Upheld, recommendations

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.

Summary

Mrs C complained that the board failed to provide appropriate nursing care to her husband (Mr A).

Mr A suffered from ischaemia (inadequate blood supply), which had previously resulted in the amputation of his right leg below the knee. He was admitted to hospital with ischaemia of his left foot and an ulcer. There was no surgical option available to address this issue and the plan was to delay amputation as long as possible. Mr A was being seen twice a week by district nurses following discharge from hospital.

Some months after discharge, a nurse identified deterioration in Mr A's foot and contacted Mr A's GP practice. The GP prescribed antibiotics; however, the district nurses did not schedule a further visit at that time. A nursing visit did not take place until six days later. The nurse who attended discovered a maggot infestation in Mr A's wound. Mr A was subsequently taken to hospital and received an above-knee amputation of his left leg.

Mrs C complained about the missed visit. She also complained about the board's communication. The board acknowledged failings had occurred and apologised to Mrs C.

After receiving independent advice from a nurse, we upheld Mrs C's complaint. We found that the board had failed to ensure twice weekly visits as required under Mr A's care plan. We also found the board's communication was below a reasonable standard. In addition, we found that while the board generally complied with wound management guidance, formal wound assessments were not conducted regularly. We made a number of recommendations to address these issues.

Recommendations

We recommended that the board:

• confirm they will audit district nursing formal wound assessment charts to ensure that they meet local and national guidelines and provide evidence of this;
• remind staff of the importance of ensuring requested visits are followed up and documented within patients' records;
• provide evidence that there are improved systems in place for communicating a patient's plan of care between team members and other healthcare providers;
• consider a scheme of each patient having a named nurse to contact if they have concerns outwith their scheduled visits;
• consider a scheme for planned visits to be on set days of the week; and
• apologise for the failings identified in this investigation.

Summary

Mrs C complained that the practice failed to provide appropriate medical care to her husband (Mr A).

Mr A suffered from ischaemia (inadequate blood supply), which had previously resulted in the amputation of his right leg below the knee. He was admitted to hospital with ischaemia of his left foot and an ulcer. There was no surgical option available to address this issue and the plan was to delay amputation as long as possible. Mr A was being seen twice a week by district nurses following discharge from hospital.

Some months after discharge, the practice was contacted by the board's district nurse who had identified deterioration in Mr A's foot. A GP at the practice did not consider a visit was necessary at that time, and instead prescribed antibiotics for Mr A. On the fourth day after the visit, Mrs C further contacted the practice when she received no subsequent visit from the board's district nurses. A second GP from the practice attended Mr A at home. The GP did not examine the wound, but prescribed further antibiotics. Two days later, the practice was further contacted as a district nurse had attended and discovered a maggot infestation in Mr A's wound. A GP attended and Mr A was taken to hospital. Mr A subsequently received an above-knee amputation of his left leg.

Mrs C complained about the actions of the two GPs. She also complained about the practice's communication with the board. The practice acknowledged communication failings had occurred, and apologised to Mrs C.

After receiving independent advice from a GP, we upheld Mrs C's complaint. While we found the first GP acted appropriately in prescribing antibiotics, we found the second GP should have examined the wound given Mr A had previously received antibiotics and his symptoms were worsening. We also found that the practice's communication with the board fell below a reasonable standard.

Recommendations

We recommended that the practice:

• ensure the relevant GP is made aware of the findings of the investigation for reflection and learning;
• issue an apology for the identified failings in care.

Summary

Mrs C complained that she had been overcharged by Business Stream. Business Stream accepted that Mrs C had been overcharged but would not pay more than five years of backdated charges. Mrs C said she had repeatedly tried to raise the issue without success and that Business Stream had ignored her correspondence.

Mrs C believed that the issue spanned a period of about 25 years. She explained that a neighbouring property had sub-meters, which deducted from the main meter reading. She used relatively little water, while the neighbouring property used a lot of water. One meter had not been read for an extended period and Mrs C had paid for water used by the neighbouring property, as well as her own water.

Business Stream had refunded Mrs C for a five-year period. A lack of records made it difficult to establish water usage before this. Business Stream stated they had rejected the first overpayment offer from Scottish Water, before achieving an offer which reflected Mrs C's overpayments during a ten-year period. This was a period longer than that for which they were legally required to pay.

We found that Business Stream had taken an excessive length of time to address Mrs C's complaint. She had had to use a firm of solicitors before Business Stream began a full investigation, which we found to be unreasonable as Mrs C had incurred unnecessary costs in order to access the complaints system. We asked Scottish Water if their refund covered a period greater than five years. Scottish Water denied this and their position was supported by their correspondence with Business Stream. We found Business Stream had unreasonably and misleadingly stated to this office and to Mrs C that their Redress and Compensation Policy had been applied, which had resulted in a payment greater than the five-year legal requirement.

We found this to be unreasonable. We found that Business Stream should have given consideration to refunding the costs incurred by Mrs C and to applying their Redress and Compensation Policy to reflect the inconvenience and loss incurred by Mrs C during the period she was being overcharged as well as the failures within Business Stream's complaints process.

Recommendations

We recommended that Business Stream:

• apply their Redress and Compensation Policy in a manner which is proportionate to the loss and inconvenience caused as they appear to have accepted that a discretionary payment should be paid in this case for the charges back to 2005, but Scottish Water's evidence that itemises the period covered by the refund for overpayment was solely for 2008 to 2013;
• provide evidence they have reviewed their complaint investigation, to establish why they provided misleading and inaccurate information regarding the period of time the allowance granted by Scottish Water was intended to cover; and
• refund the cost of the solicitors fees incurred by Mrs C during the complaint.

Summary

Mr C complained that he had twice reported faulty street lights to the council and that they had failed to repair the lights, as they were required to do. He also complained about the way in which the council dealt with his complaint.

The council had acknowledged failings in their repairs process and subsequent communication and advised Mr C that these lights would be repaired.

We found that the council's records of Mr C's initial reports and their subsequent actions were poor. We were unclear as to what action had been taken by the council as the evidence was limited. We also noted that the council had failed to address Mr C's subsequent complaints to them, to speak to Mr C to discuss his concerns, and to respond to his correspondence in line with their complaints process. We therefore upheld Mr C's complaints.

Recommendations

We recommended that the council:

• review their handling of Mr C's request for repairs to the street lamps in order to establish why they do not appear to have reacted to his multiple reports of street lighting faults within the required timescale and also review their record-keeping to ensure that accurate records are retained of reports of faults and repairs carried out; and
• reflect on their handling of this complaint in order to identify why responses were not provided within the appropriate time frames, why Mr C was not contacted to clarify his complaint and why the points he raised were not addressed in either their stage one or stage two responses.

Summary

Mr C complained that the council had failed to fully reflect his concerns about a neighbouring planning application when they made a report to committee, in particular with regard to noise and loss of sunlight.

The council acknowledged that they had failed to fully reflect Mr C's concerns. They advised Mr C that the measurement of sunlight loss used for the application was appropriate but accepted that they should have communicated more clearly in their report about the loss of daylight. They also acknowledged that they did not properly reflect Mr C's concerns about the potential impact of noise.

We took independent advice from a planning adviser. The adviser found that while the council had failed to fully reflect the representations made by Mr C, these would have been available in full to committee members. They also found that the daylight test was in line with the council's guidance. As the council did not fully reflect Mr C's concerns about possible noise, we upheld Mr C's complaint.

Recommendations

We recommended that the council:

• remind planning officers of the importance of accurately reflecting public representations on material planning matters in the report of handling.