Upheld, recommendations

Summary

Mr C and his then partner (Ms D) attended a multi-agency meeting at a school in the council's area regarding their foster son. Mr C was unhappy about the way he was spoken to at the meeting by one of the school's staff. Mr C complained to us that the council failed to reasonably investigate his complaint about the way in which he was spoken to at the meeting in line with their complaints procedure.

Mr C's concerns included that the council's investigating officer should have interviewed all four of the meeting attendees to ascertain the truth and that the council's complaints procedure available to him online was out of date. He also said that the council failed to signpost him to us and had to be pressed to confirm that their complaints procedure had been completed.

We considered that it was for the council's investigating officer to determine what evidence she needed in order to make a decision on Mr C's complaint. There was no requirement in the council's complaints procedure for her to have interviewed all persons present at the meeting. However, it would have been helpful if the council had explained to Mr C why they considered that the social worker at the meeting could be a corroborating witness for the member of the school's staff, but that Ms D could not be considered a corroborating witness for his version of events.

The council acknowledged that the complaints procedure available online at that time was out of date. The evidence showed that the investigating officer failed to inform Mr C that her response was the final stage of the council's complaints procedure and the response did not refer him to us. This resulted in several months of unnecessary communications between Mr C and the council on his complaint. We were also concerned that the council failed to make and retain notes of key events in the handling of Mr C's complaint. We upheld Mr C's complaint.

Recommendations

We recommended that the council:

• feed back our decision on Mr C's complaint to the staff involved;
• take steps to ensure that, in future, records of key events during the investigation of complaints are made and retained; and
• provide Mr C with a written apology for the failings identified.

Summary

Miss C complained about the council's communication with her over a series of suspensions to her housing benefit.

We found that the council had communicated clearly with Miss C about the reasons for the suspensions and that she had been told what further information was required.

Although during our investigation we found that Miss C expected the council to reply to her emails unreasonably quickly, we did find administrative failings on the council's part, including sending an important email to the wrong address, not finding an attachment to one of Miss C's emails, and advising Miss C that a notice had been sent when it had not. They also failed to reply to two separate emails sent by Miss C. We therefore upheld the complaint and made a recommendation to address this.

Recommendations

We recommended that the council:

• review the handling of this case to establish the cause of administrative errors, and identify what steps might be taken to avoid recurrence. The council should then share learning from the review with relevant staff members.

Summary

Mrs C and her husband decided to defer their child, who has a February birthday, starting Primary One. They wanted their child to spend a further year at nursery. Mrs C said that in terms of the Scottish Government statutory guidance, The Children and Young People (Scotland) Act 2014, children born in January or February have the right to have the deferred year funded by a local authority.

Mrs C and her husband secured a place for their child at a partnership nursery school within the council area and applied for funding. The council initially refused the application because in terms of their early years admissions policy deferred funding was only provided for the nursery the child had attended in their pre-school year. In the case of this child, the nursery was in another local authority where the family resided. The council then wrote to Mrs C stating they would fund her child's place but shortly thereafter withdrew their funding offer. The council said the letter offering to fund the child's place had been sent as a result of human error and because their database had not been updated.

Mrs C complained to us about the council's handling of her application. In terms of the statutory guidance, we were satisfied that the council were entitled to set their own local admissions policy and at the time Mrs C made her application, her child did not meet the criteria for funding. Nevertheless, we accepted that the failings in the handling of Mrs C's application had left her in a difficult situation and had caused her concern and distress. For this reason, we upheld the complaint. We also made a recommendation to the council in relation to their computer system in respect of funding applications.

The council subsequently reviewed their admissions policy and agreed to fund the child's deferred year place.

Recommendations

We recommended that the council:

• provide evidence of the process review and adjustments made to their computer system in respect of funding applications.

Summary

Mr C complained that the council failed to follow their policies and procedures in dealing with his reports of anti-social behaviour about two of his neighbours, who were council tenants. Mr C said that his health had suffered considerably due to the actions of his neighbours and the council's failure to deal with the matter appropriately.

During our investigation, we looked at whether, in their handling of Mr C's complaints about his neighbours, the council had followed their anti-social behaviour procedure (ASB procedure) and the provisions set out in their Scottish Secure Tenancy Agreement (SSTA). We found that the council had dealt with most of Mr C's reports of anti-social behaviour by his neighbours in accordance with the provisions of the SSTA and their ASB procedure.

However, the records showed that having begun action under the SSTA against one of Mr C's neighbours, in relation to a pet being unsupervised in Mr C's garden and common areas, there was no evidence that the council ensured the required action was taken. This was despite Mr C continuing to report problems with his neighbours, providing them with further evidence and telling the council that they were failing to resolve his complaints.

We considered that the council's written responses to Mr C's letters were unreasonably brief and failed to fully explain the actions taken by them. The council's responses failed to advise Mr C that some of the matters raised by him were not for the council, or to whom the issues should be reported. This lack of detail was also apparent in the council's written responses to Mr C's formal letters of complaint to them about their handling of the situation. We therefore upheld Mr C's complaints.

Recommendations

We recommended that the council:

• feed back our decision on Mr C's complaint to the staff involved;
• take steps to ensure that any future complaints from Mr C are dealt with in line with their ASB procedure and SSTA, whilst taking full account of the previous formal action taken by the council;
• ensure that, in future, they provide complainants with full written responses to written reports and formal complaints about anti-social behaviour, with signposting where appropriate; and
• provide Mr C with a written apology for the failings identified.

Summary

Mrs C complained to us about the care and treatment her late mother (Mrs A) had received in Ninewells Hospital before her death. In particular, she complained about the management of her mother's oxygen therapy immediately before her death. Mrs A had a number of health problems, including idiopathic pulmonary fibrosis (a lung condition that causes scarring of the lungs and where the cause is unclear). She was receiving oxygen therapy and a trial had indicated that she required a consistent high level of oxygen via a rebreathing mask (a mask that provides a high concentration and flow of oxygen and is used to provide patients with very specific oxygen needs).

However, a nurse had put in place a nasal cannula (two prongs that sit at the bottom of the nose and are more comfortable to wear, but which deliver a lower concentration of oxygen than a rebreathing mask), to allow Mrs A to eat her lunch and drink. A nurse had then observed Mrs A to be alert after lunch, but ten minutes later, Mrs A was found to be dead. She did not have the mask on at that time.

We took independent advice on Mrs C's complaint from a consultant in respiratory medicine. We found that, in general, the clinical treatment provided to Mrs A had been reasonable. However, the fact that her oxygen saturation had dropped to low levels when her oxygen had been disconnected several days earlier should have alerted medical staff to the fact that she needed oxygen via a rebreathing mask and not a nasal cannula. We found that her oxygen saturation levels should have been monitored during and after her lunch if the rebreathing mask was to be removed, although there was no clear evidence that Mrs A's death resulted from this. We upheld this aspect of Mrs C's complaint. We also upheld her complaint that the board did not respond reasonably to her enquiries and complaints in view of their delays in responding to her.

Recommendations

We recommended that the board:

• provide evidence that consideration has been given to establish how to prevent a repetition of this incident in the future;
• issue a written apology to Mrs C for the failings identified; and
• make complaints handling staff aware of our decision.

Summary

Ms C works for an advice and support agency. She brought the complaint on behalf of her client (Mr B). Mr B had concerns about the treatment his daughter (Miss A) received at Ninewells Hospital after she was referred by her GP with suspected appendicitis. Miss A was reviewed and appendicitis was considered to be unlikely. She was prescribed antibiotics for a urinary tract infection and was discharged home. Miss A did not improve and had to be taken back to the hospital two days later. Although initial assessment found appendicitis to be a possible cause of her symptoms, she was discharged after two days with a diagnosis of gastroenteritis (inflammation in the intestines caused by infection). Her condition did not improve and she had to be readmitted four days later. Miss A underwent surgery to investigate further. During this procedure her appendix was removed as it was found to be gangrenous. An abscess was also discovered. Miss A did not recover well and had to undergo more surgery as she had developed a deep pelvic abscess. In addition to his concerns about the treatment provided to his daughter, Mr B was dissatisfied with the time the board had taken to deal with his complaint.

After taking independent advice on this case from a consultant surgeon, we upheld the complaint about the treatment provided to Miss A. The adviser considered that Miss A's appendicitis could have been diagnosed and acted on at her second attendance at the hospital. We were advised that this would have lessened the risk of a pelvic abscess developing and the further problems that she experienced. The adviser also commented that the information about risks of the initial surgery had not been recorded comprehensively enough. As the board had introduced a new patient pathway document for children with suspected appendicitis following Mr A's complaint, the adviser was asked to review this. The adviser considered that it would benefit from further consideration by the board in light of our findings, and we made a recommendation about this.

We also upheld the complaints handling concerns that were raised. The board accepted that they had not responded within a reasonable timescale and had not met a reasonable standard as a result. They explained that their process had since been changed.

Recommendations

We recommended that the board:

• apologise for the failings we identified;
• take steps to ensure that all relevant paediatric and surgical staff are made aware of the findings of our investigation;
• consider the use of a clinical scoring tool for paediatric appendicitis;
• review the care pathway previously developed in light of the independent advice received in our investigation and provide us with a copy of this for review; and
• ensure that adequate details of the risks of surgery are explained and documented during the consent process.

Summary

Miss C complained about the clinical treatment provided to her late brother (Mr A). Mr A was admitted to Ninewells Hospital with chest pain. He was diagnosed with a chest infection and discharged the next day. Mr A died of a heart attack a few weeks later. Miss C was concerned that the hospital did not find a problem with Mr A's heart, particularly as he was admitted with chest pain and had a family history of cardiac (heart) problems.

In response to Miss C's complaint to them, the board said Mr A did not show signs of a heart attack during his admission and that they considered the care provided to have been reasonable. They noted that recovering from a chest infection can put an extra strain on the heart, which may have precipitated a heart attack, but that this could not have been predicted.

After taking independent medical advice, we upheld Miss C's complaint. While we were advised that the care provided was reasonable at first, it was not clearly recorded in the medical records that Mr A was properly reviewed before discharge and that he had no ongoing symptoms of concern.

However, we were not critical of the hospital not identifying a problem with Mr A's heart. The adviser explained that the investigations carried out were reasonable and supported the diagnosis of a chest infection. Based on the information available to the hospital at the time, the adviser considered it was reasonable that the doctors did not investigate a possible cardiac cause for Mr A's pain.

Recommendations

We recommended that the board:

• apologise to Miss C and her family for the lack of a detailed assessment on the day of discharge; and
• ensure the consultant reflects on our findings as part of their next annual appraisal.

Summary

Mr C complained to us about emergency treatment he received at the Royal Infirmary of Edinburgh after injuring his knee. He attended A&E at the hospital, where his injury was diagnosed as a soft tissue injury. Mr C was given advice on pain relief and told to see his GP if the pain persisted.

About a month later Mr C saw his GP, as the pain was continuing. An x-ray was taken of his leg and this showed a stress fracture.

The independent advice we received from a specialist in emergency medicine, which we accept, was that Mr C should have received an x-ray when he first attended A&E. As such, we upheld the complaint. However, we were advised that due to the nature of Mr C's injury it was unlikely this x-ray would have identified the fracture and it was therefore unlikely that this would have altered his treatment.

Recommendations

We recommended that the board:

• apologise to Mr C for the failure to arrange an x-ray of his leg injury; and
• share the findings of this investigation with the staff in question and ask them to reflect on this for their future practice.

Summary

Miss C raised a number a number of concerns about the care and treatment her daughter (child A) received when she attended Raigmore Hospital. In particular, she complained that staff failed to listen to her and this had an adverse effect on her daughter. Miss C also complained that there was an unreasonable delay in obtaining a jejunal feeding tube (a small tube that is passed through the nose or mouth and into the small intestine).

We took independent advice from a consultant general paediatrician. The advice we received and accepted was that, overall, the care and treatment child A received was reasonable. However, we were concerned about the delay in obtaining the jejunal feeding tube. The adviser also said that there was no evidence in the medical records of an overarching plan for child A's care and that, overall, the communication with Miss C was not adequate for her needs. We upheld Miss C's complaint. During our investigation the board met with Miss C and agreed to discuss ways in which they could improve communication with her around medical issues whilst her daughter was in hospital.

Recommendations

We recommended that the board:

• consider how staff might escalate matters when there appears to be unnecessary delays in obtaining specialist items, such as jejunal tubes, which are not kept in hospital and which result in delays in treatment;
• provide an update on the improvements implemented in relation to the communication with Miss C around medical issues whilst her daughter is in hospital; and
• consider the adviser's comments, particularly in relation to the need for an overarching care plan agreed with Miss C, in future admissions to hospital.

Summary

Mrs C raised a number of concerns about the care and treatment provided to her late mother (Mrs A). She said that the board had failed to appropriately investigate her mother's symptoms and that this led to a delayed diagnosis of a brain tumour.

Mrs A was admitted to Raigmore Hospital following a seizure. She was evaluated by the Stroke Team and various procedures were carried out including a CT scan (a scan that uses a computer to produce an image of the body) and an electroencephalogram (EEG - a test that measures and records the electrical activity of the brain). The results were reported as normal and Mrs A was discharged a few days later.

Around five months later, Mrs A was readmitted to Raigmore after suffering a further seizure. She was admitted to Nairn Hospital soon after this with a history of a loss of consciousness and episodes of twitching and seizures. There were further episodes in hospital. It was thought that these were likely epileptic seizures and an antiepileptic drug was prescribed. Mrs A was again discharged. Around seven months later, Mrs A attended a follow-up appointment at Raigmore Hospital, and the following day was admitted to A&E at Perth Royal Infirmary where Mrs C was advised that Mrs A had a brain tumour.

During our investigation, we took independent advice from a consultant neurologist. We found that, while some aspects of Mrs A's care and treatment were reasonable, there was an unreasonable delay in performing an MRI (magnetic resonance imaging - a scan used to diagnose health conditions that affect organs, tissue and bone) of her brain. This should have been arranged within four weeks of Mrs A's admission after the loss of consciousness and seizures.

We found that it was appropriate that the board started Mrs A on antiepileptic medication but that the subsequent monitoring of the medication and her condition were not reasonable. We found that there was a delay in Mrs A receiving a follow-up appointment at the neurology clinic, as best practice would have been to arrange out-patient review within a few weeks of discharge. It would also have been good practice to have involved an epilepsy specialist nurse in Mrs A's care. We also found that the management of Mrs A at the follow-up appointment fell short of best practice.

Recommendations

We recommended that the board:

• apologise to Mrs C for their handling of this matter;
• ensure that the relevant clinical teams are aware of the latest Scottish Intercollegiate Guidance Network and National Institute for Health and Care Excellence guidelines on the management of strokes, transient ischemic attacks (or 'mini' strokes) and epilepsy, and the requirements for prompt neuroimaging;
• ensure that the consultant neurologists are aware of the limitations of EEG in the diagnosis of epilepsy and that they reflect on the adviser's comments at their next appraisal; and
• consider the adviser's comments that it would be good practice to provide epilepsy specialist nurse care to patients with epilepsy.