on the ward at the time. While it was possible that Mrs A could have removed her top, the board made an assumption that she had done so. There was no mention of Mrs A wearing pyjama bottoms and this was both unacceptable and undignified. The board's complaint response, given the seriousness of Mrs C's complaint, was not a reasonable one. We upheld the complaints.

Recommendations

We recommended that the board:

• make a formal apology;
• emphasise to staff the importance of taking full and timely records;
• review their internal investigations process and consider whether this requires to be audited; and
• review the need for staff on the relevant ward to receive specific training and education regarding distressed behaviour in people with dementia.

Summary

Mrs C complained to us that the board had failed to provide reasonable care and treatment to her son (Mr A) when he attended the Royal Alexandra Hospital after taking an overdose of prescribed medication. Mr A was discharged from the hospital later the same day. Mr A had continuing symptoms of nausea and was given medication to prevent nausea and vomiting. He died two days later. This is thought to have been due to the effects of the overdose he took before attending hospital.

We took independent advice from a consultant in emergency medicine. They found that the level of medication taken by Mr A fell into the range that could cause death and required careful medical assessment and close observation. They noted that staff in the hospital ought to have contacted the National Poisons Information Service to discuss the matter, particularly as Mr A had taken a multi-drug overdose. We considered that the information service would have advised that Mr A should not be discharged until he was free of symptoms, as death can occur up to 54 hours after ingestion of the prescribed medication. Mr A was not free of symptoms as he required medication to control his vomiting.

Although we could not say whether Mr A would have survived had appropriate action had been taken, his symptoms could have been managed better had he remained in hospital. We therefore upheld Mrs C's complaint. However, we were satisfied that the board had learned lessons from the failures in Mr A's care and that the action they had taken in response to these failings was reasonable.

Recommendations

We recommended that the board:

• issue a written apology to Mrs C for the failings in her son's care.

Summary

Mr C had surgery on his prostate at Forth Valley Royal Hospital and he subsequently experienced a common complication of the procedure. He complained that he was not told in advance that this complication would be permanent and he considered that the information he was provided suggested it would only be temporary. He said he would not have gone ahead with the procedure if he had realised that the complication was irreversible.

The board noted that the potential risks were explained to Mr C before the procedure and were listed on the consent form which he signed. They also noted that he was given a patient information leaflet, which stated that three out of four men would experience the complication in question. However, Mr C stated that the leaflet said the complication would only last a few weeks.

We obtained advice from a consultant urologist, who was not critical of the consenting process and considered that Mr C was in a position to provide informed consent. They noted that the leaflet did not state that the complication would only last a few weeks. They considered that it was implicit in the leaflet that the complication could be permanent, however, they said it could benefit from being changed so that this is stated explicitly. We agreed that the leaflet did not state that the complication was temporary. However, we noted that it did refer to some other side effects as being temporary. Given that there is a 75 per cent chance of the complication in question occurring following surgery, and as it is often permanent, we considered that this position should be made clearer in the board's information leaflet. On balance, we upheld the complaint and made some recommendations.

Recommendations

We recommended that the board:

• issue a written apology to Mr C for the failure to make it clear in the information leaflet the likelihood of the complication of his surgery being permanent; and
• clarify in the information leaflet the likelihood of the complication being permanent.

Summary

Mr and Mrs C complained to us about the treatment they received at an out-of-hours centre where they took their baby on the advice of NHS 24 as he was not feeding well and was blue around his lips. There was a wait to see a GP and the baby went pale and struggled to breathe. The baby was seen urgently by a GP who examined him through his clothing and told Mr and Mrs C to take the baby to the A&E department at Crosshouse Hospital in their car. On arrival at the hospital, the baby stopped breathing and had to be resuscitated. The baby remained in hospital for three days. Mr and Mrs C felt that the GP should have given their baby oxygen and arranged for an ambulance transfer to hospital.

We took independent advice from an adviser in general practice medicine and concluded that the GP had carried out an inadequate examination of the baby as they did not remove the baby's clothing. In addition, we noted that the GP had maintained that they did not administer oxygen to the baby as it would have delayed the referral to hospital. We found that as oxygen was available at the out-of-hours centre, the GP should have administered it to the baby. We also found that it was inappropriate to have asked Mr and Mrs C to have transported their baby to hospital without clinical support. We upheld the complaint.

Recommendations

We recommended that the board:

• apologise to Mr and Mrs C for the failings in care and treatment which have been identified during this investigation;
• ensure that the GP discusses this complaint with their GP appraiser as part of their yearly appraisal; and
• ensure that the GP considers whether there is additional learning in relation to the initial management of patients with unstable blood pressure. The GP may benefit from the clinical support group in this regard.

Summary

Mr C complained on behalf of a transport company (the company) that Business Stream had unreasonably failed to fully refund overpayments going back to 2002. Mr C said that a hybrid meter should have been installed to differentiate between the water flow required for fire fighting and the water required for normal usage. Instead, a single meter had been put in in 2003, which was much larger than the company required. It was, however, smaller than the meter it replaced, which resulted in a reduction in the company's water bills. The company had, therefore, been unaware that the wrong type of meter had been installed until 2013. Mr C was able to provide correspondence sent to the company at the time of installation, in which they were told explicitly a hybrid meter had been installed.

Business Stream stated they believed the Prescription and Limitation Act (1973) (the Act) applied, and they were, therefore, justified in restricting any refund to the company to a five-year period.

We found that it would not be appropriate for us to comment on the interpretation of the Act by Business Stream as ultimately this would be a matter for the courts. We considered, however, that Business Stream had failed to demonstrate that their redress and compensation policy had been appropriately or proportionately applied to this case. Business Stream told us that they did not believe further payment was merited, but they did not provide any explanation for this decision. Nor did they explain why this consideration was only made after Mr C's complaint had been submitted to us, rather than as part of their complaint investigation. We considered that this was unreasonable and upheld Mr C's complaint.

Recommendations

We recommended that Business Stream:

• refund the cost of the original meter installation in 2003;
• provide evidence that they have reviewed the case, applying their redress and compensation policy to reflect the circumstances of the case, including both the original failings and subsequent overcharging in a manner which is proportionate to the loss suffered by the company; and
• provide evidence that they have reviewed their complaints process to ensure that due regard is given to the redress and compensation policy and that decisions relating to it are documented contemporaneously as part of the investigation.

Summary

In March 2013, Mr C requested that Business Stream, his licensed water provider, provide him with a resized meter to improve his water supply. Business Stream then contacted Scottish Water, who own and operate the water infrastructure, and they advised that Mr C would first require to provide a water impact assessment. This was completed in November 2013 and Scottish Water were contacted to progress the meter upgrade. To date the necessary work has not been undertaken. Mr C complained to us about the delay.

We found that there was much contact between Business Stream and Scottish Water but that there was evidence of long periods of delay when Scottish Water were inactive. However, quotes have now been provided to Mr C and both Business Stream and Scottish Water have acknowledged their poor service and each have agreed to make an ex gratia payment in recognition of this. We also found that after Mr C made formal complaints to Business Stream in February 2014 and October 2015, both complaints were closed despite the meter upsize not having taken place. We upheld Mr C's complaint.

Recommendations

We recommended that Business Stream:

• make a formal apology for closing the complaints made to them prematurely.

Summary

Ms C, a solicitor, complained on behalf of Miss A about the time it took for the Scottish Social Services Council (SSSC) to carry out a fitness to practise investigation after allegations were raised about Miss A's conduct. The investigation took 15 months. Ms C also complained that the SSSC did not keep Miss A informed of the progress of their investigation.

In responding to the complaint, the SSSC indicated to both Miss A and Ms C that there had been problems with obtaining statements from witnesses. The SSSC also acknowledged that Miss A had not always been kept informed of the progress of her case.

The SSSC told us that significant matters had affected their investigation of the case. These matters included the performance of individuals who had dealt with Miss A's case and the capacity of the department at the time.

While we identified that Miss A had delayed initially in responding to the SSSC's request for comments on the allegations, over a period of seven months little investigation work was carried out. We considered that a more structured approach to exploring the evidence, along with arranging interviews and statements, should have taken place sooner.

We found that the level of activity on the case appeared disproportionate to the 15 months it took to reach a decision. We were also critical of a lack of communication with Miss C about the progress of the investigation. We therefore upheld the complaint.

Recommendations

We recommended that SSSC:

• issue Miss A with a written apology for the failings identified;
• demonstrate to us that clear mechanisms are in place to ensure any protracted period of inactivity on a particular case is identified and addressed; and
• demonstrate to us that effective mechanisms are in place to ensure case workers routinely inform registrants about the progress of their case.

Summary

Miss C complained to us about the length of time it took for the Scottish Social Services Council (SSSC) to carry out an investigation following her informing them of an offence with which she had been charged. She also complained about the lack of information provided to her by the SSSC on the progress of their investigation.

After Miss C contacted the SSSC to query the delay, they apologised to her and said that their investigation could have been concluded around a month earlier had they pursued information needed from her employer and from the court service sooner. In the course of our investigation, the SSSC told us that matters such as increased case numbers and challenges with staffing had contributed to their handling of the case.

We considered that there was a substantial delay of four months during which there was very little action on the case. Although the SSSC have procedures in place for monitoring and supervising investigation work on a monthly basis, we did not see any evidence of a timely discussion of the case. We also found that over a period of five months, Miss C only received information about her case when she contacted the SSSC. The SSSC were unable to provide an explanation for this. SSSC procedures state that staff need to keep registrants informed of progress and also to plan communication when periods of inactivity are likely. We concluded that there was a failure to keep Miss C reasonably informed during the investigation process. We therefore upheld Miss C's complaints and made three recommendations.

Recommendations

We recommended that SSSC:

• demonstrate to us that clear mechanisms are in place to ensure that any protracted period of inactivity on a particular case (such as non-responses to information requests) is identified and addressed;
• demonstrate to us that effective mechanisms are in place to ensure that case workers routinely inform registrants about the progress of their case in accordance with the fitness to practise casework procedures; and
• issue a written apology to Miss C for the failings identified.

Summary

Mr C complained that the Scottish Prison Service (SPS) had unreasonably, and without proper explanation, removed an '08' number from the list of numbers he could call. The 08 number in question redirected to his home number and allowed him to make daily contact with his child at a discounted rate. He had had this number on his list for over a year, however this number was removed from his list without consultation or prior warning.

We found that the Scottish Prison Rules (Telephones) Direction 2011 stated that prisoners are prohibited from using a prisoner telephone to make a phone call, without the prior approval of the governor, to a phone number beginning with 08. The prison explained that numbers like this, which divert to numbers unknown, could present a threat to security and organised crime as well as potentially causing operational difficulties by allowing unlimited time on the prisoner phone. We were satisfied that this explanation was reasonable and that the prison was acting in accordance with the rules in removing the 08 number from Mr C's list of numbers. The prison acknowledged that the 08 number was added to Mr C's list of numbers in error and without the prior approval of the governor, as required by the rules, and that Mr C should have been properly informed when the 08 number was removed. We upheld Mr C's complaint. The prison have now taken action to try to prevent a similar situation occurring in the future by reminding staff of the correct process.

We also had concerns about the way in which Mr C's complaint was handled. Our view was that, had the complaint been properly investigated and a detailed response given to Mr C, this may have prevented escalation of the complaint. Also, an Internal Complaints Committee (ICC) response to Mr C had indicated that prison staff should meet with him to discuss alternative options for family contact; however, this had not taken place.

Recommendations

We recommended that SPS:

• apologise to Mr C for the failings identified by this investigation;
• comply with the ICC response and ensure that prison staff meet with Mr C to discuss alternative options for family contact; and
• undertake a root cause analysis of the way Mr C's complaint was handled to identify why errors were made and to learn from this.