Upheld, recommendations

Summary

Ms C, who works for an advocacy and support agency, complained on behalf of Ms A that Borders General Hospital failed to identify that Ms A had fractured a bone in her foot after she attended A&E on two separate occasions and failed to provide adequate treatment. Ms A's pain persisted for months and her GP referred her to an orthopaedic specialist. A scan identified the fracture.

In responding to the complaint, the board said that the initial x-rays were reported appropriately. However, in a late stage of our investigation the board reviewed the x-ray images and acknowledged there were failings in the fracture being identified by radiology and that the A&E department failed to review the radiology reports, which had shown abnormalities.

We took independent medical advice. We found that there had been failings by the A&E locum doctors who had reviewed Ms A. Specifically, their record-keeping and assessments were below a reasonable standard given the background to Ms A's injury and inability to bear weight. We were critical that the A&E department had not reviewed the radiology reports, which were abnormal. Furthermore, we found that both x-rays did show the fracture. We also considered that it was unreasonable that on each occasion she attended A&E, Ms A was not provided with crutches or given a follow-up appointment to check that her symptoms were resolving, given her inability to bear weight. We therefore upheld Ms C's complaint.

Recommendations

We recommended that the board:

• contact the first locum doctor in order that they may reflect on their practice at their annual appraisal for personal learning and practice improvement;
• provide evidence of the action taken in relation to the second locum doctor and the radiologist, discussing this case at their annual appraisals and ensuring the findings of this investigation are shared with them, including their assessments and record-keeping;
• provide evidence of the review they carried out into the patient management system and process for reviewing imaging reports requested by the A&E team to ensure it is effective and in line with national guidelines;
• apologise to Ms A for the failings identified; and
• consider issuing guidance for the A&E team regarding the necessity for follow-up of patients who are unable to weight bear following an injury.

Summary

Miss C complained about the college's administration of the distance-learning maths course she applied to. We found that Miss C was only contacted by the college regarding the fee waiver evidence that was required for enrolment on the course the day after the course started. We noted that this delay meant that Miss C did not receive her course materials on time and was not allocated a tutor at the appropriate time. We were satisfied that, once enrolled, Miss C received an appropriate level of support from her tutor and we noted that the college had offered a free place on an equivalent maths course in response to her complaint. We considered that this was reasonable. However, we were critical of the college's processing of the application and considered that staff should have contacted Miss C regarding the evidence needed within good time of the course start date. We upheld Miss C's complaint.

Miss C also raised concerns about the college's handling of her complaint and said that the college had exceeded its target timescales in responding to her complaint. We noted that the college had exceeded the investigation target, but we were satisfied that the college had a good reason for this as it was not able to speak to relevant staff during the summer holiday period. The college told us that they had not contacted Miss C at the appropriate time to explain the delay and agree a revised timescale. They also told us that they had introduced a new audit process to prevent this happening again. We upheld this aspect of Miss C's complaint.

Recommendations

We recommended that the college:

• review the reasons for the delay identified in contacting Miss C about her fee waiver evidence, with a view to preventing this from happening again; and
• provide us with evidence of the audit process, regarding sending holding letters, that has been introduced.

Summary

A nursery was inspected by the Care Inspectorate. Following production of the draft inspection report, the nursery contacted the Care Inspectorate to raise concerns about the inspection process. These concerns were addressed initially by the inspector's line manager. The nursery were not satisfied with the response received and they instructed their representative (Ms C) to raise a complaint on their behalf.

As well as raising concerns about the inspection process, Ms C complained about the way in which the nursery's initial concerns were dealt with. In particular she questioned the appropriateness of the line manager's role in the complaints process in light of their role in the inspection process. She also complained that the Care Inspectorate interviewed the inspectors as part of their complaints investigation but did not interview nursery staff. In addition, Ms C raised concerns that the Care Inspectorate delayed in responding to the nursery's complaint.

We identified areas where the Care Inspectorate had failed to respond to the complaint in line with their complaints handling procedure (CHP). While we did not consider it inappropriate for the line manager to have dealt with a complaint at stage 1 of the CHP (frontline resolution), we noted that the initial concerns were not dealt with under the CHP. As the concerns fitted with the Care Inspectorate's definition of a complaint, we considered that they should have been addressed in line with the CHP. We noted that the nursery initially indicated that they did not wish to formally complain; however the CHP contains provision for such a situation and the Care Inspectorate did not follow this. We noted that it is often good practice when carrying out interviews to interview both parties to a complaint. However, we were satisfied that the Care Inspectorate gave appropriate consideration to doing so and reasonably concluded that it would not have brought value to their investigation of this particular complaint. As the Care Inspectorate had initially given an indication that it was likely they would interview nursery staff, we considered that expectations could have been better managed in this regard.

In relation to the timescale for completing the investigation, we noted that this was unavoidably protracted for large parts, and that the CHP contains provision for extending certain complex investigations. However, such extensions should be fully explained to, and agreed with, the complainant and we did not consider that the Care Inspectorate took appropriate steps to do so. In addition, we noted that there was an initial delay in logging and acknowledging the complaint and, while there was regular correspondence thereafter, we noted that on one occasion the complainant was not contacted as promised. We therefore upheld the complaint.

Recommendations

We recommended that the Care Inspectorate:

• remind staff of the action to take when a complainant does not wish a matter that is clearly in line with the Care Inspectorate's definition of a complaint to be considered under the CHP;
• remind staff that where extensions to investigation timescales are required, the reason for this should be fully explained to the complainant and their agreement sought;
• review their mail-receiving processes to ensure that incoming complaint correspondence is quickly identified and passed to the relevant area to be logged and actioned without delay;
• remind staff of the importance of managing complainants' expectations in terms of how their complaint will be investigated and of adhering to any undertakings to contact complainants; and
• apologise to the nursery for failing to handle their complaint in line with the CHP.

Summary

Mrs C complained about the council's handling of a planning application to develop residential accommodation at a site next to the home of her daughter (Miss A). Mrs C complained that the council had not taken appropriate action when she highlighted issues with the accuracy of the applicant's submission. She also complained that the council had not allowed sufficient time before a committee meeting for her to submit additional information about the impact of the new development on daylight at Miss A's home.

We took independent planning advice. We found that when Mrs C raised concerns about the accuracy of the application, the council did not acknowledge or act on these quickly. The council had recognised this during their own consideration of the complaint and taken remedial action. The advice we received highlighted a failure to re-notify neighbours when the applicant submitted further information to the council. Had the council taken this action, it would have allowed Mrs C further time to submit information relating to the daylight impact of the development.

We also found the council had told Mrs C that a short turnaround time had been given due to concerns about the applicant appealing against non-determination of the planning application (the planning applicant has a right to appeal the non-determination of their application if the council has not reached a decision to grant or refuse planning consent within a specific statutory timescale). The advice we received was that the timescale for an appeal had already passed and consequently this was not a relevant factor in the case. We therefore upheld Mrs C's complaints.

Recommendations

We recommended that the council:

• provide Mrs C with an apology for the incorrect information she was given about a potential appeal for non-determination of the planning application.

Summary

Miss C said that her daughter (Miss A) was unable to go on an outdoor education trip organised through her school as she had her period that day and there were no arrangements for toilet stops during the outing. After raising a complaint about this with the council, Miss C agreed to look over draft documentation on the council's policy on offsite trips as part of a review group and provide feedback. This process subsequently broke down and Miss C complained again to the council and was given assurances that the changes that she felt should be made would be put in place. When Miss A's school next issued correspondence on an outdoor education trip, Miss C said it was clear that the agreed changes had not been made.

Miss C complained that the council acted unreasonably by failing to make the amendments to the documentation on the council's policy which she was led to believe would be put in place. The council acknowledged that this was the case and that the timescale for finalising and implementing the revised documents was unreasonable. This was supported by documentary evidence and we therefore upheld this aspect of Miss C's complaint.

Miss C also complained that the council's handling of her complaint was unreasonable. Miss C raised several issues, including that the timescale for dealing with her complaint was excessively lengthy. We found that there were unreasonable delays by the council in acknowledging and responding to Miss C's complaint. We also found that the council appeared to be operating two different complaints procedures, one of which (Complaints Procedure 1) contained an excessive number of stages and out-of-date information on rights of appeal, and did not comply with the local authority's model complaints handling procedure. We therefore also upheld this aspect of Miss C's complaint.

Recommendations

We recommended that the council:

• take steps to ensure that possible toilet stops are included in every outdoor activity plan;
• provide Miss C and her daughter with a written apology for the failings identified;
• ensure that Complaints Procedure 1 complies with the model customer facing complaints procedure on the Complaints Standards Authority Valuing Complaints website;
• feed back our decision on Miss C's complaint to the staff involved; and
• provide Miss C with a written apology for the additional failings referred to in our decision.

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.