Upheld, recommendations

Summary

Mrs C, an advocacy worker, submitted a complaint on behalf of Ms A regarding the care and treatment received by her late brother (Mr A). Mr A had a history of mental and physical health problems and was an in-patient in the Royal Edinburgh Hospital for more than 15 years. He was discharged into supported accommodation. Daily support was provided by a voluntary sector organisation and his psychiatric care was overseen by the board's community rehabilitation team (CRT). Mr A's physical health deteriorated following discharge and he was diagnosed with renal cancer around five months later. Mr A died the following month. Ms A complained about the time taken to diagnose her brother's cancer and about a failure to involve her in his care and listen to her concerns about his deteriorating condition.

We obtained independent advice from a mental health professional. They noted that the primary responsibility for monitoring Mr A's health following his discharge lay with his GP practice. However, they noted that the CRT had a role in liaising with the GP practice and monitoring Mr A's engagement with them. The adviser considered that the discharge plan lacked clarity surrounding these roles and responsibilities and lacked focus on Mr A's physical health, despite his history of physical health problems and known difficulties engaging with healthcare providers. The plan did not set out a schedule for visits from Mr A's key worker and the adviser observed that there were long gaps between visits, despite Mr A's carers contacting the CRT to raise concerns about his wellbeing.

The adviser also considered that the discharge plan should have set out strategies for involving Ms A in her brother's care and observed that the key worker did not contact Ms A directly until five months after discharge. In light of the advice received, we concluded that the CRT could have been more proactive in overseeing Mr A's care following discharge and in engaging with his family. Arrangements for doing so should have been set out in the discharge plan and we considered that closer monitoring of Mr A's physical health and evident deterioration might have resulted in medical assessments being requested earlier. We therefore upheld the complaints. We could not say that closer monitoring would have led to an earlier diagnosis or altered the outcome for Mr A but we noted that it could have allayed some of the family's distress. We obtained additional independent advice from a GP who noted that, when Mr A was referred for investigation of his deteriorating condition, he was thoroughly assessed and managed appropriately.

Recommendations

We recommended that the board:

• ask relevant staff to reflect on the failings highlighted in this investigation and advise us of identified actions to improve future discharge planning, with a specific focus on monitoring physical health and engaging with family/carers; and
• apologise to Ms A and her family for the identified failure to monitor Mr A more closely following his discharge from hospital.

Summary

Mr C and his father (Mr A) complained about the care and treatment provided to Mr A in relation to an operation to fit a pacemaker. They were unhappy about treatment Mr A received at the Royal Infirmary of Edinburgh when the pacemaker was fitted and said that there was inadequate information about possible complications of the surgery and incorrect treatment during the surgery. They also complained about the response and aftercare following surgery when Mr A reported his levels of pain and concerns. They said that as a result of the failures, Mr A's quality of life had been adversely affected and that he had to undergo another operation to repair the incorrectly positioned pacemaker.

We took independent advice from a medical adviser. We found that there was no evidence that sufficient information was given to Mr A about the procedure and possible complications or that staff took account of his additional needs (given his anxiety and loss of hearing). We also found that while there were problems with the pacemaker that had to be rectified, this does not mean that it was incorrectly implanted in the first place. Having said that, we were critical that staff failed to address Mr A's anxiety or ensure he was adequately sedated which may have contributed to an increased likelihood of lung puncture during the procedure. Moreover, while we found that clinical staff dealt with Mr A's concerns technically following the operation, staff failed to address his anxiety which may have exacerbated his symptoms. We therefore upheld the complaint and made a number of recommendations.

Recommendations

We recommended that the board:

• review their procedures around consent and ensure that the process accommodates patients with additional needs;
• bring the failures related to consent and additional needs to the attention of relevant staff;
• bring the failures related to managing anxiety during the surgical procedure to the attention of relevant staff;
• ensure relevant staff consider referral to rehabilitation in similar circumstances; and
• apologise to Mr A for the failures this investigation identified.

Summary

Over a period of time, Ms C began to experience constant bloating, was unable to lose weight and was concerned about other symptoms. She attended her GP, who examined her stomach and said there was excess fluid but he was not concerned. The GP's note of this consultation said that Ms C was doing well with her diet, had lost three stone, but felt she was putting weight on despite not changing anything. He arranged routine blood tests which came back normal. Ms C's symptoms got worse. A few weeks later she attended a different GP. The GP found what she thought was a cyst on Ms C's left ovary and a scan confirmed this. Surgery removed a very large (30 centimetres by 24 centimetres) cyst. Ms C complained that the care and treatment she received from the first GP was inadequate.

We sought independent advice from a GP adviser. The adviser considered the relevant General Medical Council (GMC), Scottish Intercollegiate Guidelines Network (SIGN) and National Institute for Health and Care Excellence (NICE) guidance. They concluded that the note of the appointment was not of a reasonable standard as it was sparse in detail, showed evidence of only a very limited recorded history, and no evidence of a medical examination. The adviser explained that Ms C's symptoms required examination and follow-up, neither of which was recorded. They also considered that the note did not show evidence of good communication or working in partnership with patients so it was not of a reasonable standard. The adviser explained that, in line with SIGN and NICE guidance on the investigations needed to exclude ovarian cancer, Ms C should have had a particular blood test and a scan. Therefore, we found that reasonable investigations were not carried out.

We upheld Ms C's complaint and made several recommendations.

Recommendations

We recommended that the practice:

• ensure the GP apologises to Ms C for the specific failings identified by our investigation;
• ensure the GP familiarises himself with the SIGN and NICE guidelines in relation to the presenting features of possible ovarian cancer, and identifies this as a learning need for his yearly appraisal;
• ensure the GP reviews his medical record-keeping and provides evidence of improvement;
• ensure the GP reviews and reflects on his communication with patients; and
• ensure they make certain their complaints handling procedure is fully compliant with the Patient Rights (Scotland) Act 2011 and the Scottish Government 'Can I help you?' guidance.

Summary

Miss C complained about the board after using their Ayrshire Doctors on Call (ADOC) out-of-hours service twice. She was unhappy with the treatment she received as, on the first occasion, her gallstones were misdiagnosed as muscular pain. The second time she received the correct diagnosis, but was sent home with painkillers and asked to attend her GP the next morning.

We took independent advice from a medical adviser who is a GP. The adviser said that the treatment Miss C received on her second presentation was reasonable. She was given the correct diagnosis and her symptoms did not justify an emergency hospital submission. Therefore, the correct course of action was to direct her to her GP to arrange an ultrasound scan. However, based on the symptoms Miss C presented with on the first occasion, the adviser considered the diagnosis of muscular pain she received from a nurse practitioner was not reasonable. The adviser felt that further investigation or a referral to the GP should have been made. As such, we upheld the complaint.

Recommendations

We recommended that the board:

• apologise to Miss C for the failings identified;
• share the outcome of this complaint with relevant ADOC staff; and
• discuss the issues identified with the nurse practitioner to assess whether any additional learning is required in the assessment and diagnosis of acute abdominal pain.

Summary

Mrs C was concerned at the care and treatment given to her late mother (Mrs A) while she was a patient at University Hospital Ayr.

Mrs A had a history of heart problems and breathing difficulties and had not been eating. She had been vomiting for three weeks. She was admitted to hospital but her condition quickly deteriorated and she died a few days later. Mrs C believed that without her knowledge, her mother been placed on the Liverpool Care Pathway (LCP - an end of life care planning system for dying patients); that she was given too much fluid and that although diuretic treatment (medication to promote water loss from the body via the kidneys) was prescribed, it was not given. Despite complaining at the time, Mrs C said that action was not taken and as a consequence, Mrs A died. Mrs C also said that after she complained, she was told that her mother had been very seriously ill on arrival, however, she complained that she had not been given this information at the time.

We took independent advice from a consultant geriatrician and from a nurse practitioner. We established that Mrs A had not been placed on the LCP but we found a number of shortcomings with Mrs A's care and treatment: her medical and nursing records were not as complete as they should have been; there were failures in communication and staff did not properly engage with Mrs A and her family; medication was not administered and staff did not appear to have been alert to Mrs A's deteriorating condition. For all these reasons, we upheld the complaint.

Recommendations

We recommended that the board:

• make a formal apology for the clinical shortcomings identified;
• remind clinical staff involved in this case of their professional obligation to complete proper and detailed clinical notes;
• remind clinical staff involved in this case to communicate appropriately and in a timely manner with the patient and their family;
• ensure Mrs A's consultant considers this case as part of his next annual appraisal;
• make a formal apology for the nursing shortcomings identified;
• remind nursing staff of their professional obligation in so far as maintaining correct records in concerned;
• remind nursing staff of their professional obligation to communicate with family members; and
• reflect on the way the complaint was handled, particularly given its serious and significant nature, to prevent similar situations arising in the future.

Summary

Mr C complained that the GP who examined his late father (Mr A) at a consultation had not provided a reasonable standard of care and treatment.  When Mr C visited Mr A later the same day, he was distressed by his father’s condition and called an ambulance.  When Mr A was admitted to hospital he was found to be dehydrated, with a chest infection.  He died four days later from aspiration pneumonia (caused by a poor swallowing mechanism whereby foreign matter enters the lungs).  Mr C also complained that his father’s medication had been unreasonably increased, despite previous knowledge that an increased dose previously reduced Mr A's appetite and he would therefore lose weight.

We took independent advice from a GP adviser.  They found the increase in the medication dosage to have been reasonable.  However, they noted that there was not a documented consultation for the day Mr A was admitted to hospital.  The adviser said this was not in line with General Medical Council (GMC) guidance.

On balance, we upheld the complaint as the practice were unable to demonstrate they had provided a reasonable standard of care and treatment.  We also noted they had failed to refer Mr C to us at the end of their complaints investigation.

Recommendations

We recommended that the practice:

• apologise to Mr C for the failings identified in our investigation;
• remind relevant staff of the importance of completing accurate documentation in line with the GMC guidance;
• ensure future complainants are referred to us at the end of the complaint response letter; and
• confirm the GP concerned will discuss this case at their next appraisal.

Summary

Mr C told us he applied for transfer to a prison elsewhere in the UK for family reasons. He said there was a delay in the Scottish Prison Service (SPS) dealing with his transfer application, and that the SPS lost his application.

The SPS investigated what happened to Mr C’s application. Although they were unable to identify exactly when and how it went missing, they accepted that they misplaced the application and that there was an unreasonable delay in identifying that it was missing. The SPS did not provide us with their policy, procedure or guidance relating to the administration of cross-border transfer applications. It was not clear to us what the SPS learned from their investigation into this incident to ensure it would not happen again. We concluded that there was no reliable system in place to log the receipt of transfer applications and to track their progress, both at the prison and possibly at SPS headquarters. We upheld Mr C’s complaints and made a recommendation to address our concerns.

Recommendations

We recommended that the SPS:

• provide us with reassurance that there is a reliable system in place for logging and tracking cross-border transfer applications.

Summary

Mr C complained about the council's handling of a planning site next to his home. In particular, he complained that the council had failed to provide the public with relevant information on a planning application for a new building; that they had failed to consider objections to the planning application (related to the excessive height at the rear of the development); and had failed to pursue enforcement action to have the building removed.

We took independent advice from a planning adviser. We noted the council accepted that they had failed to provide all the relevant information to the public. In particular, the level difference at the rear of the development should have been identified when the application was processed. The council had apologised and taken action. The council also accepted that this information would have helped Mr C to raise concerns about the development height during the application process, instead of raising the matter as an enforcement issue after the application was approved.

We found that the absence of approved external measurements made it impossible for the council to specify what height adjustments should be made for the building to comply with approved plans. However, we accepted that any variation in the height of the building from what was approved was likely to be too marginal to be enforceable. We also found that the ground levels on the application plan were entirely misleading, and should have been corrected by the council to note the likely dominant impact of the development on the garden behind. We found no evidence that the height difference at the rear of the development was fully considered during the application process. We considered that the assessment of the planning application was compromised by the lack of recognition of the extent of the change of ground level.

We accepted that the decision not to take direct enforcement action to remove the building was a discretionary decision for the council. However, we considered there had been a delay in taking enforcement action, which undermined public confidence.

Recommendations

We recommended that the council:

• consider the adviser's comments on the need for an accurate survey plan showing the relationship to adjacent developments and ground levels, and report back to us on any action proposed regarding future planning applications;
• consider whether it would be appropriate in this case to pursue a section 71 discontinuation or alteration order; and
• consider this case and the adviser's comments to see if any further lessons can be learned, and report back to us on any action taken.

Summary

Mrs C’s home is next to a facility used for outdoor sports within a school campus. Mrs C complained to the council about noise nuisance from three all-weather pitches which can be hired by the public. She was concerned about noise from users shouting and swearing, as well as balls hitting fencing, which could be heard in her home and garden. Mrs C had previously brought complaints about the facility to us under case reference 201202858. As a result of a recommendation made following this earlier investigation, the council had taken measures to reduce the noise from the facility, including erecting a sound-reducing fence. However, in 2013, Mrs C reported to the council that the measures had not worked. The council took further action but Mrs C remained unhappy with the result. She asked us to consider her concerns that the council had failed to take reasonable steps since 2013 to address continued noise nuisance from the facility.

After taking independent advice from one of our advisers, who is an environmental health specialist, we upheld Mrs C's complaint. The adviser commented that the council had not served a notice to the facility after the noise nuisance had been confirmed, and this was not in line with the relevant legislation. The adviser said that, as a result, the council had been left without a statutory means to ensure that the facility took appropriate action to reduce or stop the noise heard at Mrs C's home. We made a number of recommendations to the council about this matter.

Recommendations

We recommended that the council:

• issue a written apology to Mrs C for the failure to timeously issue an abatement notice in line with the relevant legislation;
• ensure that relevant staff are aware of their statutory duties in terms of the requirement to serve abatement notices when a statutory nuisance is confirmed;
• investigate the noise from the campus that is affecting Mrs C's property, including the anti-social behaviour aspect of swearing;
• consider, on the basis of the established situation at Mrs C's home and without further delay, whether an abatement notice should be issued in line with the relevant legislation; and
• consider whether there is any other formal action available to deal with audible swearing, if this issue persists.

Summary

Miss C complained about the housing association. They were holding her responsible for works required to repair damage to the kitchen after she had exchanged her property with the tenant of another housing association. She disputed this as, a couple of months before she moved, her property had been inspected as satisfactory and approved for a transfer. On investigation, it became clear that the association had failed to follow their procedure for carrying out a final inspection. This did not take place until after the new tenant took up residence, meaning there was no evidence to prove who was responsible. We also found that the new tenant had signed a declaration accepting responsibility for all outstanding tenant repairs. As such, we found that Miss C should not be held responsible for the repairs and upheld her complaint.

Miss C also complained about the standard of communication she received from the association regarding these issues. After reviewing the correspondence against all the evidence provided, it became clear that the association had made a number of statements that contradicted the evidence available. We also found instances where they had stated unsubstantiated third party information as fact, without giving Miss C the opportunity to respond. We also upheld this aspect of her complaint.

Recommendations

We recommended that the association:

• apologise to Miss C for the failings our investigation found; and
• write off the debt they were pursuing Miss C for and refund her rent credit.