Upheld, recommendations

Summary

Ms C complained about dampness issues on behalf of her client (Ms A). Ms A had downsized from a larger housing association property and signed a new tenancy agreement for a smaller home. She pointed out issues with dampness within the property and the association agreed to carry out works. Ms A had not yet given up the tenancy on her original home and continued to live there while work was undertaken. The association charged Ms A for rent for the new property whilst the works were being carried out. Ms C complained that the association had not ensured that the property was in a reasonable condition for Ms A to move into and that they had unreasonably charged her rent when repairs were being carried out.

We found that there had been issues with water ingress previously at the property, which work had been done on, and that the association had expected areas of damp to dry out once the house was occupied. However, this was not noted on the inspection report and we considered that there was a lack of evidence that the association had taken areas of damp in the hallway and living room into account when determining whether the property was in a habitable condition. We upheld Ms C's complaint about this.

We also upheld Ms C's complaint about rent charges. We found evidence that the association had advised Ms C's office that Ms A would not be charged rent for the property until it was ready for occupancy. We made a number of recommendations to the association.

Recommendations

We recommended that the association:

• remove any rent charges for the property covering the period from when Ms A signed the tenancy agreement to when the association notified her that she could collect the keys for the property;
• consider having an independent professional assessment of any dampness at the property; and
• consider whether a further reduction in rent would be appropriate on the basis of any ongoing dampness at the property.

Summary

Mrs C was removed from the treatment list of her GP practice following a difficult visit to the practice. Her husband (Mr C) complained about this and Mr and Mrs C were invited to a meeting to discuss the investigation. At the meeting they felt that no investigation had been undertaken and subsequently complained to us. The reasons the practice gave us for removing Mrs C from their treatment list did not meet the relevant criteria in legislation, policy or guidance for the immediate removal of a patient from a treatment list and we could see no other evidence that immediate removal was warranted. We saw no evidence that Mr C's complaints were dealt with in line with the NHS Scotland complaints procedure. As a result, we upheld both complaints.

Recommendations

We recommended that the practice:

• apologise to Mrs C for unreasonably removing her from their treatment list;
• review their policy for removal of patients to ensure it reflects the relevant regulations and General Medical Council guidance;
• ensure all staff are aware of the revised policy and are trained in managing difficult and challenging behaviour and in particular de-escalation techniques;
• apologise to Mrs and Mr C for not responding to the letter of complaint in line with the NHS Scotland complaints procedure; and
• ensure that staff with responsibility for responding to complaints are aware of the detail of the NHS Scotland complaints policy and related guidance.

Summary

Mrs C complained about the care and treatment given to her late husband (Mr A) at Ninewells Hospital where he was a patient from March to September 2014, when he died. She said that there was a delay in making his diagnosis and that information was given to him in an uncaring and uncompassionate way. She also complained that there was often confusion about her husband's medication and that his pain was not properly managed.

We took independent advice from consultants in oncology and radiology and also from a senior nurse practitioner. We found that while Mr A's care and treatment had been appropriate and reasonable, his pain had been very difficult to control (due to his complex condition) and communication had not been as good as it could have been. He was given upsetting information at a time when support was not available to him, and was given his diagnosis over the phone. There was also confusion about his medication and treatment. In particular, there was confusion about Metformin (a drug Mr A was taking for diabetes) and whether he needed to stop taking it before his imaging test. When Mrs C later complained about these circumstances, the board delayed in providing her with a response. In view of this, we upheld Mrs C's complaint.

Recommendations

We recommended that the board:

• send an appropriate letter of apology;
• ensure that the clinicians involved in this case are made aware of our findings, and that they are considered as part of the clinicians' next formal appraisal;
• review their policy on withholding Metformin;
• ensure that all patients receive suitable information prior to undergoing scans;
• provide a formal apology for the delay in responding to the complaint; and
• remind staff of the importance of replying to complaints in a timely manner.

Summary

Mrs C was referred to Perth Royal Infirmary due to a missing intrauterine system (IUS - a contraceptive device). A scan showed the IUS could be in her abdomen, but she was then found to be pregnant, so no x-ray could be done to confirm the exact location. The pregnancy was not viable and a medical miscarriage was performed. Mrs C was discharged after this without an x-ray to locate the missing IUS. Her GP arranged an x-ray, which showed the IUS was in her abdomen, and she was referred to gynaecology for surgery to locate and remove it. Mrs C raised concerns about the failure to x-ray her after the medical miscarriage, and about her surgery (which was more complex than expected). Mrs C said she was told an x-ray would be taken before the surgery to confirm the exact location of the IUS, and she queried why this did not happen. Mrs C also complained about delays in her gynaecology appointment and in the board's response to her complaint.

The board agreed Mrs C should have been x-rayed after her medical miscarriage and they apologised for this. They said the delay in gynaecology appointments was due to increased demand, and they were taking action to improve this. However, they considered the surgery was carried out appropriately.

After taking independent medical advice, we upheld Mrs C's complaints. We agreed the board should have x-rayed Mrs C earlier, and we found unreasonable delays in arranging the gynaecology appointment. However, we found that the surgery was carried out reasonably. The adviser explained that x-rays are not normally used to confirm the location of an IUS before surgery, as an x-ray cannot show the exact location (in three dimensions) and the position of the IUS can also change during the surgery as the patient is moved. We found the delay in responding to Mrs C's complaint was unreasonable, as the bulk of the delay (over five weeks) was caused by a delay in the draft response being signed off, rather than the investigation itself.

Recommendations

We recommended that the board:

• demonstrate to us the steps being taken to ensure the national standards for waiting times for gynaecology can be met;
• apologise to Mrs C for the failings we found; and
• review their processes for clearing draft complaint letters, to ensure this does not cause undue delay.

Summary

Mr C complained about the length of time he had to wait for surgery for prostate cancer and said that the board did not provide treatment in line with the national waiting time targets. We took independent advice from a medical adviser. We found that the GP referral for Mr C was acted on promptly by the board's urology service and the time taken to reach a diagnosis of prostate cancer was reasonable taking into account the complexity of Mr C's case. However, after the decision was reached to proceed with surgical treatment for Mr C's cancer there was a lack of co-ordination in gathering all the information and beginning treatment which meant the waiting time target was not met. Although we found that the delay was unlikely to have affected the long-term outcome, the delay and lack of information provided would have added to the uncertainty and anxiety for Mr C at what would have been a very difficult time for him. We concluded that the overall care he received was not of an acceptable standard and led to an avoidable delay.

Recommendations

We recommended that the board:

• apologise to Mr C for the failings identified; and
• review the circumstances regarding Mr C's case to ensure that, in future cases, care is appropriately co-ordinated with adequate information given to the patient and taking into account appropriate waiting time targets.

Summary

Mr C complained on behalf of his partner (Miss A) about the delay in her parathyroid surgery (surgery to remove glands next to the thyroid which secrete a hormone that regulates calcium levels in a person's body), and the board's communication with them about this. Mr C said the consultant physician at the endocrine clinic at the Royal Infirmary of Edinburgh who first dealt with Miss A's case told them the surgery would take place within approximately ten weeks of their initial appointment. Mr C said he attended appointments with Miss A (who is profoundly deaf) about her care and communicated with the board on her behalf about the delay in her surgery.

We obtained independent medical advice on the complaint from a consultant in general medicine. The adviser said there was an avoidable delay in the consultant physician at the endocrine clinic arranging Miss A's referral to the consultant surgeon who was to perform her operation. The adviser also said that once the referral was made, there was an avoidable delay in Miss A's surgical review with the consultant surgeon taking place and these delays resulted in an avoidable delay in Miss A's surgery. Mr C and the consultant physician gave differing accounts of what was said about when the surgery would take place. In the absence of supporting evidence from any independent witnesses, it was not possible for us to conclude what was said at the consultation.

The adviser said the board had a responsibility for keeping records of communications with patients and, on balance, they considered that the board should have been able to provide a clear record of the communication with Mr C on Miss A's case. As they could not, the adviser said the communication by the board was unreasonable.

Recommendations

We recommended that the board:

• feed back our decisions on both complaints to the staff involved;
• take steps to ensure that, in future, staff record emails and phone calls made by patients or their representatives in the patients' electronic records; and
• provide Mr C and Miss A with a written apology for the failings identified in both complaints.

Summary

Mr C complained to us about the care and treatment his son (Mr A) received when he was admitted to the Royal Edinburgh Hospital under a short-term detention certificate under the Mental Health Act. Mr A has severe autism, learning disabilities and epilepsy. We took independent advice on Mr C's complaint from a mental health adviser and a consultant physician.

With regard to Mr A's physical health, we found that the action taken in relation to Mr A's bowel problems was reasonable. The medication given to him was also appropriate. However, staff had failed to medically review Mr A on the day he was admitted to hospital and there was no evidence that a structured nursing needs assessment was carried out in the days following his admission. In addition, there was a significant delay in obtaining a full psychology and occupational therapy assessment for him. In view of these failings, we upheld this aspect of Mr C's complaint.

Mr C also complained that staff in the hospital had failed to provide his son with appropriate care needs. We found that the records in relation to whether Mr A's family had been asked to leave when he was admitted and whether the family had initially been asked not to visit were inadequate. We also considered that more could have been done to explore potential options for safely personalising Mr A's room. In addition, a structured nursing assessment had not been carried out on one of the wards Mr A was in and there was no personal hygiene/grooming care plan for that ward. There was also a delay in referring Mr A to advocacy services. In view of all of these failings, we also upheld this aspect of Mr C's complaint.

Recommendations

We recommended that the board:

• issue a written apology to Mr C for the failings identified; and
• provide detailed evidence that steps have been taken to prevent the failings identified from occurring in other cases.

Summary

Mr C complained about his late father (Mr A)'s care and treatment in Wishaw General Hospital in the period before his death in June 2015.

Mr A had been diagnosed with terminal cancer in 2014 and in late May 2015 he was taken into hospital to have an oesophageal stent (a mesh tube in his throat) inserted. However, the procedure did not take place and only an endoscopy (a procedure where a tube-like instrument is put into the body to look inside) was performed. In June 2015, Mr A was admitted again and during his admission he suffered a number of falls. Mr C complained that Mr A was not provided with appropriate clinical or nursing care.

We took independent advice from a consultant geriatrician and from a nurse. We found that when Mr A was first admitted in May 2015, there were problems with the documentation available to the surgical team. It was brief and did not show that his condition had been considered in detail. Furthermore, we found that although a number of clinicians had been involved in his case, none of them had been involved with Mr A in any detailed or personal way and communication had been poor. On his second admission, our investigation showed that although it had been detailed in his notes, one-to-one care had not been provided to Mr A. Had it been, a third fall may have been avoided. For these reasons, we upheld Mr C's complaint.

Recommendations

We recommended that the board:

• make a formal apology for the failures identified;
• ensure that the clinicians involved in the case are aware of the adviser's comments and that they discuss them at their next formal appraisal;
• make a formal apology for the failure to provide one-to-one care observation; and
• review their processes for providing one-to-one care.

Summary

Mr C complained that his GP practice did not offer him an urgent appointment with a doctor after he attended the practice with chest pain. Mr C turned down the offer of an appointment with the nurse as he felt his symptoms were too severe. The duty doctor called him later that day and offered an appointment for the next working day (which was a Monday). Mr C chose instead to attend A&E where it was identified that he had a pneumothorax (collapsed lung). The practice accepted and apologised that Mr C should have been offered an urgent appointment to be seen the same day given his reported symptoms.

We took independent advice from a GP. We were concerned about the procedures in place at the practice for managing patient appointments. There was a lack of evidence to demonstrate that non-clinical staff were adequately trained and supervised in the procedures. We concluded that the care provided by the practice fell below a reasonable standard, and we upheld Mr C's complaint.

Recommendations

We recommended that the practice:

• work with Lanarkshire NHS Board to review their patient signposting procedures as a matter of urgency.

Summary

Mr C complained to us that staff at Monklands Hospital had failed to provide his mother (Mrs A) with appropriate clinical treatment in relation to her nasojejunal (NJ) feeding tube (a tube placed through the nose and into the small bowel to maintain nutrition when patients are unable to take sufficient food by mouth). Mrs A had been admitted to the hospital with high output from her stoma (a stoma is a surgically made pouch on the outside of the body; when the output from a stoma is high, it means that you are losing more fluid and are at a greater risk of becoming dehydrated) and acute kidney injury.

We took independent advice on this case from a consultant general surgeon. We found that Mrs A had initially been treated appropriately. It was likely that the NJ feeding tube was exacerbating the high output stoma. It had been reasonable to allow Mrs A to remove the NJ tube under supervision, as this reduced her anxiety about having it removed. This did not cause an oesophageal perforation (a tear in the tube that takes food from the mouth to the stomach) that she subsequently experienced.

However, we found that Mrs A had been discharged from hospital without evidence that the measures taken in relation to her high output stoma were fully effective and would prevent a readmission with the same problem. During our investigation, the board told us that they were working on guidelines on high stoma output for staff, but these had yet to be finalised. We also found the records of communication with Mrs A and her family were inadequate. In view of these failings, we upheld Mr C's complaint.

Recommendations

We recommended that the board:

• issue a written apology to Mr C for the failings identified;
• provide evidence that guidelines for high output stomas have been developed and circulated to relevant staff; and
• feed back our findings to relevant staff.