Upheld, recommendations

Summary

Mrs C complained about the care and treatment provided to her stepfather (Mr A) during his admissions to Gartnavel General Hospital and the Western Infirmary, Glasgow. She was unhappy about the standard of nursing care and the medical treatment Mr A received. Mrs C said there were delays in admitting Mr A and, once admitted, he was not properly cared for and nursing staff did not take his disabilities into consideration. Mr A was discharged from his first admission with a diagnosis of cancer, which proved to be incorrect, and there was a substantial delay in providing the correct diagnosis. The family said that this diagnosis came too late, as Mr A passed away some weeks later. Another of the board's departments then contacted them, offering assistance with Mr A's proposed discharge home, which added to their distress.

We took independent advice on this case from a nursing adviser and a medical adviser. We found the board had already acknowledged and apologised for a significant number of failings in Mr A's nursing care, and had provided evidence of what they had done to stop this happening again. Our nursing adviser said that Mr A's care was clearly substandard, but the board had demonstrated they had taken this seriously and had responded by taking proportionate and reasonable steps. Our medical adviser said that although Mr A's cancer diagnosis was not unreasonable, the delay in providing a conclusive diagnosis breached Scottish Government targets and that the board had not addressed this. We concluded that Mr A had experienced failings in nursing care, and in communication with the family, but that the board had taken reasonable steps to address these issues. They had not, however, identified that there was a failure to provide a follow-up appointment for Mr A following the cancer diagnosis.

Recommendations

We recommended that the board:

• provide evidence they have taken steps to identify the cause of the delay following Mr A's referral;
• provide evidence they have taken steps to ensure the delay experienced by Mr A when waiting for a follow-up appointment could not reoccur;
• provide evidence that they have taken action to ensure community-based staff are informed timeously of a patient's death; and
• apologise in a simple unqualified way for the failings our investigation identified, and the distress experienced by Mr A's family.

Summary

Mr C complained about the pain relief he was being prescribed by the prison health centre as he did not find it effective. He also complained about the way the board handled complaints and feedback he had submitted.

The board considered that Mr C was being prescribed appropriate medication to manage his pain. After taking independent advice from one of our GP advisers, we upheld this part of Mr C's complaint. The adviser did not consider that a thorough enough assessment of Mr C's pain had been recorded to determine if the pain relief he was prescribed was appropriate. In looking at the board's handling of Mr C's complaints, the evidence available confirmed that they did not respond to feedback that he had submitted in line with the relevant process and had failed to identify this during their investigation of his subsequent complaint. We also upheld this part of Mr C's complaint.

Recommendations

We recommended that the board:

• ensure that heath centre staff consider and reflect on how they assess a patient's pain;
• ensure that health centre staff consider the use of alternative treatments like local anaesthetic patches for the treatment of isolated areas of pain such as Mr C's;
• ensure that staff update their learning by reading the revised Scottish Intercollegiate Guidelines Network guideline 136;
• apologise to Mr C for failing to respond in line with the relevant process; and
• review their complaints handling procedure alongside the prisoner healthcare feedback, concerns and complaints form to ensure they provide a consistent approach.

Summary

Ms C, who suffers from back problems, attended the practice as she had pins and needles in her foot. Hospital anaesthetists had previously advised her to contact her GP if she had any symptoms affecting her legs, bladder, bowel or back. She said that when she went to an appointment, the GP did not appear interested, prescribed inappropriate medication and failed to examine her legs.

Ms C complained to the practice, who said that the GP had suggested the medication as it could assist with nerve-related symptoms and that he was aware that Ms C already had an urgent neurology referral. The GP also advised Ms C to seek further medical assistance should her symptoms worsen. Ms C brought her complaint to us.

After taking independent medical advice from our GP adviser we upheld the complaint that the GP failed to adequately examine Ms C despite her reported symptoms and known medical history. We found that the GP should have carried out a more thorough examination which should have involved testing reflexes and muscle strength in the feet and legs; checking for loss of anal tone by performing a digital rectal examination; checking for numbness in the perineum (region between the thighs); and checking the location of the pain to see if it ran along the sciatic nerve.

Recommendations

We recommended that the practice:

• provide a written apology for the failings identified; and
• discuss the complaint at the GP's next annual appraisal.

Summary

Mr C's business occupies premises on the ground floor of a building. Mr C also used to own a property on the floor above. This second property was unoccupied until Mr C sold it to its current owner in 2011. The properties share a water supply and meter, which Business Stream used to bill Mr C for his current business premises. However, due to the shared supply he was also billed for the water used in the second property. Business Stream also charged the new owner of the second property for unmeasured/estimated charges, effectively charging two customers for the same water supply. Business Stream became aware of the shared supply in August 2012, and Mr C told us that in November 2012 he was advised to install a sub-meter to measure the water usage at the second property, which would be used to bill the user. Mr C installed the meter but was later advised that it would not be read and could not be used for billing purposes. Mr C complained that he had been incorrectly advised about installing the meter and that he was being unreasonably billed for water used at the second property.

We found no evidence that Business Stream had advised Mr C beforehand that although he could install a private sub-meter at his own expense to measure the usage at the second property, it would not be used for billing purposes. We were critical that many of the staff he dealt with did not appear to be aware of the policy on sub-meters, and that the call logs did not accurately note what advice he was given. During our investigation we also discovered that Business Stream had applied a section of their billing policy relating to landlords and tenants. We did not consider that this applied in Mr C's case and found that they had no policy that specifically related to shared supplies for properties with different owners. We upheld his complaint and were also critical that Business Stream did not tell him how he could fix the double billing issue when they became aware of the shared supply.

Recommendations

We recommended that Business Stream:

• take steps to ensure that their frontline staff are fully aware of the policy on sub-meters;
• take steps to ensure that information provided during calls is accurately reflected in the event log;
• refund Mr C the cost of the sub-meter and its installation;
• reconsider whether their policies allow for situations similar to these and ensure that we are kept updated in their discussions with the Scottish Government about shared supplies; and
• refund Mr C an amount equal to the unmeasured charges billed in the period we investigated.

Summary

Mr C, who is a solicitor, complained on behalf of his client (Mrs A) about Business Stream's handling of non-domestic water charges for her previous property. He complained that they delayed in issuing Mrs A with an invoice and that as they were not aware that a meter had been installed they had not been billing previous tenants of the property. When the meter was discovered, Mrs A was of the view that she was being held liable for all the water charges since the meter was installed.

During our investigation we found no evidence that Business Stream had failed to act on information about Mrs A's property. She had not told them that she was occupying it, as she should have done, and once they discovered that she had taken over responsibility for it they sent her an invoice. We were concerned, however, that they initially charged Mrs A on unmeasured charges, as they had not realised that a meter had been installed, and so needed to make a number of changes to her account. We also discovered that, while Business Stream had not billed Mrs A for water used by previous tenants, they had opened her account on a reading of zero units rather than 40 units, so she had been billed for an incorrect amount of water usage. We considered that this had been poor customer service and upheld Mr C's complaint. We noted that Business Stream had already offered Mrs A some financial redress for their handling of her account.

Recommendations

We recommended that Business Stream:

• apologise to Mrs A for their handling of this matter; and
• reinforce the apology and financial redress already offered and credit a further amount to Mrs A's account as a recognition of the time and trouble caused by their failings.

Summary

Mr C complained that prison 1 did not properly investigate his claim for his lost property after he submitted two claim forms. When Mr C was transferred from prison 2 to prison 1, he signed on his property card that he had a mobile phone in storage in prison 2, but there was no record of it having being received by prison 1 when he arrived there. Although prison 1 had obtained evidence that Mr C had a mobile phone before transfer, they rejected his claim on the basis that there was no evidence to show that prison 2 sent it. They also said that Mr C had signed a form to say that his property was correct.

We found that prison 1 should have pursued the matter with prison 2 on Mr C's behalf, as there was evidence to show that the mobile phone had been in storage there and then gone missing. We acknowledged that prison 2 appeared to have looked for evidence during their investigation of the claim, but we decided that they unreasonably overlooked evidence of the mobile phone having gone missing while in the care of the Scottish Prison Service (SPS). This has since been acknowledged by the SPS during our investigation.

We were also critical there was no evidence to show that prison 1 told Mr C in writing of the reasons why they had rejected his first claim form. In addition, they did not appear to have told him how to appeal their decision.

Recommendations

We recommended that SPS:

• consider reimbursing Mr C for the cost of the mobile phone; and
• ensure staff at prison 1 notify prisoners in writing of the reasons why a claim has been rejected and give information about appealing the decision in accordance with the claims procedure.

Summary

Mrs C complained that the council did not meet her child's additional support needs at school. She was also unhappy about how they handled her complaint.

Our investigation found that while the school recognised that Mrs C's child had additional support needs and that support was provided, there had been a complete breakdown in the relationship between Mrs C and the school. Because of this, the issue of whether appropriate support was being provided was never going to be resolved. Mrs C had clearly lost confidence in the service and support provided by the school, and had a genuine belief that it was failing to meet her child's needs.

Mrs C, therefore, had a right to be made aware of the alternative dispute resolution provision available under the Education (Additional Support for Learning) (Scotland) Act 2004, where there is a complaint that a school is not meeting a pupil's additional support needs. This includes access to independent mediation and adjudication, and an appeal to the Additional Support Needs Tribunal for Scotland. The council did eventually offer Mrs C access to mediation (which they should have offered sooner) but we found no evidence that they made her aware of her rights under the legislation as they should have done.

We also found that there were occasions when Mrs C's child went home from school during the day but these were not recorded as an exclusion from school as they should have been (in accordance with the council's school exclusion policy). Accounts of incidents at the school involving Mrs C's child were also not recorded at the time they occurred.

The council had acknowledged delay in responding to Mrs C’s complaint, for which they had apologised and advised her what they had done as a result of this. We were satisfied that they had taken appropriate action to address this part of the complaint. However, Mrs C had also raised concerns about her child being bullied. Given the seriousness of Mrs C's allegations, in particular that her child had been assaulted, we considered that the council had not carried out appropriate investigations to address the allegations of bullying.

Recommendations

We recommended that the council:

• issue a written apology to Mrs C for the failings identified;
• ensure that all relevant staff are made aware of the alternative dispute resolution avenue available for complaints about schools failing to meet additional support needs;
• ensure that all relevant staff are made aware of the council's Management of Exclusion on Schools policy and what constitutes an 'exclusion' from school; and
• ensure that all relevant staff are made aware of the requirement to complete incident report forms, where appropriate.

Summary

Ms C complained that, after an incident at her child’s school, she was not told that day that her child would be excluded from school the following day. The council said that written notification was provided on the day. This was given to the child to pass on to Ms C, but they did not do so.

Our investigation found, however, that the council failed to follow their own guidance which required them to notify a parent orally and in writing on the day a decision is taken to exclude a child. We upheld the complaint and made recommendations.

Recommendations

We recommended that the council:

• ensure that the school apologise to Ms C for not advising her orally on the date of the incident that her child was not to return to school the following day; and
• ensure that staff in the school in question are aware of their obligation to advise parents/carers orally on the day they decide to exclude a young person and they are required to seek agreement from parents/carers if a young person is out on investigation.

Summary

Ms C, an advocate, told us that her client (Mr A) was referred to the neurology department at Ninewells Hospital because of continuing back pain. In November 2012, a neurologist (a specialist in diseases of the nerves and the nervous system) decided that further investigations, including an magnetic resonance imaging scan (MRI scan - used to diagnose health conditions that affect organs, tissue and bone), would not be beneficial as it was extremely unlikely that further back surgery would be considered. The following month, Mr A was admitted to hospital for a different problem but his back and leg pain were noted. An anaesthetist suggested that the neurosurgical team review him but they declined, saying he had been seen three weeks previously. Mr A continued to suffer back pain and in March 2013 his GP wrote to the neurosurgical team requesting an MRI scan, who responded saying that this would not be helpful. In June 2013, because of the level of his pain, Mr A paid for a private MRI scan which was forwarded to the neurosurgical team. Several weeks later, an out-of-hours (OOH) doctor saw Mr A, again because of his pain, and phoned the hospital about admitting him. Mr A was not, however, admitted and said that a member of the neurosurgical team refused to see him again. However, after reviewing the MRI scan the neurosurgical team did then arrange decompression surgery (used to treat some conditions affecting the lower back that have not responded to other treatments), which was carried out at the end of July.

Ms C complained that Mr A had to organise and pay for the MRI scan himself. He was concerned that his assessment in November 2012 was inadequate, and that a scan should have been arranged then. He felt that his pain and distress was not taken seriously and that the neurosurgical team should have acted on the reports from the anaesthetist and the OOH doctor. He was also concerned that his records said that he was to be treated for sciatica, which he believed unreasonably influenced his treatment, and about the length of time it took the board to respond to his complaint.

We took independent advice on this complaint from one of our medical advisers, who is a specialist consultant spinal surgeon. The adviser said that it was unreasonable not to order a scan in November 2012, and that a neurosurgeon should have ordered the test based on the evidence available at that point. The medical adviser also said there may have been undue reliance on the results of a test (the Hoover test) used by the neurosurgeon, which the adviser did not consider was an evidence-based diagnostic tool. The results of the private MRI scan informed subsequent treatment decisions by the board's neurosurgery team, and it was clear to us that they should have arranged this earlier. Their failure to do so meant that Mr A both paid for a test that was required for his NHS treatment, and endured prolonged suffering. We also found that there were several missed opportunities to consider requesting a scan and that it would have been reasonable to have referred Mr A to a spinal specialist in light of the evidence of his condition. However, the reference to sciatica was reasonable.

We found too that, given the complexity of Mr A's complaint, it was clear from the beginning that the investigation and response would take time and that the board should have better managed his expectations around this. The holding letters they sent him did not give him likely timescales for responses, and the delay in responding to his further concerns was unreasonable.

Recommendations

We recommended that the board:

• consider the use of the Hoover test as a diagnostic tool in light of our medical adviser's comments and advise us of the outcome;
• ensure the findings of this investigation are fed back to the relevant clinicians and the learning points discussed at their next appraisal;
• refund Mr A the cost of his private MRI scan; and
• apologise to Mr A for the failings this investigation identified.

Summary

Mr C complained on behalf of his wife (Mrs C) about the care and treatment she received at the Princess Alexandra Eye Pavilion. Mr C said that mistakes were made during an operation, and that his wife was left virtually blind in her left eye. Mr C also complained about the board's response when his wife complained about this.

During our investigation, we took independent medical advice from an experienced cataract surgeon. The advice we received was that the care and treatment Mrs C received was appropriate and that no mistakes were made during the surgery. Mrs C had, however, suffered two rare complications. While the advice we received was that, in general, both complications were handled well, there was a small error in relation to the first one, in that the vitrector (a machine used in eye surgery) used as a result of the complication was not tested before it was used on Mrs C's eye, and was not working. Our adviser said that this was unlikely to have had a material impact on the outcome and was not the cause of the second complication, but we were concerned that the machine was not fully tested before it was used. We were satisfied that there was no evidence that work continued on Mrs C's eye after it was discovered that the machine was not working.

We did, however, find that the complications that arose in Mrs C's case were not discussed with her before the surgery and were not included in the information leaflets that she was given. In addition, we were concerned that Mrs C was not given enough time to make a considered decision about the surgery. We were also concerned about the handling of Mrs C's complaint - in particular that the response she received to her representations contained unnecessary, confusing details and did not meet her needs.

Recommendations

We recommended that the board:

• ensure that the relevant staff members are made aware of our adviser's view that it is wise, where a vitrector has been set up, that the flow of fluid through the vitrector is checked and that a check is carried out to ensure the guillotine cutter is working before it is used;
• consider the process for informed consent for cataract surgery to ensure that it complies with guidance about informed consent, in particular, in relation to the information provided about serious or frequently occurring risks;
• draw to the attention of relevant staff our adviser's comments that where potentially serious complications have occurred it would be wise to make a note in the medical records of the discussions held with patient/relatives;
• apologise to Mrs C for the handling of her representations; and
• ensure that their written responses to complaints meet the needs of the patient in relation to tone and language etc.