Upheld, recommendations

Summary

Mr C phoned the Scottish Ambulance Service (the service) for an emergency ambulance as he was suffering from severe abdominal pains. He described his symptoms to one of the service's clinical advisors who told him to attend his local out-of-hours centre. He attended the centre and was examined by a doctor who immediately phoned for an ambulance and Mr C was taken to hospital where it was diagnosed that he had perforated ulcers. Mr C complained that the service should have sent an ambulance when he originally reported his symptoms.

We took independent advice from an adviser, who is a paramedic, and they explained that, although Mr C's condition was not immediately life threatening, the service's clinical advisor failed to ask sufficiently detailed questions about the character of the pain or associated symptoms. As a result, the service's clinical advisor failed to put himself in a position to safely judge whether or not to despatch an ambulance.

Although there was not a need to send an immediate ambulance, we upheld the complaint because there was a failure to assess Mr C's symptoms appropriately.

Recommendations

We recommended that the service:

• apologise to Mr C for the failure to ask appropriate and relevant questions regarding his abdominal pain; and
• share our decision with the clinical advisor involved and consider whether a training need has been identified.

Summary

Mrs A had fallen at home and sustained a head injury and suspected fractured hip. She had contacted the medical practice and a GP attended and decided that she required to be taken to hospital. The GP arranged that an ambulance should attend within an hour and left Mrs A with a neighbour to wait for the ambulance. Mrs A's daughter (Mrs C) complained that the GP should have arranged an emergency ambulance and should have waited with Mrs A, who is elderly, until its arrival. The practice maintained that Mrs A was stable and the situation was not life-threatening and the GP was satisfied that she did not need to wait for the arrival of the ambulance.

We took independent medical advice from one of our GP advisers, who said that given the situation, Mrs A required an immediate ambulance and the GP should have remained with her in case she deteriorated. The adviser noted that Mrs A was immobile; had symptoms of a hip fracture; had a significant head injury which was bleeding; was unable to recall how the fall occurred; and had a complex medical history. Our adviser was also concerned that the GP had noted the possibility that Mrs A may have required a brain scan to rule out any possible bleed to the brain. In light of this advice, we upheld Mrs C's complaint that the GP failed to provide Mrs A with appropriate medical treatment when she attended the home visit.

Recommendations

We recommended that the practice:

• apologise to Mrs A for the failure to arrange an emergency ambulance; and
• ensure the GP reflects on the comments made by our adviser and discusses the matter at their annual appraisal.

Summary

Ms C complained about the care provided to her when she was admitted to the Western General Hospital (the hospital). Ms C, who lives within another board area, was visiting Edinburgh when she became ill with abdominal pain, severe constipation, and vomiting. She attended the A&E department of another hospital in the board's area and was transferred to the hospital. Ms C was seen by one consultant on admission who said that he planned to do a sigmoidoscopy (an investigation of her intestines by way of a flexible camera) the following day.

The next day Ms C was reviewed by a different consultant who said that the sigmoidoscopy was not necessary and that it would be better for her treatment to be undertaken at her home hospital, where she had previously been treated for a condition involving her intestines. No treatment was provided for Ms C's constipation; her pain was not sufficiently addressed; and when she was discharged on the Saturday, she was told to self-refer to the hospital nearer her home (in another board area) for treatment on the following Monday.

We took independent advice from one of the our medical advisers and a nursing adviser who were of the view that Ms C's condition could and should have been investigated and treated at the hopsital. The medical adviser was of the view that if the team at the hospital felt specialist input was needed from a hospital in another board, Ms C should have been transferred there in a formal process rather than told to self-refer. The result was that Ms C's condition went untreated from Thursday to the next Tuesday as Ms C was admitted to the hospital in another board area on the Monday but there was then a delay in sending the result of a scan done in the hospital to another hospital nearer Ms C’s home.

Ms C also complained that some of the responses from the board to her complaint were inaccurate and this was upheld as some of the matters referred to were not documented in the clinical notes.

Recommendations

We recommended that the board:

• take action to remind all staff involved in this complaint of the importance of effectively monitoring, recording and addressing patients' pain;
• ensure all the staff involved are made aware of the findings in this case;
• give consideration to formulating guidelines on adequate arrangements for patients being discharged for on-going care which is expected to take place at a different institution;
• remind all staff involved in this complaint of the importance of effectively monitoring, investigating, recording and addressing patients' care and treatment;
• remind all staff involved in this complaint of the importance of accurately responding to complaints, based on the clinical records and other evidence available; and
• issue an additional written apology for the failings identified during this investigation.

Summary

Mr C complained that the prison health centre failed to provide appropriate treatment for the injury to his knee. After injuring his knee, Mr C attended the health centre and was prescribed pain medication. Mr C saw the doctor again a few days later because of the pain in his knee and also because the pain medication had given him a rash. The doctor prescribed a different pain medication and referred Mr C for physiotherapy and an x-ray. Mr C said his pain medication was not working but was advised that the doctor would review his medication after the x-ray results were received. The result confirmed Mr C had fluid and a loose fragment in his knee and the health centre referred him to an orthopaedic consultant.

NHS Scotland’s national guidelines for the management of knee pain indicates that if a patient presents with a significant knee injury then they should be referred to A&E, a minor injuries unit or to an orthopaedic specialist which would allow for imaging of the knee to be carried out by x-ray or MRI scan. We took independent advice from one of our GP advisers about the treatment Mr C received and they confirmed that the correct referral protocol – as outlined in the guidelines – was not followed by the health centre when Mr C presented with his knee injury.

In light of the evidence available, and given our adviser’s view which we accepted, we concluded that the health centre failed to provide appropriate treatment for the injury to Mr C’s knee because they did not refer him to A&E for further assessment when he first presented with the injury. Therefore, we upheld Mr C's complaint.

Recommendations

We recommended that the board:

• apologise to Mr C for the failures we found with the treatment he received;
• ensure relevant health centre staff familiarise themselves with the NHS Scotland guidelines; and
• reflect on Mr C's case and feed back any learning to us.

Summary

Mr C complained that the board required him to post a complaint to their patient relations team, rather than allowing him to submit a complaint to his prison health centre. Mr C felt this was unfair as he only had access to one second class stamp each week.

The board explained that in order to meet the national 20 working day target for dealing with complaints, they had asked prisoners to post their complaints directly to the patient relations team. In the board's view, this helped to remove any unnecessary delays in complaints being passed from the prison health centre to the patient relations team. The board also felt this approach was in line with the national complaints guidance 'Can I Help You' (CIHY).

We decided that the board's approach was not in line with CIHY, as the guidance does not specify to whom complaints should be made, only that the board must accept written or verbal complaints. This means complaints can be made to any member of board staff, including prison health centre staff. It is for the board to resolve any internal problems that might delay complaints being passed from the prison health centre to the patient relations team, and we would expect the board to deal with this without requiring prisoners to post a written complaint to the patient relations team. We upheld Mr C's complaint.

Recommendations

We recommended that the board:

• apologise to Mr C for requiring him to post his complaint;
• reimburse Mr C for the cost of a second class stamp;
• revise their process so that prisoners can submit complaints to their prison health centre; and
• put in place internal arrangements to expedite the transfer of complaints from prison health centres to the patient relations team.

Summary

Mr C, a patient with long standing heart problems, complained that he was not provided with a cardiology service at Borders General Hospital for a period of nearly 18 months. We found that Mr C was not recalled for his routine six-monthly cardiology review appointment. The board said this was because, after Mr C declined surgery for an unrelated medical condition, surgeons did not let the cardiology department know that the surgery did not go ahead. We found that even after Mr C’s GP referred him again it took too long, and considerable effort on his part, to get another cardiology appointment. We asked the board to review the process by which patients are discharged from one service to another and back again. We asked them to build in safeguards to ensure the system was robust and, following review, that the process was shared and understood across specialist areas as well as within administration teams.

Mr C told us there was an unreasonable delay when a letter from the board took 49 days to reach him. The board acknowledged that there were problems with workload within the administration team and apologised for their failing. They acknowledged the delay was unacceptable. They also took steps to monitor workflow within the administration team. We found that these were reasonable actions.

We found some shortcomings in the handling of Mr C’s complaint. The initial response to Mr C’s complaint made no reference to key points he had raised. Nor did it refer to the difficulties he experienced when he contacted the board by phone. We found the board had apologised for the fact that a room used for the meeting caused Mr C distress in that it was very small and full of people when he arrived. The board acknowledged the agenda could have been better arranged. We found that the cumulative effect of these errors made Mr C feel that his complaints were not being taken seriously.

Recommendations

We recommended that the board:

• review the process by which patients are discharged from one service to another and back again and ensure, following this review, that the process is shared and understood across specialist areas as well as within administration teams.

Summary

Mr C complained that the prison inappropriately failed to give him the opportunity to make representations prior to seeking to extend his removal from association. A prison can seek approval from Scottish Ministers to stop a prisoner from associating with others to maintain good order and discipline. The prison said Mr C had been unable and unwilling to make representations and it was unlikely that his representations would have been any different from the previous extension request. They also suggested that he was only entitled to make representations if the prison governor felt it was practicable to do so. Mr C disputed that he had been unable and unwilling to make representations and he also said he was entitled to make representations in line with prison rules.

The prison rules confirmed that Mr C was entitled to make representations prior to the request being submitted to Scottish Ministers for approval. The rules say that representations should be made in writing by the prisoner or transcribed by an officer or other official on the prisoner's behalf. We obtained a copy of the relevant paperwork and in the section that should be completed by the prisoner, it noted that Mr C was unable and unwilling to complete representations. However, instructions on the paperwork confirm that a witness should sign the form, and give reasons, if the prisoner refuses to complete representations. In Mr C's case, an officer signed the form but failed to note why he was unable and unwilling to give representations.

Based on the evidence available, we were unable to establish whether Mr C was unable or unwilling, or both, to give representations because the relevant paperwork was incomplete in important aspects. We concluded that the Scottish Prison Service could not adequately evidence that they had given Mr C the opportunity to make representations, or having given him the opportunity, he refused, when seeking to extend his removal from association. In addition, we felt the fact that Mr C had been given opportunities in the past to make representations was irrelevant and the issue was that the proper process had to be followed and the relevant paperwork completed correctly. Therefore, we upheld Mr C's complaint.

Recommendations

We recommended that Scottish Prison Service:

• reflect on Mr C's case and consider how errors can be avoided in the future;
• feed back any learning to us; and
• apologise to Mr C for the failures our investigation identified.

Summary

Mr C complained that Audit Scotland failed to respond to an email asking whether they were able to investigate a complaint about a third party organisation. As no response was received to this email Mr C sought a response from Audit Scotland and, following investigation, they responded to him almost ten months later. Mr C complained that Audit Scotland unreasonably delayed responding to his earlier email, that they unreasonably shared details of his complaint with the third party organisation and that the quality of the investigation of his complaint was poor.

Audit Scotland acknowledged, and apologised to Mr C for the delay in responding to, his complaint. They upheld this element of his complaint. They did not uphold the elements relating to a potential breach of his confidentiality and failures in their investigation of his complaint. As Mr C remained unhappy, he complained to us.

We noted the steps taken by Audit Scotland prior to Mr C coming to us. We also noted that Mr C had not given his permission for them to pass his details to the third party organisation, nor had they demonstrated that Mr C had made his complaint known to the third party organisation himself. As this was, in our view, a breach of their own procedures, we upheld his complaint.

Recommendations

We recommended that Audit Scotland:

• apologise to Mr C for making his identity known to the third party agency without his permission and without evidence that he had made his identity publicly known; and
• apologise to Mr C for stating the outcomes he was seeking were outwith their complaints procedure.

Summary

The property where Mrs C lives was subject to a statutory repairs notice which meant that the council did the works by default and then recouped the cost (plus an administration fee) from the owners. Mrs C complained about the final costs of the works and said that the owners had not been kept informed or up to date about increasing costs.

We found that, upon starting work as required by the notice, the extent of damage caused by vegetation was greater than first considered (affecting the gable as well as the chimney stack of the property). While Mrs C was alerted to the fact that this would lead to an increase in costs, she was not given details of the costs incurred nor reasons why the council thought it was appropriate to continue with the works under the existing notice rather than issuing another. Accordingly, we upheld Mrs C's complaint.

Recommendations

We recommended that the council:

• provide Mrs C with a full explanation for the reasons why further works (and associate costs) were required and why it was not considered necessary to issue a further statutory notice; and
• make a full formal apology for the failures in this matter and add weight to the apology by considering waiving the administrative costs associated with the works.

Summary

Ms C owns an end of terrace house that is joined to a council owned property. When the council carried out improvement works on the roof of their property they required access to it through Ms C's garden. Ms C complained that she had not been told in advance by the council that the works would be carried out. She also complained that the council's contractors had damaged her garden and her roof while carrying out the works, and that she had to pay for the damage.

The council said that Ms C was sent a letter in advance of the works. They offered to remedy the damage made to the garden, however said they were not liable for the damage to the roof.

During our investigation we found that the council did not have any evidence that Ms C was informed of the works in advance and so upheld this complaint and made a recommendation to address it in future. We noted that the council had offered to remedy the damage in the garden, however the contractor had then not done this. For this reason, we upheld the complaint and recommended that the works take place as soon as possible. We concluded that the council had caused some of the damage to Ms C's roof and had not taken steps to remedy it. We upheld this complaint and recommended they reimburse Ms C for the cost of the repairs.

Recommendations

We recommended that the council:

• consider how to record neighbour notification of works;
• ensure remedial gardening works are carried out; and
• reimburse Ms C for the cost of the roof repairs.