Upheld, recommendations

Summary

Ms C, an advice worker, complained to us on behalf of Ms A, following the council's refusal of her application for a Community Care Grant from the Scottish Welfare Fund. Ms C felt that the council had failed to properly consider the application, as the reasons for refusal given at each stage of the process were either very limited or absent.

On investigation, we found that the council had failed to follow Scottish Welfare Fund guidance in a number of areas. Their record of the decision-making process was limited, and fell short of what was required, and their decisions appeared to be based on a misquote or misinterpretation of the guidance. They had also failed to comply with the guidance on communicating accurate reasons for their decisions at each stage of the process, which affected Ms A's ability to effectively appeal their decisions. As such, we upheld the complaint.

Recommendations

We recommended that the council:

• apologise to Ms A for the failings identified in this investigation;
• provide a fast-tracked reconsideration of Ms A's application from the first stage, ensuring the guidance is followed; and
• provide training to relevant staff, including review panel members, on the contents of the guidance.

Summary

Mrs C said the council failed to repair potholes (in a lane she used to reach her work car park) by two dates they said they would get the work done. We found that the council's records said repair works took place by the first date, although Mrs C said she saw no sign of such works being carried out. The council's second response to Mrs C did not mention the repairs scheduled for completion around this date. The council acknowledged that they did not carry out repair works by the second date they gave to Mrs C and, given this, we upheld Mrs C's complaint.

Recommendations

We recommended that the council:

• apologise to Mrs C for failing to repair potholes in the lane by a date they previously stated; and
• provide us with a copy of their investigation into why the works to be completed by the second date were not instructed.

Summary

Mr and Mrs C complained that their landlord, the council, failed to take reasonable steps to carry out appropriate plumbing repairs to clear a blocked pipe in their property.

We found that there were a number of failings by the council who accepted that the blocked drain should have been treated as an emergency repair and dealt with within 24 hours. However, the council changed the repair category to 'urgent' which meant that it took several days for the blocked drain to be cleared. We considered that it was unsatisfactory that the council were unable to supply evidence of the reason the category had been changed. The council also failed to jet the drains although they claimed they had done so.

Mr and Mrs C had also made a claim to the council for a new cooker, as they said their cooker had suffered water damage, which was rejected by the council's claim handlers. The council accepted they had initially provided inaccurate information to their claims handlers but we were satisfied that the correct information was latterly supplied by the council and that Mr and Mrs C's claim was reassessed. However, we were unable to determine whether the damage to the cooker was caused by the blocked drain.

We found that the repair to the blocked drain was a qualifying repair under the Housing (Scotland) Act 2001 Right to Repair Scheme. In terms of the scheme, secure tenants have the right to compensation if certain repairs are not carried out by their landlord within a given timescale. As we considered the council failed to take reasonable steps to carry out the appropriate plumbing repairs within the required timescale, we found that Mr and Mrs C were entitled to receive compensation for the inconvenience caused. We made a number of recommendations to the council.

Recommendations

We recommended that the council:

• apologise to Mr and Mrs C for the failure to take reasonable steps to carry out appropriate plumbing repairs within their property;
• pay Mr and Mrs C compensation in terms of the Housing (Scotland) Act 2001 Right to Repair Scheme;
• ensure that when a repair category is amended, the reasons for the change are recorded; and
• ensure the works are appropriately recorded when repairs are carried out.

Summary

A window at Mr C's property was damaged. The council made a repair that was not effective and it was not until some weeks later that they fixed the problem. Mr C complained and the council told him the initial repair had been effective. He remained dissatisfied and complained to us. We found there was evidence to suggest that the repair had not been effective and that, if it had been, it would be reasonable to expect the council to hold evidence that showed this. We upheld the complaint.

Recommendations

We recommended that the council:

• apologise to Mr C for the failures identified;
• remind appropriate staff to check that responses to complaints make reference to all council actions relevant to the subject of complaint;
• remind appropriate staff that correspondence indicating that the complaints process has been completed should not be provided to complainants while investigations are still on-going; and
• provide Mr C with a goodwill payment equivalent to four weeks of his rent in recognition of the inconvenience he suffered due to their not providing an effective repair to windows at his property within a reasonable timescale.

Summary

Mrs C complained about a lack of communication from clinical and nursing staff when her late father (Mr A) was admitted to Wishaw General Hospital. Mr A was 95 years of age and along with other health problems, he suffered from dementia. Mrs C had power of attorney (a legal document appointing someone to act or make decisions for another person) for her father. Mrs C complained that she was not allowed to remain with Mr A when he was initially admitted to hospital and that staff did not ask her for information about his medical history or the symptoms which he presented with. Mrs C also complained that staff failed to inform the family of the seriousness of Mr A's condition and that a Do Not Resuscitate form had been completed for him.

The board maintained that the level of communication from staff was appropriate and that he received a good standard of clinical treatment and nursing care.

After taking independent clinical and nursing advice from a consultant geriatrician and a senior nurse, we upheld Mrs C's complaints about the lack of communication from staff towards Mr A's family: we found that this had had a detrimental effect on the level of clinical treatment and nursing care which he received. We found that Mrs C would have been a valuable source of information to the clinicians and nurses and that would have assisted in the delivery of appropriate care and treatment. Generally, the level of clinical treatment and nursing care which was provided was appropriate for a patient with complex health issues but integral to this is a need for good communication to ensure that staff were aware of Mr A's symptoms and medical history, and that the rationale for their decision-making is communicated to relatives. We also found that there was some confusion between staff about the care and treatment planned for Mr A.

Recommendations

We recommended that the board:

• apologise to Mrs C for the failings in communication which would have improved their ability to provide Mr A with appropriate clinical treatment;
• ensure that the contents of our investigation are shared with relevant clinical staff in order that they can reflect on their actions and discuss it during their appraisal process;
• apologise to Mrs C for the failings in communication which would have improved their ability to provide Mr A with appropriate nursing care;
• ensure that the contents of this investigation are shared with relevant nursing staff in order that they can reflect on their actions;
• apologise to Mrs C for the failings in general communication from staff regarding Mr A's clinical condition and prognosis; and
• provide an action plan which evidences that lessons have been learned from this complaint.

Summary

Mrs C complained that doctors at Monklands Hospital did not examine her mother (Mrs A)'s ear for infection, or do a CT scan (computerised tomography: a scan which uses x-rays and a computer to create detailed images of the inside of the body), when she went to the hospital's emergency receiving unit. Mrs C felt that hospital staff did not take all steps to ensure that Mrs A received the best care.

We looked at Mrs A's medical records, and we took independent advice from one of our medical advisers. We also took into account relevant clinical guidance in Scotland about the diagnosis and management of headache in adults. The guidance referred to 'red flag' features, some of which could have applied in Mrs A's case given what was recorded in her medical and nursing records. We concluded that a CT scan should have been carried out, or at least the relevant hospital staff should have specifically recorded the decision not to perform a CT scan, in line with the guidelines. We also found that hospital staff should have examined Mrs A's ear for infection. We upheld Mrs C's complaints.

Recommendations

We recommended that the board:

• apologise to Mrs C and Mrs A's family for the failings identified in our investigation;
• remind relevant staff, in particular locum consultants who usually work elsewhere in the UK, of the specific national guidelines which are used in Scotland; and
• make reasonable efforts to share the result of our investigation with the staff involved.

Summary

Mrs C complained about the treatment she received when she was admitted to Monklands Hospital to have a blockage in her bowel investigated. This was examined in the operating theatre and the blockage was resolved there and then. However, Mrs C experienced excruciating pain and complained that she was not given an anaesthetic for the procedure. She said the consultant ignored her requests to stop. She also complained that she was asked to sign a consent form on her way to theatre, and she raised concerns about the board's handling of her subsequent complaint.

We took independent advice from a consultant colorectal (relating to the colon and rectum) surgeon. We were advised that Mrs C could have been offered anaesthesia or sedation for the procedure. The adviser noted that Mrs C was already taking strong pain medication when she was admitted, potentially indicating that she may have wished to receive something to control her pain during the procedure. We upheld this complaint.

The adviser confirmed that it was not appropriate for Mrs C's consent to have been obtained on her way to theatre, which the board had already acknowledged. We identified inconsistencies in relation to what happened during the procedure. The board said both that the consultant had stopped when asked by Mrs C, and that they had proceeded with Mrs C's verbal consent, but neither of these scenarios was documented in the operation note. We concluded that the informed consent process was not handled reasonably and we upheld this complaint.

We also upheld the complaint about the way the board handled Mrs C's complaint to them. There was an unreasonable delay that the board had already acknowledged and apologised for. We noted that there were omissions and inconsistencies in the board's response, and that it was overly technical in parts. We also noted that the board had not sought comments from relevant medical and nursing staff who were involved, and that could potentially have added value to the board's complaint investigation.

Recommendations

We recommended that the board:

• bring this decision to the attention of the consultant and team, and ask them to reflect on their decision not to offer Mrs C sedation or anaesthesia;
• review their process for obtaining informed consent, taking account of the failings this investigation has identified and relevant guidance in this area;
• ask the consultant to reflect on their operation note from this procedure with a view to identifying areas for improvement and ensuring that any significant interactions are documented in order to avoid similar future uncertainty;
• review their handling of Mrs C's complaint in order to identify areas for improvement and ensure compliance with their statutory responsibilities as set out in the Can I Help You? guidance; and
• apologise to Mrs C for the failings this investigation has identified.

Summary

Miss C complained to her mother (Mrs A)'s medical practice about how they dealt with Mrs A in the last two days of her life. Miss C then complained to us that a GP failed to diagnose and treat Mrs A's condition; that reception staff wrongly referred her mother to NHS 24 rather than arranging for a house call from a GP; and about the practice's handling of her complaint.

We looked at the practice's file on Miss C's complaint and at Mrs A's medical records, and we took independent advice from one of our GP advisers. We found that Mrs A had a number of risk factors for a heart condition, and we decided that the GP should have taken these into account by reviewing Mrs A's blood pressure and pulse, given the possibility of a heart-related cause for her symptoms. We concluded that the assessment and treatment provided by the GP was not of a reasonable standard. We also concluded, on the balance of the available evidence, that reception staff were wrong to refer Mrs A to NHS 24, rather than offering an emergency appointment at the practice or a home visit from the on-call GP. We also found that the practice's handling of Miss C's complaint was not in keeping with the principles set out in the national NHS complaints handling guidance. We upheld Miss C's complaints.

Recommendations

We recommended that the practice:

• apologise to Miss C for not providing a reasonable standard of care, treatment and service to Mrs A;
• apologise to Miss C for the failure to deal with her complaint adequately;
• provide us with evidence of how practice medical staff learned from this case;
• review the practice protocol for late calls and emergency appointments; and
• refresh their understanding of national complaints guidance and review their complaints procedure to ensure that the procedure, and staff practice in dealing with complaints, is in line with the guidance.

Summary

Mr C complained on behalf of his brother (Mr A) that the board failed to diagnose Mr A's testicular torsion (the twisting of a testicle, which shuts off the blood supply and can result in the loss of the testicle) and inappropriately discharged him from the Southern General Hospital. Mr A later had to have a testicle surgically removed. Mr C was also unhappy with the board's handling of his complaint.

We found that, as acknowledged by the board, there was a series of failings when Mr A was in hospital. The main issue was that an on-call urologist (a doctor who treats conditions of the urinary tract) should have examined Mr A in person to exclude or confirm testicular torsion. We also found that hospital staff who were asked to comment on Mr C's complaint agreed that Mr A should not have been discharged without being examined by the urologist and being given an ultrasound scan (a scan that uses sound waves to create images of structures inside the body). A lack of available beds may have been a factor in Mr A's discharge.

We found that the board's investigation of Mr C's complaint was reasonably thorough, and their letter to him acknowledged failings and apologised for them. However, we found that the investigation was missing a statement from the doctor who took the decision to discharge Mr A. This was an important aspect of the events in question because it was this doctor who raised the issue about there being no available beds. In our view, the lack of evidence from this doctor compromised the board's investigation. We upheld all of Mr C's complaints.

Recommendations

We recommended that the board:

• share widely within the urology service the circumstances of Mr A's care;
• discuss the details of this case with the on-call urologist;
• share the circumstances of Mr A's care with the out-of-hours service and the emergency department;
• explain to us why a statement was not obtained from the doctor who discharged Mr A;
• ensure that the details of this case are discussed with the doctor who discharged Mr A; and
• provide us with confirmation regarding the availability of beds in relation to Mr A's discharge.

Summary

Ms C was referred by her GP for her painful right ankle to be reviewed. She complained that she experienced an undue delay in receiving appropriate treatment.

We took independent advice from a consultant orthopaedic and trauma surgeon. We found that Ms C's first appointment for treatment with a foot surgeon was just over 39 weeks after her referral. This was longer than the board's waiting time policy. However, in the meantime, Ms C had been sent on a different treatment pathway by being referred to a podiatrist (a clinician who diagnoses and treats abnormalities of the lower limb), a consultant orthopaedic surgeon and then finally a foot surgeon. She had also refused appointment times that had been offered and had been quite specific about where she would receive treatment. This all affected her waiting time.

We took the view that it would have been more appropriate, given the terms of her referral, for Ms C to have been referred directly to a foot surgeon and, therefore, we upheld the complaint.

Recommendations

We recommended that the board:

• apologise for the overall delay in providing a date for surgery; and
• bring the complaint to the attention of those staff who assess referrals of this type for them to reflect on the advice given.