Upheld, recommendations

Summary

Mrs C complained about the care that her mother (Mrs A) received in Borders General Hospital. Mrs A had a collapse/fall while she was alone at home and was taken to A&E. As Mrs A had a pacemaker and had a number of issues with her heart while she was at the hospital, she was transferred to another hospital in a different NHS board area for specialist investigations (the second hospital). Tests there showed that there were no abnormalities with Mrs A's pacemaker. She was scheduled for transfer back to Borders General Hospital but an outbreak there of norovirus (winter vomiting bug) prevented this. The second hospita carried out further tests, and Mrs A was diagnosed with pulmonary emboli (blockages in the blood vessels that carry blood from the heart to the lungs, usually caused by blood clots). She was prescribed warfarin (a medicine that prevents blood clotting) to treat this and a few days later was transferred back to Borders General Hospital. The medical transfer documentation did not include information about the new diagnosis and treatment, although the nursing transfer document specifically identified them. When Mrs A was readmitted to Borders General Hospital, staff only considered the medical transfer documents, and missed the pulmonary emboli diagnosis.

Mrs C had been concerned about her mother's ability to cope at home, but as Mrs A was considered to be medically fit to return there, she was discharged two days after she went back to Borders General Hospital. She became increasingly breathless, however, and was readmitted two days later where the pulmonary emboli diagnosis was picked up and treated.

Mrs C complained to the board about the care Mrs A received. The board apologised for the errors in communication between Borders General Hospital and the second hospital. They also advised that steps would be taken to ensure that the issue was followed up with the second hospital and that doctors would now check both medical and nursing transfer documents when admitting patients.

After taking independent advice from one of our medical advisers who is a consultant physician, we upheld Mrs C's complaint. The adviser considered that the failure to identify Mrs A's diagnosis of pulmonary emboli from the nursing transfer document was unreasonable and that insufficient effort was made to assess her before she was discharged. We were also critical that there appeared to have been a delay in the board carrying out the actions advised in their response to Mrs C's complaint.

Recommendations

We recommended that the board:

• apologise for the standard of care and treatment provided to Mrs A during the period relating to the complaint;
• take steps to ensure that actions agreed following a complaint investigation are followed up promptly;
• consider the adviser's comments about taking the views of family members into account and determine whether there are lessons that can be learned; and
• make medical staff involved in Mrs A's care aware of the adviser's concerns regarding the decision to discharge, including the lack of documentation, to ensure that a similar situation does not occur in future.

Summary

When Mr A was refused a street trader's licence, he asked the council for a statement of reasons for the refusal. He then complained about the refusal, the reasons given for refusal and the time taken to provide those reasons. He remained dissatisfied when he received the council's responses and Mr C complained to us on his behalf.

The council argued that various court opinions indicated that the timescale given in legislation for the provision of statements of reasons was not mandatory. We considered the council's argument but decided that the view courts may take in the event of appeals being made to them was not relevant to a complaint about administrative handling. We, therefore, upheld that complaint along with others relating to the council's handling of Mr A's complaints.

Recommendations

We recommended that the council:

• apologise to Mr A that they did not provide the statement of reasons within ten days;
• apologise to Mr A that they did not respond reasonably to his complaints; and
• remind relevant staff that they should be clear from the start of the investigation stage exactly what matters they will be investigating, and that complaint responses address all the areas that the council is responsible for and explain the reasons for any decisions reached.

Summary

Mr C complained to the council that a survey they had undertaken about the introduction and location of glass recycling banks at the apartment blocks he lives in was not carried out in line with their plan for local involvement. The council told him that they considered the consultation had met the terms of the plan.

Mr C was dissatisfied and complained to us. The council's plan said that three weeks would be given for individuals to respond to surveys, but only two weeks had been given in this case. The plan also said that relevant groups would be consulted, but the residents' association for the apartment blocks were not consulted. The council said that they did not consider this necessary as all residents were sent surveys to complete. However, the council provided no evidence to indicate that this, or any aspect of the local involvement plan, was considered before undertaking the survey. In light of this, we upheld Mr C's complaint and made recommendations.

Recommendations

We recommended that the council:

• remind staff that consultations should be carried out in line with the local involvement plan;
• put up signage on the glass recycling banks asking that glass only be deposited within specific hours of operation; and
• deliver information to each property in the apartment blocks, giving details of the hours of operation of the glass recycling bank.

Summary

Mr C complained that the council had installed a new culvert (a tunnel carrying a stream or open drain) under the road above his property. The culvert drained directly onto his land, and he said that it had eroded his driveway and caused problems with water run-off around his house. Mr C said that he was there when workmen constructed the culvert, and there had been no management presence on site. He had contacted the council at the first available opportunity, but was told that although the location of the culvert was detrimental to his property, the council had no option but to locate it there. Mr C said he was also told that the culvert replaced an existing culvert which had collapsed, and as it was not considered a new culvert, the council had no obligation to tell him about it.

Mr C complained and was told that the council's primary obligation was to ensure the road was safe by preventing surface water collecting on it. The council said that the Roads (Scotland) Act 1984 gave them the necessary authority for their actions. They recognised that the culvert had a detrimental impact on Mr C's property and offered to pay half the cost of additional drainage to reduce its impact.

We upheld Mr C's complaints. We found that the logical conclusion of the council's position was that they were entitled to install drainage, regardless of the impact this had on an individual's property. Although it was reasonable for them to take action to provide drainage, our investigation found that they could not provide evidence to prove that a culvert had previously been there. We also found no evidence that they tried to identify or contact Mr C, even though it was apparent his house would be directly impacted. Because of this, we found that the council had acted unreasonably, as they had not given him the opportunity to discuss this before putting the culvert in place.

Recommendations

We recommended that the council:

• meet the cost in full of providing adequate drainage from the culvert to the burn at the edge of the property affected;
• review their roads drainage policy, to ensure that affected owners and occupiers are identified and appropriately consulted before works commence;
• provide evidence that they are compiling an asset register of all culverts; and
• apologise for the failings identified by our investigation.

Summary

Mr C had written to the council to ask if a condition of planning approval had been purified (agreed to have been discharged) by their planning department. Under the council's planning enforcement charter he was entitled to a formal response within ten working days, but he did not receive this. When he wrote again this email was also ignored. Mr C then complained to the council and received their final response which signposted him to us. He then complained that the council did not respond in good time to his concerns about a possible breach of planning control at a neighbouring property.

The council told us that they did not send a formal response as Mr C had met one of their officers at a council office (although Mr C said that this was while on other business). We decided, however, that they should have formally responded to his enquiry, in line with their charter. We upheld his complaint and were also critical of the council's complaints handling.

Recommendations

We recommended that the council:

• apologise to Mr C for the failings identified by our investigation;
• remind staff that the model complaints handling procedure from our Complaints Standards Authority requires them to clearly communicate the outcome of an investigation to the customer; and
• demonstrate to us that action has been taken to resolve the discrepancy between the response time stated in the charter and the one stated in their automated acknowledgement email.

Summary

Mrs C complained about how her child's primary school dealt with an incident involving her child and a teacher. She said that the school had not communicated appropriately with her as a parent and that she had been unaware of what was upsetting her child and why they were reluctant to go to school. She complained to the council that she was not told about the incident, was not involved in a meeting with her child and school staff, and did not receive a full response from the school.

Our investigation considered all the correspondence between Mrs C, the school and the council. We also reviewed the records of the school's investigation and the council's handling of Mrs C's complaint, after which we upheld her complaints. We found that, given the seriousness of the complaints made by her child, Mrs C should have been included and involved in discussions. We also found that the council's record of the handling of her complaint did not match the response she received, so we made recommendations to the council about this.

Recommendations

We recommended that the council:

• apologise to Mrs C and and her child that she was not informed and involved when the incident occurred; and
• remind relevant staff to ensure that complaints are clearly set out and responses clearly relate to agreed complaints.

Summary

Mr C complained that, although he was awarded backdated housing benefit, the housing association did not refund the overpayment until he wrote to ask about this seven weeks later. He was also unhappy that they continued to take his rent by direct debit for a further month.

We found that the association did not have a procedure in place for instances where a rent account is in credit. They said that, when housing benefit is backdated and a significant overpayment occurs, there is an expectation that housing officers will deal with this quickly. However, this did not happen in Mr C's case.

We found that the association delayed in refunding the overpayment, so we upheld Mr C's complaint. We also upheld his complaint about the further direct debit payment being taken, as we found that there was a delay in notifying the bank that it should be cancelled, due to staff absence.

Recommendations

We recommended that the association:

• consider implementing a procedure for instances where a rent account is significantly in credit; and
• consider contingency plans for the cancelling of direct debits in the event of the absence of the responsible staff member.

Summary

Mrs C complained about the treatment that her son (child A) received from his dentist. She complained that the dentist failed to identify that her son was missing two lower premolar teeth. Mrs C said that this caused her son stress, led to a delay in diagnosis and impacted on the cost and the potential success of his future dental treatment. Child A had attended for a routine examination. A bitewing x-ray (a type of dental x-ray) was taken which showed spacing between his lower premolar and the first molar, but the dentist did nothing about this. Mrs C only found this out when her child attended another dentist several months later. He was referred for orthodontic assessment and it was identified that both his lower second premolars were congenitally absent (not present since birth).

We obtained independent advice from our dental adviser who explained that bitewing x-rays are normally taken to detect dental decay. Although this is the primary reason for using bitewing x-rays, they could be expected to show that the lower premolars were not developing. The adviser said that the dentist missed an opportunity for early diagnosis of the absence of the two lower second premolars and said that it would have been reasonable for the dentist to have investigated further at that time. The adviser also explained that there are guidelines on the use of x-rays in dental practice, which recommend that even in the event of a child being assessed as having a low risk of decay, bitewing

x-rays should be taken at intervals of 12 to 18 months whilst they have baby or milk teeth. We found that the dentist did not follow these guidelines in child A's case, so we made a recommendation about this.

Nevertheless, the adviser also said that an earlier referral to an orthodontist would not have achieved anything further, and that any delay in child A's treatment was marginal and would have made no difference to possible treatment. Given this, although on balance we upheld Mrs C's complaint, we did not consider that the treatment her son received impacted on the cost and potential treatment success for him.

Recommendations

We recommended that the dentist:

• reflects on our adviser's findings in terms of future dental practice and in particular takes into account the relevant European guidelines in relation to the frequency of taking bitewing x-rays.

Summary

Mrs C complained that the board failed to provide her with appropriate treatment after her GP referred her to a cardiologist because of her worsening shortness of breath and pitting ankle oedema (where areas of skin temporarily hold the imprint of a finger when pressed). We obtained medical advice on the complaint from one of our medical advisers, who is an experienced cardiologist. We found that it was reasonable for the cardiologist to repeat an echocardiogram (an ultrasound scan of the heart) that her GP had already carried out. The adviser said that if an abnormality is found in a test requested by a GP, then most hospital-based cardiologists would repeat the echocardiogram, so that not only can the hospital-based doctor review the images him or herself, but is also aware of the experience and training of the technician making the recording.

The adviser said that although Mrs C had two leaking heart valves, they were unlikely to affect her health in the future and did not account for her current symptoms. He also agreed with the board that it would not be appropriate for Mrs C to have heart bypass surgery. That said, the adviser said that it was not reasonable for the cardiologist to increase Mrs C's dose of ramipril (medication used to prevent high blood pressure and heart failure) based on a single blood pressure reading. The cardiologist had not taken account of the commonplace observation that when any patient meets a new doctor, particularly in a hospital setting, their blood pressure is elevated. It was also unclear why the cardiologist prescribed bisoprolol (a beta blocker used to slow down the activity of the heart), as the results of relevant tests that the cardiologist had requested were not available at that point.

We also found failings in the board's communication. The cardiologist should have explained the alterations to Mrs C's drug therapy to her and should have met her to explain why she required indefinite treatment with warfarin (a medicine that stops blood from clotting). The cardiologist also delayed in informing both Mrs C and her GP of test results. In view of these failings, we upheld Mrs C's complaint. However, we noted that the board had since addressed many of the communication failures, and had apologised to Mrs C for the poor communication when they later met her.

Mrs C also complained to us about the board's handling of her complaint. They had asked the cardiologist for comments on the complaint. The response was dismissive and failed to demonstrate that the cardiologist had reflected on the complaint and considered if any lessons could be learned. The board's response to Mrs C simply set out the cardiologist's views. There were also problems with the arrangements for a meeting that the board set up to discuss Mrs C's complaints with her. In view of all of this, we also upheld this aspect of Mrs C's complaint.

Recommendations

We recommended that the board:

• make the cardiologist aware of our findings;
• confirm that the case will be discussed at the cardiologist's next annual appraisal; and
• issue a written apology to Mrs C for the poor handling of her complaint.

Summary

When Mrs C joined the medical practice, she met the practice manager and expressed concerns about her experiences with her previous practices. In particular, Mrs C was concerned that the abbreviation 'DNR' was in her medical notes, as she believed that this related to a 'do not attempt cardiopulmonary resuscitation' order (a decision taken that means a doctor is not required to resuscitate the patient if their heart or breathing stops). The practice manager told Mrs C that in her records DNR stood for 'diabetic nurse review', and followed this up with a letter explaining, amongst other things, that there was nothing anywhere in Mrs C's medical records about not attempting cardiopulmonary resuscitation. Mrs C acknowledged that she had spoken inappropriately to the practice manager in a phone conversation, although she had apologised for this afterwards. Following a consultation the next month, the practice then decided to warn Mrs C about her behaviour. Before they could do this, Mrs C wrote to them seeking clarification about issues arising from her clinical notes. The practice then wrote back saying there had been an irretrievable breakdown between her and the medical and management staff, and asked the health board to remove her from their list.

Mrs C complained about the way the practice responded to her complaint and the way they removed her from their list. We found that it would have been reasonable for them to have warned Mrs C before removing her, and that they did not explain why they did not do so. We upheld her complaint about this, and made recommendations. We also took independent advice from one of our medical advisers regarding the practice's explanations about the queries arising from Mrs C's medical notes. As we found that these were reasonable we did not uphold Mrs C's complaint about this.

Recommendations

We recommended that the practice:

• review their practice and processes in relation to removing patients, including training for staff where appropriate;
• review their practice and complaints processes, including training for staff where appropriate; and
• apologise to Mrs C for the failures this investigation identified.