Upheld, recommendations

Summary

Miss C complained about the way COPFS handled her complaint, which concerned the death of a relative. Miss C said the handling of her complaint was very poor and took an unreasonably long time, and there was a lack of respect and compassion towards her as a bereaved relative in the written response to her complaint by COPFS. Our jurisdiction in complaints about COPFS is very limited, and we could look only at whether they acted in line with their complaints procedure.

We found that Miss C raised a number of issues in her complaint to COPFS and, in their letter, COPFS provided a response to those issues. From an administrative point of view this showed there was a reasonable level of investigation into, and response to, Miss C's complaint. We were in no doubt that their response would have been difficult to read, given the distressing subject matter dealt with in the letter. However, we concluded that the letter was not lacking in respect or compassion; rather, it was empathetic and tried to deal with a difficult subject sensitively.

In terms of the time taken to deal with Miss C's complaint, it took considerably longer than the 20 working days allowed for in the COPFS complaints procedure; it was in the region of 85 working days. COPFS explained why it took this length of time, and the explanation appeared to be reasonable. However, COPFS failed to update Miss C every 20 working days, as required by their complaints procedure. Miss C should have had at least three, if not four updates. This was particularly important given the impact on Miss C of her relative's death and subsequent events. Therefore, on this specific point, we upheld Miss C's complaint.

Recommendations

We recommended that COPFS:

• confirm to us what measures they have in place to ensure that complainants are given progress updates in line with their complaints and feedback policy.

Summary

Mrs C, a tenant of the council, complained about difficulties arranging repairs to her home. Mrs C said there were delays in carrying out several repairs, and the council failed to return her calls or communicate with her, except when she made formal complaints. Mrs C was also concerned that her energy costs for the year were very high, which she thought could be due to the delays in repairs to windows and doors, or to a fault in her boiler (which was not inspected by the council for two months after she reported it).

The council accepted that their communication was poor, and apologised to Mrs C for this. However, the council said that the energy costs could not have been affected by the faulty boiler, as this would have used less, not more, electricity.

After investigating these issues, we upheld Mrs C's complaints. There was no evidence that the faulty boiler increased Mrs C's energy costs and, while the delays in repairing the doors and windows might have affected her heating costs, it was not possible to determine this for certain. However, we found that there was unreasonable delay in the council inspecting Mrs C's faulty boiler, as well as in carrying out several repairs to her house. We also found that the council did not respond reasonably to Mrs C's attempts to contact them, except when she made formal complaints.

Recommendations

We recommended that the council:

• consider inspecting boiler and heating systems (to ensure they are functioning properly, in addition to electrical safety) as part of the preparation of a void property for a new tenancy;
• apologise to Mrs C for the failings our investigation found;
• review their processes to ensure that repair requests are promptly recorded and carried out, including where requests are made verbally, or as a result of a property visit; and
• take steps to ensure there is a robust process for logging and following up calls relating to housing repairs.

Summary

Ms C applied to the council on behalf of her son for a Young Scot card and education maintenance allowance. There were delays in processing her applications and because of that, Ms C complained to the council. She then complained to us because she said the council failed to address her complaint appropriately.

Having reviewed the council's complaint file and related documents, we found that the council could have taken steps to outline what the relevant procedures and likely timescales were in relation to each application. We also considered that they could have explained in more detail what had happened to the Young Scot card application. In addition, the council failed to address Ms C's concerns about her application for education maintenance allowance.

Recommendations

We recommended that the council:

• make a time and trouble payment in recognition of the failings identified with the handling of the application for a Young Scot card; and
• apologise for failing to address Ms C's complaint about the handling of the application for education maintenance allowance.

Summary

Miss C complained that the association delayed in processing her application to buy her home. It took seven months for them to issue her with an offer, which should have been issued within two months. In addition, as the association said they did not receive Miss C's acceptance of the offer, the process was delayed by a further three months. Miss C said she handed the initial acceptance in to the association and received a receipt. She provided a copy of the receipt but it did not specify what it was for. The association were not able to suggest what else it might have been for, and confirmed that they had since tightened up their mail logging process.

We found that the initial delay was due to the time taken to establish details of Miss C's tenancy. The association should have refused the application within one month of receipt if they disputed her right to purchase, or within two months if they considered her application to contain incorrect material information. In the absence of a refusal, they were required to issue an offer within two months of receiving the application. After this time, Miss C was entitled to serve notice on them, giving them a further month to issue their offer, after which the purchase price would be reduced by the amount of rent paid between then and the eventual issue of the offer. We saw no evidence of the association having told Miss C this, or referring her to her solicitor for information. We also found that the association should have instructed a valuation of the property within three days of receiving the application but this did not happen for almost four months. They should also have instructed a solicitor to issue the offer but it was issued by a housing officer and the association did not contact their solicitors until after the acceptance was received. We concluded that the delays in this case were unreasonable.

Recommendations

We recommended that the association:

• review their process to ensure that future right to buy applications are handled in line with the guidance;
• refund Miss C eight months' rent payments in recognition of the delay in processing her application to buy her home; and
• apologise to Miss C for the failings we identified.

Summary

Mr A had suffered a morphine overdose and become unwell. An ambulance was called and the crew assessed Mr A. He was nauseous and vomiting, had abdominal (stomach) pains and was unable to keep down food or drink. He was taken to Perth Royal Infirmary, where he was triaged and sent to the out-of-hours service. He was assessed there by a primary care nurse, and deemed fit to be discharged.

His niece (Mrs C) complained on behalf of Mr A. She said that when Mr A had been discharged he had phoned her and was confused and disorientated. Mrs C complained that her uncle was not reasonably assessed at the hospital and should not have been discharged.

During our investigation we took independent advice from both a GP adviser and a nursing adviser. Both advisers expressed concerns that the assessment of Mr A was not thorough. The nursing adviser was concerned that Mr A's recent morphine overdose history was not noted and that his abdomen was not examined, in light of the pain reported to the ambulance crew. The GP adviser was also concerned that Mr A was not assessed for dehydration due to his inability to keep down liquids. In light of the advice we received, we upheld Mrs C's complaints.

Recommendations

We recommended that the board:

• share the outcome of this investigation with the practitioner concerned to reflect on assessment and record-keeping; and
• apologise to Mr A for the failings identified.

Summary

Mrs C had an operation at Perth Royal Infirmary, after which she experienced complications and was transferred to Ninewells Hospital for more surgery. Her husband (Mr C) complained on her behalf about how clinical and nursing staff responded to her pain levels and other concerns. He also complained that, after Mrs C was transferred, there was a delay before she was taken to an operating theatre. Finally, he said that the risk of the complications (perforation of the uterus and damage to the bowel) were not included in the information leaflet sent to her before the surgery.

During our investigation, we took independent medical advice from a consultant obstetrician and gynaecologist, and nursing advice from a nursing adviser. Our medical adviser said that Mrs C had an appropriate operation in Perth Royal Infirmary, and experienced a recognised complication of the procedure, for which she received appropriate treatment.

We did, however, uphold Mr C's complaints. There was no written record by doctors at Perth Royal Infirmary, so our medical adviser could not say whether there was a delay in diagnosing the perforation or whether a consultant should have been contacted earlier. Because of this lack of records, we also could not confirm whether there was a delay in transferring Mrs C. We were concerned that her consent for the procedure had not been properly obtained. The board explained that their consent process for hysteroscopy (a procedure that lets the doctor look inside the womb) was being reviewed to ensure that it follows guidance from the Royal College of Obstetricians and Gynaecologists.

Our nursing adviser said that, given Mrs C's level of pain, nursing staff at Perth Royal Infirmary should have increased the frequency of their observations, and should have told the nurse in charge. They did not follow guidance on the Scottish Early Warning Scoring System (a set of patient observations to assist in the early detection and treatment of serious cases and to support staff making clinical assessments). The board told us that staff had been reminded of the need to increase the frequency of observations in such cases, but did not explain how this would be monitored. The board had also accepted that more proactive observation of Mrs C's vital signs should have been undertaken, and had taken action on this.

In relation to Mr C's concern about delay, the board accepted that a senior doctor should have been alerted immediately after Mrs C arrived, and that better communication might have helped her reach theatre earlier. Our adviser said that there was no evidence that this had a detrimental effect on the eventual outcome, but we were concerned about a possible delay in carrying out surgery. We were also concerned that, when Mrs C was so unwell, her family were asked to leave as visiting times had ended. Finally, patients have the right to information about the treatment that is proposed and we noted that the board now include in their leaflet information about the risk of perforation.

Recommendations

We recommended that the board:

• apologise for the failings identified in this case;
• report back to us on the outcome of the review of the consent process for hysteroscopy;
• report back to us on how they will monitor the action taken to remind nursing staff of the need to increase the frequency of observations when there is unresolving pain;
• remind all staff in the gynaecology unit of the need to record their findings when reviewing patients;
• report back to us on the action taken to share this case with all medical staff in gynaecology, to ensure patients who require senior review are seen as a matter of urgency; and
• report back to us on action taken to discuss the issue of relatives and visiting times with nursing staff in the relevant ward.

Summary

Mrs C complained that the board's decision to discharge her from the A&E department of the Royal Infirmary of Edinburgh was not reasonable.

Mrs C had accidentally swallowed her dental plate and was taken to A&E by ambulance. She complained that her plate caused her to choke and that she waited a long time in A&E before being sent for an x-ray. Although the x-ray did not identify her dental plate Mrs C said she knew it was still in her throat when she was discharged; around two weeks later, she started choking, coughed and dislodged it.

As part of our investigation, we took independent advice from two of our advisers (the first was an experienced ear, nose and throat specialist and the second was an A&E consultant). Our first adviser said the focus of staff in A&E appeared to have been on Mrs C's digestive system, as opposed to her throat (her chest was x-rayed and she was told to return if she developed abdominal pain). He explained that there were additional steps that could reasonably have been taken by A&E staff prior to Mrs C's discharge and our second adviser also said that A&E staff could reasonably have done more.

Our role was to consider whether the care and treatment Mrs C received in A&E was reasonable in the circumstances at the time. This meant we could not rely on hindsight and, as our first adviser pointed to some things that may not have been immediately apparent to a non-specialist, we took his relative expertise and experience into account (in addition to our second adviser's view). Taken as a whole, we were satisfied that the board's decision to discharge Mrs C had been unreasonable in the circumstances and we upheld her complaint. We made two recommendations.

Recommendations

We recommended that the board:

• apologise to Mrs C for the failings we identified; and
• use this case as a learning point for staff at the next departmental meeting, in particular in relation to carrying out appropriate examinations and recording this in the medical records.

Summary

Ms C complained about the care that her father (Mr A) received from the board. Mr A's optician referred him to the Princess Alexandra Eye Pavilion (the hospital) when he complained of failing sight in his left eye. He was referred to the stroke clinic to check for a possible mini-stroke, and was given medication to prevent blood clots. Ten days after his initial hospital referral, Mr A was referred by his optician again, having started to experience problems in his other eye. Upon examination, issues highlighted by the optician were not recorded by the hospital eye specialist and Mr A was advised to attend an appointment he already had scheduled around three weeks later. Mr A attended that appointment, but his vision had deteriorated further. Staff were concerned that Mr A might have giant cell arteritis (GCA: inflammation of the arteries, particularly around the temples) and prescribed steroids. A scan and biopsy (tissue sample) of an artery in his head were also ordered. The biopsy was inconclusive, and Mr A was continued on steroid treatment in line with a diagnosis of GCA.

We took independent advice from one of our medical advisers - a consultant ophthalmologist (a doctor who examines, diagnoses and treats diseases and injuries in and around the eye). Our adviser said that Mr A suffered from anterior ischaemic optic neuropathy (AION: loss of vision due to damage to the optic nerve through lack of blood supply). This can be either arteritic, or non-arteritic (either caused by inflammation of the artery walls or not), and there is no treatment for non-arteritic AION.

We found that Mr A did not display symptoms normally associated with GCA when he first attended the hospital, and that his referral to the stroke clinic was appropriate in the circumstances. When he returned to the hospital, he and his optician had clearly reported a deterioration in his condition, with new symptoms affecting his right eye. The eye specialist did not observe these, but we were critical that he did not seek a second, senior, opinion, given Mr A's recent history and the optician's comments. We took the view that this resulted in an unreasonable delay in Mr A receiving steroid treatment. Our adviser also said that GCA is normally diagnosed by biopsy, but in Mr A's case the sample was too small to provide a definitive diagnosis. It was, therefore, impossible to say whether or not he had GCA or non-arteritic AION. However, we took the view that had steroid treatment started sooner the sight in Mr A's right eye might have been preserved.

Recommendations

We recommended that the board:

• apologise to Mr A for the issues highlighted in our investigation;
• share our decision with the staff involved in Mr A's treatment; and
• conduct a review of Mr A's case with a view to identifying any points of learning.

Summary

Mr C suffered from ongoing problems urinating and tried to treat these himself, but this caused him further problems. He went to A&E at St John's Hospital and the urology department at the Western General Hospital several times. He was prescribed antibiotics for infection and given an appointment for a cystoscopy (an operation using a special telescope to examine the urethra - the tube that allows urine to pass out of the body - and bladder).

Mr C did not attend the appointment, as he said he did not receive the letter and did not know where to go. Another appointment was arranged, but Mr C developed another infection before this. He was prescribed more antibiotics, and although the operation could not be carried out, the surgeon met Mr C to discuss his condition and treatment. Another appointment was made for the cystoscopy, but Mr C was worried about the operation. He wrote to the surgeon about it, and they met again to discuss his concerns and his treatment plan, after which the operation went ahead with a different surgeon. Follow-up tests, however, showed that it was not successful and the new surgeon arranged for Mr C to have an urethrogram (an x-ray examination of the urethra). He planned to follow this up in his clinic, but Mr C was not given a follow-up appointment.

During this time, Mr C made several complaints about his treatment, in particular about medical staff being reluctant to give him ongoing antibiotics, which he thought he needed. He emailed the board's complaints team regularly about his complaints and ongoing health problems. While the board investigated and responded to several complaints, they eventually told him that the complaints team was not able to influence his medical treatment. They said that they would not respond to further complaints about antibiotics, but would investigate any new matters. However, when Mr C wrote to complain that he had not heard back since his urethrogram, the board told him that his complaint was closed and would not be investigated. Mr C asked his MSP to complain on his behalf, but the board told the MSP that the complaint was too old, as the events had happened over six months before. Mr C then complained to us about his medical treatment and the board's handling of his complaints.

We investigated Mr C's complaints and took independent medical advice on his case. As a result of our enquiries, the board acknowledged that he had not been given a follow-up appointment, and they arranged this as a matter of urgency. We upheld Mr C's complaint about treatment, as it was unreasonable that the board had at first failed to arrange this. We also found no evidence that Mr C was sent an appointment letter for his first surgery date, and we were critical of this. Finally we noted a lack of continuity in Mr C's care (with nine doctors involved over a six-month period). Although the first surgeon showed particular care in meeting twice with Mr C to explain his treatment, the lack of continuity meant that Mr C did not fully understand the treatment plan, or the importance of treating his underlying problems as well as taking antibiotics.

We also upheld Mr C's complaints about the board's complaints handling, as they did not correctly follow their complaints handling policy or their unacceptable actions policy. In particular, the board should have tried to clarify Mr C's complaints earlier, and should have told him as soon as they had concerns about the amount of contact he was having with them. We also found that they should have investigated his last complaint about the lack of follow-up appointment, as it raised a new issue that had occurred within the last six months and had not previously been investigated.

Recommendations

We recommended that the board:

• issue a written apology to Mr C for the failings our investigation found, and provide a reassurance that his future requests for medical care will be treated with respect;
• review the processes for arranging urology appointments at the Western General Hospital, to ensure there are clear records of when an appointment is required and when an appointment letter (or replacement letter) has been sent;
• consider identifying a single clinician to maintain continuity of care in cases where the patient may benefit from this;
• remind complaints handling staff of the requirements of the complaints policy in relation to clarifying complaints at the outset and the time-frames for acknowledging and responding to complaints;
• identify and address any training needs for complaints handling staff in relation to supporting vulnerable complainants (including responding appropriately to comments relating to self-harm); and
• review complaints handling processes and procedures to ensure they comply with the unacceptable actions policy.

Summary

Mr C had concerns that action was not being taken to prevent patients, visitors and staff from smoking at entrances to buildings at Monklands Hospital. He tried to report the matter via the contact number displayed on the 'no smoking' signs but no such number existed. When Mr C spoke to staff about the matter they seemed resigned to the fact that smoking outside the premises was an ongoing problem that happened all the time. He complained to the board but their response did not address all the issues he raised, and he brought the matter to us. We upheld his complaint, as we found that the board's response lacked detail and did not address a number of Mr C’s questions.

Recommendations

We recommended that the board:

• apologise to Mr C for the failings which have been identified as a result of our investigation; and
• review their original response and provide Mr C with a further response which addresses the specific concerns which were raised.