Upheld, recommendations

Summary

Mrs C complained to us regarding a planning application at a neighbouring site. In particular, she was concerned that the council had failed to re-notify neighbours following the submission of further information from the applicant. Mrs C also complained that the development management sub-committee had not been provided with a reasonable standard of information about ground levels.

We took independent advice from a planning adviser. They noted that when responding to Mrs C's complaints, the council had accepted that neighbours should have been notified of the additional information submitted and been given the opportunity to make further representations. The council also accepted that members of the development management sub-committee should have been made aware of the proposed site levels. We were advised that while reasonable action had been taken by the council to address these findings, further action should be taken by the council. We therefore made five recommendations.

Recommendations

We recommended that the council:

• consider the need for the planning service to accept direct responsibility for securing an acceptable solution in this case and report to us on any action taken;
• ensure that all options, including a specific proposal, are identified and considered and report back to us on the progress of a resolution;
• consider the need to ensure that where they are both planning authority and developer, it is essential to ensure that the standards of the planning service are met, and report back to us on any action taken;
• provide an update on the options developed for landscaping; and
• provide a copy of the practice note on site levels which has been prepared by the service delivery team.

Summary

Mr and Mrs C's child made a disclosure to their class teacher about an incident they found upsetting within the family home. The class teacher spoke to the head teacher and the child was interviewed by the head teacher. The head teacher then contacted another member of the education department for advice and they suggested that social services be contacted. The head teacher said they were clear that they did not make a social services referral. However, the social work department contacted Mr C and arranged a meeting with him and Mrs C.

Mr C was unhappy about this and complained that the head teacher had not followed the correct Getting It Right For Every Child (GIRFEC) procedures. Mr C believed the head teacher should have spoken to him prior to contacting the social work department and they should have created a written assessment of the risk to the child. Mr C also complained the council's investigation into the matter had been rushed and unfair since they had refused to meet with him, despite meeting with the council staff involved.

We found there was no evidence that the head teacher had followed the appropriate GIRFEC procedures as set out in the council's guidance to staff. We found that the head teacher was unaware social services had recorded their contact with them as a referral. We considered it inappropriate that teachers did not know how the social work department recorded requests for advice. We found the council's investigation had not identified the failure to follow council guidance, nor had it explained to Mr and Mrs C why they had been contacted directly by the social work department. We considered the council's investigation into the complaint had not been conducted to an appropriate standard.

Recommendations

We recommended that the council:

• remind the staff at the school of the importance of recording information when following the council's GIRFEC guidance;
• review information sharing between the social work department and education staff, to ensure staff are aware when contact is recorded as a referral;
• review their investigation of the complaint to establish why issues around their failure to follow GIRFEC were not addressed in either response;
• review the investigation to establish why no explanation was provided for the recorded social work referral;
• provide evidence that the learning points identified in the response to us regarding meeting with complainants have been actioned; and
• apologise for the failings we identified.

Summary

Mr C complained on behalf of his daughter (Miss A) about the transfer of school work when she moved between two schools.

We found that while the first school had updated Miss A's exam results promptly after she withdrew from the school, they did not properly deal with requests from Miss A and staff from the second school for evidence of those marks in the form of coursework.

We also found that the council had not identified this poor communication in their complaint investigation. We noted that they appeared to have contacted only the first school during their investigation and not the second school. We found this to be unreasonable. We therefore upheld Mr C's complaints and made two recommendations.

Recommendations

We recommended that the council:

• share the outcome of this complaint with relevant staff; and
• apologise to Mr C for the failure to conduct an effective investigation into his concerns and to his daughter for the distress caused to her by the inadequate communication between the schools.

Summary

Mr C complained to the council about a local bus company's use of the street outside his house for driver changeovers. Various options that would help resolve this problem had been considered but none had been put in place. Separately to this, there were plans to upgrade a nearby junction. This project included measures to accommodate driver changeovers and the council anticipated these would resolve Mr C's problems with driver changeovers.

Following a local consultation, the council began formal proceedings to carry out the upgrade, including a statutory consultation. Mr C complained that the length of time taken by these proceedings was unreasonable. He also complained that the council was not enforcing regulations on buses stopping in a restricted area near his home.

We acknowledged that the statutory process and the way the upgrade project was funded affected the timescale and that this was outside the council's control. However, we found that the council had introduced some avoidable delays that extended the timescale. We also found that the council was aware of drivers being asked by the bus company to stop in the restricted area. We therefore upheld Mr C's complaints.

Recommendations

We recommended that the council:

• apologise to Mr C for the avoidable delay in the process;
• provide Mr C with an update and schedule for the works at the junction near his home; and
• consider whether enforcement of relevant traffic-related legislation is required.

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 for a review appointment, where she complained of tenderness above an incisor tooth when she pressed on the gum. No treatment was provided by the dentist and Mrs C was advised to book a further review appointment at a later date.

We took independent advice from a dental adviser who said Mrs C's symptoms were suggestive of an infection. The adviser said the dentist should have carried out some form of investigation, as a minimum an x-ray, in order to determine the cause and confirm a diagnosis. There was no evidence that they did so.

The adviser said that remedial treatment may then have been appropriate or arranging a further review appointment if it was considered that the problem would resolve without further treatment. The adviser considered that the dentist had not provided Mrs C with appropriate treatment. 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, so we made a recommendation about this.

Recommendations

We recommended that the dentist:

• issue Mrs C with an apology for failing to undertake treatment when they saw her;
• reflect on the comments of the adviser in relation to ensuring that they can confirm any clinical findings with an accurate diagnosis before providing advice 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 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.