Upheld, recommendations

Summary

Miss C's father (Mr A) was admitted to Glasgow Royal Infirmary from another hospital where he had been admitted earlier following a fall at home. Mr A was admitted to A&E and then moved to a ward. Mr A died several days after his admission.

Miss C was concerned that many mistakes and problems had occurred during Mr A's admission to Glasgow Royal Infirmary. Miss C met with the board who accepted there had been a number of failures in Mr A's care and treatment, and offered apologies for these. They also shared information with Miss C about actions taken to discuss failings identified with staff, and the procedures put in place to help avoid any repeat for other patients in the future. Miss C, however, remained concerned.

We took independent advice from a medical adviser and a nursing adviser.

Our medical adviser said that on admission, Mr A was noted to have had a fall, underlying liver disease, vomiting and diarrhoea, and a new acute kidney injury. Our medical adviser said that Mr A's medical records were comprehensive and that, overall, his care was of a good standard. However, our medical adviser also said there was a failure to prescribe continuous fluids, and to record and monitor Mr A's fluid balance which, in a patient with vomiting and diarrhoea and a diagnosis of acute kidney injury, were serious failings.

Our nursing adviser said that, overall, Mr A's nursing records and charts were of a good standard and there was a reasonable level of communication with Mr A's family. However, she also considered there was a serious failure in the recording and monitoring of Mr A's fluids by nursing staff. Therefore, Mr A's nursing care had fallen short of the expected standard in relation to the recording and monitoring of his fluid balance.

Recommendations

We recommended that the board:

• provide evidence of policies for fluid balance documentation and of compliance with such policies for the A&E department and the ward involved in this case at Glasgow Royal Infirmary.

Summary

Mr C complained about the care provided to his late father (Mr A) at Aberdeen Royal Infirmary. Mr A was blind, elderly and frail. He had cancer. Early in 2014 he had had many emergency admissions to hospital and in May 2014 he was admitted again. During his stay he experienced two heart attacks and was noticed to have become increasingly more agitated. Mr A required the lavatory and was assisted there by two members of staff and, at his insistence, he was given privacy. However, he fell and broke his hip. After that his condition declined. Due to this, it was not possible for him to undergo surgery and he died. Mr C believed that Mr A should not have been left unattended and he considered that this contributed to his death.

We investigated the complaint and took independent advice from our nursing adviser. We found that while there was a difficult balance to strike between safety and allowing someone dignity and privacy, in this case, because of Mr A's blindness and medical conditions, he should not have been left alone. We upheld the complaint.

Recommendations

We recommended that the board:

• provide an update of the actions/action plan they instigated since the complaint in order to ensure that their staff have the skills and resources to manage older people with delirium.

Summary

Mrs C was referred to Aberdeen Royal Infirmary with pain on her left side, which her GP thought might be due to kidney problems. She was x-rayed, had an ultrasound scan (a scan that uses sound waves to create images of organs and structures inside the body) and was discharged with a diagnosis of constipation with no planned follow-up. Mrs C continued to be unwell and was treated by her GP for constipation (as advised in her hospital discharge letter). Mrs C collapsed at home and was readmitted to the hospital several months later. At that time a computerised tomography (CT) scan (a scan that uses x-rays and a computer to create detailed images of the inside of the body) was performed and a large mass, thought to be an ovarian cyst, was found. Mrs C had surgery to remove this mass and was advised that primary cancer had been found in her colon and it was this that had spread. Mrs C was offered chemotherapy but was advised that this was only to relieve symptoms as the diagnosis was terminal.

Following surgery to remove the primary cancer from the colon, Mrs C was told she was not terminally ill and that the spread of the cancer had not occurred as had been previously suspected.

We took independent advice from a medical adviser who said that the board's initial actions and their diagnosis of constipation were reasonable. Our adviser also considered that the treatment provided once the cancer was detected was reasonable and appropriate.

Nevertheless, our adviser said that it would have been good practice to have a bowel surgeon present during Mrs C's surgery given the known presence of abnormalities in the colon. Our adviser was also of the view that the pathology report following this surgery did not suggest a terminal diagnosis and he did not consider that the terminal diagnosis given to Mrs C had been appropriate. For these reasons, we concluded that the care Mrs C received was not reasonable.

Recommendations

We recommended that the board:

• apologise to Mrs C for incorrectly diagnosing her condition as terminal;
• ensure the staff involved in the diagnosis reflect on their diagnosis in light of our medical adviser's comments, in particular to ensure pathology reports are appropriately taken into account; and
• review the surgery carried out in light of our medical adviser's view that a bowel surgeon should have been directly involved.

Summary

Ms C, who is a member of parliament, complained about the care and treatment Mrs A received at Peterhead Hospital. Ms C brought the complaint to us on behalf of two of her constituents, the late Mrs A's daughter (Mrs B) and sister (Mrs D). Mrs A had been admitted to hospital after suffering from sickness and diarrhoea for several days. Ms C said that staff at the hospital failed to provide Mrs A with appropriate clinical treatment and nursing care. Ms C raised a number of concerns, including that there was an overall lack of concern or anxiety about Mrs A's condition shown by nursing staff and the doctor involved, and not enough was done to help her. Mrs A died whilst in hospital.

We obtained independent medical advice about the complaint from a GP and a nurse. Both of our advisers said that Mrs A's SEWS score (Standardised Early Warning System – a system which uses special observation charts completed by nursing staff to recognise deterioration in patients) was such that medical assessment should have occurred, but nursing staff failed to request a review by a doctor.

Our nursing adviser explained that Mrs A's oxygen reading was very concerning and, along with Mrs A being 'clammy' and her 'limbs discoloured', this indicated a very serious deterioration in her condition. She said nursing staff should have been aware of the significance of these signs of shock and should have acted immediately.

Our GP adviser said that when the doctor saw Mrs A, he did not carry out a reasonable assessment, did not record accurate observations and did not take action upon these. She said that the doctor failed to respond appropriately to the abnormal and deteriorating observations recorded on Mrs A's SEWS recording chart and arrange further investigation.

We concluded that there were clear failings in the clinical and nursing treatment provided to Mrs A by the staff at Peterhead Hospital.

Recommendations

We recommended that the board:

• ensure the failings identified by the adviser are addressed with the doctor;
• confirm that the doctor has discussed his full report with the independent GP appraiser and confirm the outcome to us;
• remind nursing staff involved in this case of the importance of SEWS and the reason for using this across Scotland;
• provide us with an update regarding the current use, monitoring and any relevant accuracy of completion of SEWS and response audits;
• provide us with evidence of their on-going assessment and training for medical emergency, including sepsis; and
• provide the family with a written apology for the failings identified.

Summary

Mr C asked the prison to cover the cost of providing him with contact lenses instead of glasses. The prison advised Mr C that the Scottish Prison Service (SPS) would not cover the cost of contact lenses, only glasses. Mr C complained that the prison failed to appropriately consider his request because they failed to seek any clinical advice about whether he needed contact lenses, and he said he had previously received them in a different prison.

We asked the SPS to tell us if steps had been taken by the prison to confirm whether an optician had recommended that Mr C receive contact lenses instead of glasses. We also asked whether steps had been taken to check whether the other prison had provided Mr C with contact lenses. In their response, the SPS provided a statement from the other prison which confirmed that they had not purchased contact lenses for Mr C. The SPS also received confirmation from the health centre that the optician had not recommended that Mr C wear contact lenses instead of glasses, and there was no medical reason why Mr C could not wear glasses. This information was only sought by the prison following our enquiry to the SPS about Mr C's complaint.

At the time of making his complaint, the prison did not take steps to check whether Mr C had previously been issued contact lenses. They also did not clarify whether Mr C did in fact require contact lenses. We considered that both of those steps should have been taken by the prison at the time of investigating Mr C's request and therefore we upheld the complaint.

We also upheld Mr C's complaint that the prison failed to handle his complaint appropriately. In particular, the information provided by the SPS indicated that the chairperson of the internal complaints committee (ICC) invited the health care manager to attend the hearing but she chose not to. We concluded that the chairperson considered that the evidence the health centre manager would have brought was of relevance and value to the ICC's consideration of Mr C's complaint. However, there is nothing contained within the prison rules which suggests that a witness can be compelled to attend an ICC hearing. Instead, the rules indicate that a witness can be called by the prisoner to give evidence in support of their complaint and the ICC chair can decide whether the witness will be permitted to attend. There is no suggestion that the witness must attend even if they are permitted to do so by the ICC chair. However, as noted earlier, we considered that steps should have been taken by the prison to explore whether the optician had recommended that Mr C wear contact lenses as opposed to glasses. The ICC could have, with Mr C's consent, obtained that information easily and without the health care manager's attendance at the hearing. Taking those steps would have ensured the ICC had access to the relevant information that the health care manager could have brought to the hearing before reaching their decision on Mr C's complaint. The SPS accepted that they did not respond to Mr C's complaint within the relevant timescale and offered an apology. Therefore, we upheld the complaint.

Recommendations

We recommended that the SPS:

• provide feedback to the relevant members of staff in relation to the handling of Mr C's request to ensure that all relevant information is obtained prior to taking decisions;
• explore what their position would be if a clinician recommended a prisoner be supplied with contact lenses instead of glasses; and
• apologise to Mr C for the failings our investigation highlighted about the prison's handling of his complaint.

Summary

Mr C raised a number of complaints with the prison about disciplinary reports that were noted on his computerised record. Mr C asked the prison to provide copies of the relevant paperwork in relation to each report or remove them from his record. The prison confirmed that there was no paperwork available to support the particular entries Mr C had complained about. However, the prison said although the paperwork could not be located that, in itself, was not reason to doubt that the reports existed. The complaint we investigated was that the Scottish Prison Service (SPS) unreasonably refused to remove disciplinary reports from Mr C's record.

The SPS disciplinary hearings guide says that the disciplinary paperwork should be retained for the period the prisoner remains in custody or three years after the outcome of the hearing, in case of a subsequent complaint or legal action. In addition, the SPS prisoner records retention schedule confirms that disciplinary paperwork should be retained for five years after the date of the hearing. In relation to Mr C's complaint, the SPS told us the paperwork relating to one of the reports was in storage but they were unable to access it at the time of responding to our enquiries. In addition, they were able to locate some of the disciplinary paperwork in relation to another report but they could not locate other paperwork and were unable to explain why. The SPS told us Mr C had accumulated over 140 disciplinary reports whilst in custody and, because of that, he was more susceptible to administrative errors.

It was clear that the disciplinary paperwork for each of the reports in question should have been retained by the SPS given that the timing of them fell within that outlined by both the disciplinary hearings guide and the records retention schedule. In relation to the paperwork that could not be located, the SPS were unable to provide evidence to support their position that the breaches of discipline occurred because they had been unable to provide copies of the relevant paperwork to substantiate the information recorded on the computer record. Therefore, we considered that their refusal to remove those particular reports from Mr C's record was unreasonable.

Recommendations

We recommended that the SPS:

• remove the reports in question (for which there was no paperwork available) from Mr C's record on their computerised prisoner records system;
• remove a report from Mr C's record on their computerised prisoner records system if the associated disciplinary paperwork cannot be retrieved from the storage facility; and
• remind relevant staff of the terms of the disciplinary hearings guide and the prisoner records retention schedule and how they relate to retaining disciplinary paperwork.

Summary

Mr C kept items of property in a locked storage cupboard on the ground floor of his building. Mr C tried to gain access to the cupboard but the lock had been changed. Mr C discovered that council staff had changed the lock and had given the key to a neighbour. Mr C complained to the council, but was not satisfied with their response. Mr C complained to us that the council failed to check whether the storage cupboard was in use or owned before changing the lock, and that the explanation given to him about why his complaint was rejected was inadequate.

The council confirmed that they did fail to check whether the storage cupboard was in use. We found inconsistencies in the council's investigation of Mr C's complaint, and we felt their decision was based on flawed or incomplete information, which meant their explanation to Mr C was inadequate. We also found that the council failed to respond to Mr C's complaint within the timescales set out in their complaints procedure. We upheld Mr C's complaints.

Recommendations

We recommended that the council:

• reinvestigate Mr C's case in order to clarify the inconsistencies, and provide evidence for a full and accurate account of events, then reconsider Mr C's claim for reimbursement notifying us of the outcome;
• apologise to Mr C for the mishandling of his complaint;
• remind relevant staff of the requirements of the model complaints handling procedure in relation to timeframes, and delays or extensions; and
• raise the complaints handling failings with relevant staff to ensure a similar situation does not recur.

Summary

Since 2011, Mrs C had been raising issues with the council about the damage caused to her boundary fence by the council's grass-cutting contractor. Although her complaints were referred directly to the contractor, she received no response. The damage to her fence continued each year, and each year she contacted the council to complain about the work of the contractor. In September 2014, she complained again when the contractor's machine slipped down a bank beside her fence which was further damaged when the machine was pulled out. She complained again at a later date and a claim was submitted to the contractor who did not uphold her claim, stating that the fence was in a very poor condition. Mrs C escalated her complaint to the council, and they investigated but did not uphold her complaint.

Our investigation considered all the communication between Mrs C and the council, the council's records of their contact with Mrs C, and the complaints handling procedure. We found that, although it was not possible to assess whether the fence had been damaged by the contractor, the council had not ensured that the contractor had provided an adequate level of service and had not dealt reasonably with her complaints.

Recommendations

We recommended that the council:

• apologise for the handling of Mrs C's complaints about the contractor;
• review how complaints referred to contractors are logged and recorded on the council's system;
• consider what steps to take to ensure that complaints to contractors working on the council's behalf are reasonably handled; and
• consider whether some form of financial redress is appropriate to reflect the failings identified.

Summary

Mrs C complained to the council that her child's school had not reasonably addressed reports of bullying or provided support to her child. The council investigated and found that there was no evidence that bullying had taken place or that this was the cause of the anxiety and stress that her child was suffering from.

Mrs C was unhappy and brought her complaint to us. Our investigation found that the council did not consider the incidents to be bullying as the other pupil involved had significant additional support needs which caused their behaviour towards Mrs C's child. We considered that this was in line with the anti-bullying policy in place at the time. We also found that the school was small and that, although it was clear that steps had been taken to keep the children apart, this was difficult to achieve. There was evidence that support had been provided to Mrs C's child for his specific needs, including the difficult relationship with the other pupil.

However, we considered that the council had inappropriately made reference to Mrs C's relationship with the school in their complaint report rather than centring on her child. We found evidence of an incident between the children that had not been included in the Council's report and considered that this did not provide reassurance that all matters had been included when assessing Mrs C's concerns. We also considered that there was no evidence that the school had assessed the potential impact on Mrs C's child before proposing a strategy to inform visiting staff of the difficulties in the class. Finally, we found that the council's complaint investigation had not fully considered the impact of the situation at the school on Mrs C's child in terms of their anxiety and stress. On balance, we upheld Mrs C's complaint.

Recommendations

We recommended that the council:

• apologise to Mrs C for the failings identified.

Summary

Between 2007 and 2012, Mr C said he lived in five different properties in the council's area. Mr C complained that the council unreasonably failed to refund him overpaid council tax at one of the five properties and instead used the money for his outstanding council tax liabilities at the other properties. Mr C questioned the dates the council said he was resident at the properties as he said for much of the time he was in prison.

Our investigation established that the council were entitled to offset an overpayment of council tax at one property to settle an outstanding amount on another property. However, we would have expected the council to take appropriate steps to ensure their calculations were accurate prior to doing so.

The council provided us with copies of the documentary evidence they relied on regarding the dates of Mr C's tenancies and the dates he was in prison. This information was supplied by Mr C and the owners of the properties where he resided and it was therefore reasonable for the council to have relied on this.

However, we had concerns about the council's handling of the issue. There appeared to have been failings in the way in which Mr C's council tax liability was calculated which meant a refund of overpaid council tax may have been payable to Mr C from the outset. There also appeared to have been discrepancies in the start dates for one of Mr C's tenancies and the transfer of monies to this account. On balance, we upheld Mr C's complaint.

Recommendations

We recommended that the council:

• review their calculations of Mr C's council tax liability after giving him the opportunity to provide any further documentary evidence of his periods of detention and notify him of any adjustments in his council tax balance; and
• provide Mr C with a written apology for the failings identified.