Upheld, recommendations

Summary

After Mr C's daughter (Miss A) was in a road traffic accident, paramedics took her to A&E at Ninewells Hospital strapped to a spinal board (a specialised stretcher, designed to protect patients with spinal damage). Mr C complained that the board then failed to adequately assess and treat Miss A, and said that she was not x-rayed at any point before she was discharged. Following her discharge she remained in significant pain and discomfort and Mr C took her to the family GP who, after a brief examination, referred her as an emergency to a different hospital. An x-ray taken there revealed a fractured vertebrae in Miss A's back and a CT scan (a scan that uses a computer to create an image of the body) revealed two further fractures.

We took independent advice from one of our medical advisers. He said that while the initial examination of Miss A was of a reasonable standard, a second more comprehensive examination should have identified the need for an x-ray of the spine. The adviser also said there was no record of Miss A's mobility having been assessed and that, as she was suffering pain in her abdomen, she should have been assessed for liver damage, given the speed at which the vehicle was travelling immediately before the crash.

In light of this advice we upheld Mr C's complaints, as we concluded that the board had failed to adequately assess and treat Miss A and had unreasonably failed to arrange for x-rays or scans to be taken of her spine.

Recommendations

We recommended that the Board:

• apologise for the failings identified in the care provided; and
• provide evidence that they have addressed the failings our investigation identified with the doctor responsible, through the staff appraisal process.

Summary

Miss C complained about her care and treatment when she was admitted to St John's Hospital for planned surgery. In particular, Miss C said that she had left hospital with an open wound, and was given inadequate post-discharge advice and care. She also complained about the care and treatment she received after being re-admitted nine days later with a severe wound infection, and said that her wound packing had been removed on the ward without adequate pain relief, and that packing was left in it.

During our investigation, we took independent advice from two of our advisers, one who is a specialist gynaecology consultant and another who is a plastic surgery consultant. The gynaecology adviser said that the operation appeared to have been straightforward but that Miss C was at high risk of infection. He found no evidence that prophylactic antibiotics (drugs that treat bacterial infection, given in advance of a procedure to reduce the risk of infection) had been given to Miss C during surgery, although he accepted that there might have been a reason for not doing so. He also said that she should have been given antibiotic therapy on discharge. However, he said that there was no evidence that she was discharged with an open wound.

After Miss C returned to hospital she had a further surgical procedure. The plastic surgery adviser was satisfied that the initial assessment and surgery were carried out to a high standard. He also indicated that it was routine practice to remove the wound packing on the ward, but noted that Miss C had not been given any additional pain relief for this procedure which can be traumatic and that this should have been considered. He also advised that it was unlikely that the full extent of Miss C's wound was observed during the procedure and that it was likely some of the large gauze swabs used as packing were left in the wound. We were critical of these apparent failures by the board.

We found nothing in Miss C's clinical records to indicate that at her pre-operative assessment she was given the information the board said she should have. There was also nothing to indicate whether it had been explained to Miss C that she was responsible for passing a discharge letter to her GP. We noted, however, that the board said they had already taken steps to remind staff of the importance of providing appropriate information and advice.

Recommendations

We recommended that the Board:

• apologise to Miss C for the inadequate care and treatment we identified, that she was not given adequate information about post-operative care at her pre-operative assessment, and that it was not properly explained to her that she was responsible for passing on the discharge letter to her GP;
• make relevant staff members aware of our adviser's comments and give them an opportunity to reflect on these for their future practice - in particular in relation to consideration of the use of prophylactic antibiotics both during surgery and prior to discharge, and the issue of pain relief and wound observation at dressing change; and
• provide us with evidence of the steps taken to remind staff of the importance of providing appropriate information and advice as stated in the board's response to Miss C's complaint.

Summary

Mrs C complained that communication from staff and the care provided to her husband (Mr C) in Caithness General Hospital were inadequate. Mr C had been taken to A&E after collapsing, and although Mrs C thought he had symptoms of a stroke, he was discharged. The board said that this was because Mr C did not want to stay in hospital overnight. He suffered a significant stroke shortly afterwards. Mrs C also complained about the nursing care after her husband was admitted to hospital, saying that when visiting him the next day she found him in a side room, lying on a mattress on the floor. She was distressed that Mr C's dignity was compromised, as he was not wearing pyjama bottoms.

After taking independent advice from one of our medical advisers and our nursing adviser, we upheld all Mrs C's complaints. We found that the junior doctor and the consultant physician involved did not give enough consideration to Mr C's diagnosis, particularly to the likelihood that he had suffered a minor stroke. Had they done so, it might have led them to have assessed the risk of this happening again and provided treatment if appropriate. However, our medical adviser pointed out that the outcome for Mr C might not have been different even had he been admitted to hospital at the start.

Although both the nursing staff and the doctors had indicated in the clinical records that Mr C did not want to stay overnight, there was no clear written information to show that they had recommended that he should be admitted before having an urgent scan in the morning. As the doctors had not indicated what they thought was wrong with Mr C, he would not have been aware of any potential risks in being discharged. We considered that the communication with Mr and Mrs C fell below a reasonable standard. We also found that the nursing staff should have told Mrs C before she visited that they were nursing Mr C on a mattress on the floor, to reduce the likelihood of him falling out of bed. The board had acknowledged that his care in terms of his dignity was unreasonable and had taken steps to address this with relevant nursing staff.

Recommendations

We recommended that the Board:

• draw to the attention of the junior doctor and the consultant physician our findings in relation to the lack of consideration given to Mr C's initial diagnosis;
• draw to the attention of the junior doctor and the consultant physician the importance of ensuring that communication about likely diagnosis is clearly explained to patients and their families where appropriate; and
• apologise to Mr and Mrs C for the failings we identified in Mr C's care.

Summary

Ms C, who suffers from mild cerebral palsy and epilepsy, complained that when she attended the Western Infirmary Glasgow following a fall, staff failed to take her concerns seriously and discharged her without taking an x-ray of her left knee. Ms C says she was told to carry out exercises, which she did, but the pain worsened and she returned to the hospital three days later to be told, following an x-ray, that her left knee had suffered a fracture.

In response to Ms C's complaint, the board apologised for the delay in the diagnosis of a left knee fracture and told Ms C that the member of staff involved had been asked to reflect on her practice and attitude. We contacted the board and were told that they had upheld Ms C's complaint that staff had not carried out an x-ray when Ms C first attended the hospital and that advice should had been sought from a senior member of the medical staff. The board also said that the member of staff involved did not follow recognised protocol and that all staff are required to have an up-to-date Knowledge and Skills Framework and a Personal Development Plan, both of which are used to ensure that staff are kept up to date in their clinical practice. We found that the board's response to Ms C was lacking in specific detail and did not make clear that her complaint had been upheld. The board's response also failed to include information about what action had been taken to prevent a repeat occurrence.

Recommendations

We recommended that the Board:

• apologise to Ms C for failing to make clear that her complaint was upheld and that appropriate action had been taken to help prevent a similar situation occurring in future.

Summary

Mrs C, who is an advice worker, complained on behalf of her client (Mrs A), whose late brother died during an investigative procedure in Glasgow Royal Infirmary. The complaint was about the way the board investigated Mrs A's complaint about her brother's care and treatment.

Mrs A complained to the board in July 2012 and two weeks later she and a friend met with members of the clinical, nursing and complaints team staff to discuss her concerns. Mrs A expected to receive a copy of the meeting notes shortly afterwards, but this did not happen. She chased this up over the next few weeks but did not receive the notes until October that year.

When Mrs A reviewed them, she found several inaccuracies and omissions according to her recollection of the meeting and sent the board a list of these in early November. She asked them for a final written response, so that she could escalate her complaint to us if necessary. This did not happen, although she had several more contacts from the board. Mrs C eventually complained to us in October 2013. The board eventually, and only after our intervention, provided an amended copy of the notes. Mrs A still thought that there were inaccuracies and omissions, and was confused by conflicting information about the board's process for investigating significant clinical incidents and how they are reported on the NHS system (known as Datix).

In response to our enquiries, the board said that the complaint file was closed in error after the meeting, so no automatic reminders were sent to the complaints team or the clinical staff involved in the complaint about the outstanding meeting notes.

Our investigation found that the board had not complied with the timescales in their own complaints handling procedure. We were concerned at the time taken, firstly to produce the meeting notes, and then to correct them. We were particularly concerned that we had to intervene before the amended notes were issued. It was also of concern to us that when Mrs A contacted senior members of staff because she had not received any response from the complaints team, they did nothing to progress this or assist Mrs A. We noted that the members of the clinical team that Mrs A contacted did not respond to her because they assumed the complaints team would do so.

Recommendations

We recommended that the Board:

• issue a written apology for failing to notify Mrs A of her right to complain to this office and the inconsistent explanations she received about the significant clinical incidents policy;
• take steps to review their procedures for preparing and issuing notes of complaints meetings to ensure they are issued to complainants as soon as possible after the meeting and that they address any concerns about accuracy appropriately at the time; and
• review the current Datix form and consider how best to reflect the outcomes for incidents which, following initial review, do not escalate to full investigation.

Summary

Mr C, who is a prisoner, complained that the prison health centre had unreasonably failed to explain why his complaints were being managed in line with NHS Scotland's policy for dealing with habitual and vexatious complaints. In response to our enquiries, the board confirmed that the prison health centre inappropriately applied the incorrect version of a national policy and said that the decision to manage his complaints in line with that policy had now been revoked.

In addition, Mr C said the board failed to respond appropriately to his complaint about the decision to manage his complaints in line with the policy. In response to our enquiry, the board said that they were not in a position to confirm that the steps taken by the prison health centre in responding to Mr C's complaint were appropriate, given that the prison health centre had implemented the incorrect policy.

In light of the information available, we upheld Mr C's complaints.

Recommendations

We recommended that the Board:

• take steps to ensure staff within the prison health centre are fully aware of the correct complaints policy and its procedures.

Summary

Ms C complained that Business Stream calculated her water charges using the historic rateable value (RV) of her premises. She explained that they had been revalued since then and the RV was now at a lower figure than that used by Business Stream. In Ms C's view, Business Stream's invoices were incorrect and too high.

Our investigation found that Business Stream's policy is to use the RV from 31 March 2000 unless the property has been built or modified since then. The RV may also be adjusted if the official RV has been successfully appealed. Business Stream took the view that, as Ms C had not provided evidence that her property had been altered, the default RV was being correctly applied.

We found evidence to suggest that structural modifications to Ms C's property led to an increase in the building's RV in 2005 and Business Stream were using this, as permitted by their policy. However, our investigation also established that the RV was significantly reduced in 2009 after a successful appeal by the landlord. We were critical of Business Stream for not checking and confirming this with the assessor, and for failing to amend Ms C's account so that charges were based on the lower RV.

Recommendations

We recommended that Business Stream:

• apologise to Ms C for calculating the drainage charges for her business incorrectly; and
• confirm the date that the rateable value appeal was upheld with the assessor, recalculate Ms C's account using the lower rateable value from that date and issue a refund for any overpayments.

Summary

Mr C's company owned several office units at one address and a series of warehouse units at another. He complained about the rateable value (RV) Business Stream used for charging his properties at the first address and also about his difficulties in resolving a separate billing query at the second.

We upheld both of Mr C's complaints. The key issue about the RV was whether Business Stream should use the valuation from 2000 or 2012. Their policy said that the RV from 2000 was the default – although there were exceptions to this – but they said that, in this case, they were entitled to use the 2012 valuation. Mr C maintained that, because the properties had not been physically modified since they were built and had simply been leased to one tenant, they were wrong to use the 2012 valuation. After considering the evidence, on balance, we took the view that Business Stream's use of the 2012 RV was not in accordance with their RV policy.

There had been a considerable amount of correspondence about the billing query involved in the second complaint. Mr C had been in touch with several staff members and there was a delay because of their initial view about the charges involved. Business Stream then made enquiries of their wholesaler and changed their view on this. Although the issue was resolved we found that, on balance, their administrative handling of this fell below a reasonable standard.

Recommendations

We recommended that Business Stream:

• recalculate and backdate Mr C's account based on the appropriate rateable value in line with their rateable value policy; and
• apologise to Mr C for the unreasonable delay in resolving his complaints about their charges.

Summary

Mr C, who is a prisoner, was placed on closed visits (where a prisoner and a visitor cannot make physical contact) due to his unacceptable behaviour. Mr C complained to us because he said the prison failed to review his closed visits status appropriately. He said he was not told that this was being reviewed, was not given the opportunity to make representations and was not told the outcome of the reviews.

In response to Mr C's complaint, the prison initially indicated that the correct process had been followed. We asked them to provide evidence to show us that this had happened. In response, they said that reviews of Mr C's closed visit status did take place. They could not, however, provide sufficient evidence to show us that this had actually happened, because the relevant paperwork was incomplete or unavailable. In the light of this, we upheld Mr C's complaint.

Recommendations

We recommended that Scottish Prison Service:

• apologise to Mr C for the failings identified in the prison's handling of the reviews of his closed visits status.
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Summary

Mr C phoned the council's Scottish Welfare Fund team to ask about applying for a crisis grant. The call handler said that he was not eligible because he was not in receipt of a qualifying benefit. Mr C then complained because he felt the call handler did not deal with his enquiries properly. In responding to the complaint, the council said they were sorry that Mr C was unhappy with the service, but confirmed that because he was not in receipt of an appropriate qualifying benefit, he was not eligible.

In response to our enquiries, the council told us that they did not process a claim for Mr C because it was clear he did not meet the relevant criteria for a crisis grant. They also said that, since then, the Scottish Government had relaxed the eligibility criteria and if he was now to apply with similar circumstances, they might be able to consider his application. We checked the Scottish Government guidance that was in place when Mr C contacted the council. This confirmed that those applying for a crisis grant should normally be in receipt of certain benefits. However, the guidance also said that the key test of eligibility for a crisis grant was the severity of the applicant's circumstances and the likely impact on them and their family. It also said that if an applicant was not in receipt of qualifying benefits, the council could make an exception to the requirement for this if they were satisfied that the person had no other means of support, and an award would avoid serious damage or risk to the health or safety of them or their family.

We found that in saying that Mr C was not eligible for a crisis grant the council effectively made a decision on his request. In addition, when the Scottish Government clarified the guidance, they did not relax the criteria. The guidance in place when Mr C contacted the council clearly said that the key test of eligibility was the need of the individual, not whether they were in receipt of a qualifying benefit, and that the authority had discretion to make an exception to that requirement. In light of this, we upheld Mr C's complaint and found that the council should have processed his application. Had they done so, Mr C could have accessed the review process after being told that he did not meet the criteria, which might have changed the outcome of his application.

Recommendations

We recommended that the council:

• apologise to Mr C for failing to handle his enquiries about a crisis grant appropriately; and
• remind staff administering the Scottish Welfare Fund that, if a person clearly wants to apply, they should process an application appropriately even if success is unlikely.
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