Upheld, recommendations

Summary

About six weeks after the birth of her child, Mrs C attended her GP practice with bleeding and abdominal pain. She was treated with antibiotics. She was reviewed several times over the next few months, and a urine test and vaginal swab were carried out, with further antibiotics prescribed. Mrs C was then referred to gynaecology as a private patient, and subsequent investigations showed there were retained products of conception (pieces of placenta) left after the birth. Mrs C complained about the delay in referring her, and said she was only referred after telling the GPs she had private medical insurance.

The practice explained that the cause of Mrs C's bleeding had been unclear. Mrs C had had a CT scan (a scan which uses x-rays and a computer to create detailed images of the inside of the body) after the birth which had returned a normal result (suggesting there were no retained products of conception). In relation to the delay, the practice noted that on one occasion the GP asked Mrs C to come back in one to two weeks, but Mrs C did not return until six weeks later. Mrs C said this was the first available appointment, but the practice said there were a number of earlier appointments available with the same or different GPs. The practice gave us a copy of their audit records, which showed the appointment was booked only a few days before the date of the appointment.

After taking independent medical advice from a GP, we upheld Mrs C's complaint. The adviser said that the GPs should have arranged an ultrasound in view of Mrs C's symptoms of unexplained bleeding for six weeks after birth, and they should have referred Mrs C to gynaecology earlier. However, we agreed that part of the delay was caused by Mrs C returning in six weeks, rather than two (which may have been due to a misunderstanding or miscommunication).

Recommendations

We recommended that the GPs concerned:

• apologise to Mrs C for the failings our investigation found;
• familiarise themselves with postpartum complications and consider identifying this as a learning aim; and
• reflect on our findings as part of their next annual appraisals.

Summary

Mr C, who works for an advice agency, complained on behalf of Mr A who was concerned about the care and treatment given to his late wife (Mrs A). In particular, he was concerned that there was an avoidable delay by staff at Forth Valley Royal Hospital in establishing that Mrs A was suffering from breast cancer. While the board accepted that there had been a delay and apologised, they said that Mrs A had suffered from a rare form of cancer which had been difficult to diagnose.

We took independent advice from a consultant breast surgeon. We found that while Mrs A's form of cancer was a very rare variant, opportunities had been missed to diagnose her sooner. There had also been an initial delay in Mrs A being seen and her cytology (examination of tissue samples under a microscope) results had been incorrectly reported. We therefore upheld the complaint and made recommendations.

Recommendations

We recommended that the board:

• make a formal apology recognising the shortcomings we identified; and
• check that the changes they outlined to Mr A are now in place and that all excision biopsies, as well as cytology aspirates and needle biopsies, are formally discussed at multi-disciplinary team meetings.

Summary

Mrs C's mother (Mrs A) was admitted to the Medical Assessment Unit (MAU) at Dumfries and Galloway Royal Infirmary via A&E after showing signs of a stroke. Whilst in hospital, Mrs A suffered a major stroke. Mrs C raised a number of complaints about the board, including that they unreasonably failed to give Mrs A a clot buster rtPA (an injection to break down blood clots) and that nursing staff failed to monitor Mrs A appropriately.

We obtained independent medical advice from a consultant physician and a nurse. The medical adviser said that the board unreasonably failed to give Mrs A a clot buster rtPA, although they said that the decision would have been a difficult one and would have had to have been made by a specialist.

In addition, the medical adviser said that when Mrs A was in A&E, the board should have carried out a specific risk categorisation using the ABCD2 score (a risk assessment tool designed to improve the prediction of short-term stroke risk after a 'mini stroke'). Had they done so, this would have shown that Mrs A was at very high risk of progression to acute stroke. The medical adviser also said that Mrs A should have been admitted to an acute stroke unit and given a carotid Doppler (a scan to detect a narrowed artery in the neck, which may cause a stroke). She should also have been monitored continuously by experienced staff, rather than being admitted to the MAU. The medical adviser also said that a plan should have been made for Mrs A's care in the event of a deterioration, which should also have been explicit about what to do if new stroke deficits were detected.

Both advisers said the nursing staff did not monitor Mrs A appropriately or observe her every two hours, as required. The medical adviser said that the scoring system used by staff to monitor Mrs A (the Glasgow Coma Scale or GCS) was not entirely suitable. The nursing adviser said that not taking Mrs A's vital signs for a period of over five hours was a serious failing. We upheld Mrs C's complaints and made a number of recommendations to address the failings we identified.

Recommendations

We recommended that the board:

• feed back the failings identified regarding the clot buster rtPA, the ABCD2 score, carotid Doppler and admission to an acute stroke unit to the staff involved;
• identify and address training needs for staff in A&E and the MAU on guideline 108 of the Scottish Intercollegiate Guidelines Network;
• provide Mrs C and her family with a written apology for the failings identified in the first recommendation;
• feed back the failings identified in Mrs A's nursing care to the staff involved;
• complete their review of the use of the GCS score, taking into consideration the medical adviser's views, and provide us with evidence of the outcome of the review; and
• provide Mrs C and her family with a written apology for the failings identified.

Summary

Mr C complained about the board following the death of his partner (Mrs A). Mrs A had attended A&E at Galloway Community Hospital with abdominal pain. She was recorded to have a high temperature and fast heart rate. The doctor who examined Mrs A diagnosed her as having a urine infection, and he discharged her with antibiotics. The next day, Mrs A was accompanying a friend to a hospital in another board area when she collapsed. She developed signs of sepsis (blood poisoning), originating in the gall bladder, and despite resuscitation and intensive care, she passed away.

In their response to Mr C's complaint, the board accepted that the early signs of sepsis had been missed at Mrs A's initial attendance at A&E and apologised for this. However, Mr C brought his complaint to us as he wanted further assurances that appropriate steps had been taken to avoid similar mistakes in the future.

We took independent advice from a medical adviser, who considered Mrs A's initial diagnosis when she attended A&E to be unreasonable based on her symptoms at the time. We also found Mrs A's elevated heart rate and temperature to be of sufficient concern that further investigation should have been warranted and admission to hospital considered. As such, we upheld the complaint.

In response to our enquiries, the board provided extensive details of procedural changes and training that had taken place in Galloway Community Hospital to aid in the diagnosis and treatment of sepsis, so we did not consider that any recommendations of this kind were necessary. We did, however, make a recommendation regarding the doctor who assessed Mrs A, and we asked the board to apologise to Mr C.

Recommendations

We recommended that the board:

• apologise to Mr C for the failings identified; and
• confirm that the doctor who assessed Mrs A has discussed the treatment they provided to Mrs A at their annual appraisal.

Summary

Miss C was concerned about the high water charges in her pub, which she had taken over in 2006. She said she queried her charges in 2009 or 2010 and several times since, but Business Stream had no record of contact before 2014.

In 2014, Business Stream wrote to Miss C noting her high consumption, and she asked them to check the meter. They arranged a survey and initially told Miss C the meter was serving both the pub and the two flats above, but then explained the meter was only serving her pub, although it appeared to be faulty (the numbers were jumping back and forth). Business Stream sent the meter for testing, but this showed it was under-reading (so it did not explain the high consumption). However, since installing a new meter in a new location, Miss C's water charges reduced by about two thirds, despite her not having changed anything in the pub. Miss C asked for a refund, saying that the meter must have been faulty, but Business Stream refused on the basis that the meter test had not found an over-reading fault.

After taking independent advice from a water consultant, we upheld Miss C's complaint. We found the high readings were likely caused either by a problem with the meter or with its location on the old pipework (causing air turbulence). However, it was not possible to tell whether the over-reading was caused by the installation of the meter or by a problem with Miss C's pipework. Given the possibility that Miss C's pipework contributed to the problem, and the time taken to raise this matter with Business Stream, we did not consider a full refund was reasonable. We recommended Business Stream pay a full refund from the date they first noted the meter needed to be moved, and consider paying a partial refund for the period before this.

Recommendations

We recommended that Business Stream:

• refund the difference between Miss C's total water charges and her estimated actual consumption (based on her current consumption) for a specified period; and
• consider making an ex gratia payment of 20 percent of the difference between Miss C's charges and estimated consumption for a specified period.

Summary

Mr C's typewriter stopped working, so he asked his prison for a form to order a replacement. Mr C did not receive a response to his request, and when he complained (known as a PCF1 complaint) about this he was not happy with the responses to the complaints and brought his complaint to us.

We looked at the Scottish Prison Service (SPS)'s file on Mr C's complaints, and correspondence about the typewriter request. We also took account of The Prisons and Young Offenders Institutions (Scotland) Rules 2011 (the prison rules) and the SPS' complaints guidance. A prison governor has discretion under the prison rules to decide whether a prisoner can have specific property, and it is not for us to challenge this. However, we can look at how a specific case has been handled, in terms of the administrative processing and communication with a prisoner.

We found the prison's handling of Mr C's request was unreasonable, as they set aside the fact that Mr C had had a typewriter for over ten years. The prison had to make a defensible decision on Mr C's request (where the prison have to be able to defend their decision should another prisoner make a similar request at another time), but they put the onus for this on him rather than on themselves. There was no record of the consideration of Mr C's request, which took the prison three months to deal with. The prison's letters to Mr C included too much official-sounding jargon. Communication with Mr C in plain language would have been more helpful in the circumstances. We concluded that the prison needed a simple process to deal with non-standard requests. We also found that the prison's responses to Mr C's complaints did not consistently let him know what was being done and when; and when this was not possible, the prison did not provide a full explanation. We upheld Mr C's complaints.

Recommendations

We recommended that SPS:

• apologise to Mr C for the failings identified;
• remind relevant prison staff of the SPS complaints guidance on PCF1s;
• remind relevant prison staff of the importance of writing letters in plain language; and
• consider introducing a simple process to deal with requests for items not on the generic articles in use list.

Summary

Mr C complained to us that the Scottish Prison Service (SPS) had failed to pay him at the correct rate for his attendance at work and education sessions in prison. The amount a prisoner is paid for work in prison depends on the activity level their job falls into. Although this is a discretionary decision for the SPS to take, we found that the SPS had provided Mr C with conflicting information about the activity level of his job. We also found that they had given Mr C inaccurate information about the level of payment for attending education sessions. In view of these failings, we upheld Mr C's complaint.

Recommendations

We recommended that SPS:

• issue a written apology to Mr C for the inaccurate information they provided to him;
• ensure that relevant staff in the prison are aware of the correct rate of payment that prisoners are paid for attending education sessions; and
• review the payments made to Mr C in the prison to ensure that he received all the payments he was entitled to.

Summary

Mr C complained about the time taken to install a warning sign on the road near his home, about the council's communication with him, and their handling of his complaint.

We looked at the council's file on Mr C's complaints and concluded that, in the circumstances, they had taken an unreasonable time to install the sign (it had taken eight months from the date it was agreed that the sign should be installed). The council failed to respond to Mr C's requests for progress updates or took an unreasonable time to do so, and they did not give him a detailed explanation for the delay in installing the sign, which he specifically asked for. We also found that the council failed to follow the complaints procedure, and their responses to him did not always include clear apologies. We upheld Mr C's complaints.

Recommendations

We recommended that the council:

• provide us with evidence of action taken to prevent the incorrect prioritisation of road sign requests;
• provide us with evidence of improvements made in record-keeping and task handover management;
• refresh their understanding of the complaints procedure;
• reflect on the handling of stage 1 of Mr C's complaint, taking account of the complaints procedure; and
• familiarise themselves with our guidance on apology.

Summary

Mr C complained about the council after waiting over a year for repairs to the front door of his council tenancy. At the time he first approached us the repairs had still not been completed and the council had advised him that this was due to numerous issues regarding door suppliers, two of whom had ceased trading in the last year. The repairs took place during our investigation, 17 months after they were first reported.

In response to our enquiries, the council accepted that the suppliers going out of business did not justify the length of time Mr C had waited for the repairs. They stated that there had also been a number of errors of communication and monitoring on their part, contributing to the delays. As a result of this, they committed to implementing new systems to avoid similar mistakes in future.

On investigation, we found that, whilst some of the delays were outwith the council's control, the majority had been caused by poor administrative handling on their part. We also found that they had failed in some of their duties in relation to the Right to Repair scheme. As such, we upheld the complaint.

Recommendations

We recommended that the council:

• apologise to Mr C for the additional failings identified by our investigation;
• offer Mr C the maximum compensation of £100 available under the Right to Repair scheme; and
• remind relevant staff of the council's responsibilities under the Right to Repair scheme.

Summary

Mr and Mrs C complained to the council about the treatment their child received from the head teacher and another teacher at their school. Their child has attention deficit hyperactivity disorder (ADHD) and has additional support needs. Mr and Mrs C were concerned that this was not being properly taken into account by the school. The council investigated but concluded there was no evidence to support Mr and Mrs C's concerns about unfair treatment or bullying by staff. Mr and Mrs C said the investigation was not impartial and complained about how it had been carried out. The council did not respond to this complaint.

During our consideration of these complaints, the council wrote to us and acknowledged a number of issues with their original investigation and response to Mr and Mrs C's complaints. They identified five recommendations that they were taking forward as a result of their review of the case. The council also advised that Mr and Mrs C's later complaint about how the council's investigation was carried out had not been responded to appropriately. We considered that the failings identified in the council's investigation amounted to maladministration and we upheld both of Mr and Mrs C's complaints. We made a number of our own recommendations to address the issues identified.

Recommendations

We recommended that the council:

• issue Mr and Mrs C with a written apology for the failings identified during our investigation;
• provide us with an update on the outcome of the five recommendations identified by the council following their own review of the investigation;
• carry out checks at the school to ensure that appropriate support strategy records are being maintained for pupils with ADHD; and
• make staff aware of the importance of their tone and use of language in case notes and correspondence.