Upheld, recommendations

Summary

Mr C's GP referred him to hospital for a surgical opinion on the GP’s diagnosis of a hernia. When Mr C attended for his operation, a consultant surgeon examined him and decided not to operate as he could not detect a definite hernia. Mr C complained that the board failed to deal with his hernia appropriately. He was unhappy that he had spent money on transport to the hospital, and on accommodation in the local area, as he had moved away since being referred.

We looked at Mr C’s medical records and the information provided to him by the board, and obtained independent advice from our medical advisers. We found no evidence that the consultant surgeon misdiagnosed Mr C. Our advisers said that where there was uncertainty over a diagnosis, especially for a difficult to diagnose condition such as a small hernia, it would be unwise to proceed with surgery. We were, however, concerned that Mr C’s pre-operative assessment did not follow good practice or the board’s direct access hernia patient pathway. Nor could we find evidence that Mr C was warned that surgery might not take place when he attended the hospital. For these reasons, we upheld his complaint, and made a recommendation for a payment for the unnecessary inconvenience to which Mr C was put, linked to the costs of his visit to the hospital.

Recommendations

We recommended that the board:

• apologise to Mr C for failing to provide a reasonable level of pre-operative care;
• make a goodwill payment to Mr C; and
• review practice in the hospital's handling of hernia cases, to ensure that patients are adequately assessed before surgery and, where appropriate, cautioned that surgery may not proceed.

Summary

Mrs C's son (Mr A) suffered from epilepsy. When Mr A began feeling increasingly unwell, his GP had requested a scan. However, the hospital consultant declined to carry this out. A couple of months later, a specialist registrar saw Mr A. He also requested a scan, but again, the consultant declined. The following year, Mr A's condition was worse and he was seen by another consultant who recommended a change in medication. However, within a few months, Mr A died suddenly. Mrs C believed that if Mr A had had a further scan, the outcome for him could have been different. She said insufficient investigations were made into his worsening condition and that he had been prescribed medication which made this worse.

We obtained independent advice from one of our medical advisers, who is a consultant neurologist (a specialist in diseases of the nerves and the nervous system), and carefully considered all the available documentation and the relevant clinical records. Our investigation found that, generally, the care and treatment given to Mr A was appropriate. The reason that he was not recommended for a further scan was that some years earlier he had had an MRI scan (Magnetic Resonance Imaging - a scan used to diagnose health conditions that affect organs, tissue and bone), which showed only some evidence of brain atrophy (wasting away). Because of this, and because there were no new neurological symptoms, it was not necessary to repeat the scan. The clinical records showed that Mr A had been given advice about his drug regime and that recommended doses were proportionate to his symptoms.

However, our investigation also revealed that, some years earlier, nursing notes had recorded an abnormal EEG (electroencephalography - a technique that records the brain's electrical activity). This was never picked up in Mr A's clinical notes and the EEG had not been carried out again, as our adviser would have expected in the circumstances. Similarly, after a specialist epilepsy nurse lost phone contact with Mr A, no action was taken to contact him. We noted that, although Scottish health guidelines suggest that these specialist nurses should have continuing involvement with epilepsy patients, there was no evidence that Mr A had been referred back to them for help or review. We, therefore, upheld Mrs C's complaint that Mr A's treatment had not been reasonable.

Recommendations

We recommended that the board:

• formally apologise to Mrs C for the omissions; and
• emphasise to appropriate neurology staff, in accordance with the Scottish Intercollegiate Guidelines Network guidance, the importance for patients of the assistance of specialist epilepsy nurses.

Summary

Mr C, who is a prisoner, complained that it took five months for him to see a dentist. He was dissatisfied with the board's response to his complaint, in that they did not tell him what had gone wrong or what they would do to ensure this did not happen again. After Mr C asked to see the dentist, the healthcare team gave him an acknowledgement slip advising that he would be placed on the waiting list. However, a member of staff lost Mr C's paperwork and he was not listed to see the dentist. When the health care team became aware of the problem, they placed Mr C on the waiting list and he was later seen by the dentist.

We were concerned that during our investigation the board sent us conflicting responses about the guidance they were using as a standard for treating prisoners. This showed that there was confusion for their staff in relation to the standards they applied. We noted, however, that since taking over responsibility for NHS care in prisons, the board aim to have routine patients seen by a dentist within ten weeks. They also apologised to Mr C for the delay in his case, and told us that they would introduce a new appointments system to reduce the likelihood of this happening again.

We were aware that at the time of the complaint the Scottish Government had developed draft guidance for a robust framework for oral health improvement and dental services in Scottish prisons. This says that prisoners will have access to a dentist within ten weeks (the current target timescale). Whilst the board had apologised for the delay, we concluded that it was unreasonable for Mr C to wait 22 weeks to see a dentist and we upheld his complaint. We were satisfied that the board were introducing a new system but considered that they should have explained to Mr C what had gone wrong and the improvements they were making, in order to reassure him.

Recommendations

We recommended that the board:

• apologise to Mr C for failing to inform him that there had been an error in his paperwork being lost and the steps being taken to improve their appointment system;
• highlight to relevant staff that responses to complaints should contain information about what happened and any improvements identified, in line with the Scottish Government's complaint handling guidance; and
• provide a copy of their new guidelines once the Scottish Government's national guidance on oral health and dental services is published.

Summary

Mrs C's husband (Mr C) was referred to hospital by his medical practice because he was suffering from fatigue and shortness of breath on exertion. He had some tests, but it was not until almost five months later that he was diagnosed with lung cancer. Mr C died shortly after the cancer was diagnosed. Mrs C said that her husband had a complicated medical history, but she was concerned that there appeared to be a lack of urgency by the hospital in establishing the cause of his symptoms.

To investigate the complaint, we carefully considered all the relevant documentation, including the complaints correspondence and Mr C's medical records. We also took advice from one of our medical advisers, who is a consultant in respiratory medicine.

We upheld Mrs C's complaint. Our investigation found that there was a three week delay before Mr C was seen at the respiratory clinic and, later, it took four weeks for the GP specialist's urgent referral request to be seen by the hospital's consultant respiratory consultant, although the reasons for this could not be established. After Mr C was seen, there was then little urgency in dealing with him. Our adviser confirmed that although an earlier appointment would have led to an earlier diagnosis, the outcome for Mr C would not have been different. However, Mr C would have had more time for palliative care (care to prevent or relieve suffering), which would have alleviated his pain and discomfort.

Recommendations

We recommended that the board:

• make a formal apology to Mrs C for the delay and lack of urgency; and
• ensure that, where cancer is suspected, there is a robust cancer pathway in place in accordance with the Scottish referral guidelines for suspected cancers.

Summary

Ms C complained about her care and treatment during the birth of her son. In particular, she was concerned about the attitude of the midwife - she said that the midwife had snapped at her, had not listened to her and had not explained what was happening. She was concerned that the actions of the midwife had almost cost her son's life.

Our investigation took into account all the available information, including the complaints correspondence and the relevant clinical records. We also obtained independent advice from a medical adviser. We found that the board had already accepted that there had been a failure in communication and had taken action to address this and had apologised to Ms C.

Overall we found that the level of care provided was adequate and safe and that there was nothing in the clinical records to suggest that a different course of action should have been taken. However, we were concerned that Ms C's blood pressure or pulse were not taken as required. We were also concerned that record-keeping was not to an acceptable standard, and that the failure in communication, in particular the failure to explain what was happening, had added to Ms C's concern that her baby was at risk. We upheld Ms C's complaint and made relevant recommendations.

Recommendations

We recommended that the board:

• bring the failures identified in this investigation to the attention of the relevant midwife; and
• undertake an audit of record-keeping at the maternity unit to ensure that their record-keeping is in line with Nursing and Midwifery Council guidance.

Summary

Miss C complained to us on behalf of her son (Mr A) about the way his college treated him. Mr A has a developmental disorder and behavioural symptoms, and Miss C was concerned that the college had put in place additional requirements before accepting him on to a course, after he had withdrawn from previous courses.

Mr A withdrew from his first two courses without completing them. When he withdrew from the first course, he was assessed to identify any learning support needs. The assessment found that he would benefit from support and he was encouraged to seek this with his next course. However, Mr A did not do so, and again withdrew before completing the course. Shortly after he enrolled for a third course, he had to withdraw on medical grounds. However, he applied for the same course the following year. At this point he was told he had to complete an additional module before he could gain a place on this course, to show he could commit to a full course.

We took independent advice on this case from our equalities adviser, who said that the college needed to put in reasonable adjustments relating to Mr A's support needs during his college courses. Given Mr A's disabilities, the adviser considered that the college had not done enough to support him during his first two courses. She also noted that the level of support was less than that indicated by the college's policies.

In reviewing the evidence available, we found that Mr A had withdrawn from the third course on medical grounds, and that he had done so early enough for his place to be allocated to another student. We also noted that he and his mother had moved house to facilitate his access to the college. However, the college had no evidence relating to any discussions with Mr A at the time, either in relation to why he was withdrawing, his circumstances or what this might mean for any new application for the course. There was also no evidence that they provided appropriate guidance at this time, as required by their policies.

We upheld Miss C's complaint as we found that the college did not provide sufficient support to Mr A during his courses, and we were critical of the lack of evidence of discussions at that time or of any proactive offer of support. We also found that the college failed to take account of Mr A's full circumstances in their decision on his later application, and concluded that they had inappropriately put in place an additional requirement for him to achieve before he could access the course.

Recommendations

We recommended that the college:

• review their policies and procedures to ensure that it is clear to staff when reasonable adjustments should be considered for students with disabilities;
• consider Mr A's current application for a place on the course in light of this decision;
• ensure that significant interactions between students and staff relating to withdrawals from courses are suitably documented; and
• apologise to Mr A for the failures identified in our investigation, and to Miss C for the time and inconvenience caused in bringing this complaint.

Summary

Mr C complained that for three years Business Stream had failed to read the meter for a village hall run by a committee of volunteers. As a result Mr C had been unaware that the hall had two meters and that there had been a significant increase in consumption. Once the committee were made aware of the increased consumption they took steps to reduce it.

During our investigation we discovered that, during the three year period, Business Stream had taken meter readings for the hall but in the year before the high consumption occurred they had not taken two actual readings. In addition they had only issued invoices for one meter and had incorrectly identified its location.

As a result Business Stream had addressed the accuracy of the location of the meter and had decided not to backdate the second meter charges to when it was installed. However, we considered that had the invoices accurately described the location of the meter Mr C would have been able to identify that there were two meters instead of one and would have had the opportunity to monitor them. Because Business Stream had not read the meters in line with their policy we were unable to identify when the increase in usage occurred, and we made a recommendation about this.

Recommendations

We recommended that Business Stream:

• apologise for the failings identified in our decision letter; and
• consider crediting the account with an amount equivalent to 50 percent of the increased water usage during a specified period.

Summary

Mr C, who is a prisoner, complained there was an unreasonable delay in the prison finalising his report after he completed a treatment programme. Mr C said the delay in completing the report meant he was prevented from undertaking any further work required before the parole board review his case.

The Scottish Prison Service (SPS) told us that Mr C's report should have been finalised 16 weeks after he completed the programme. However, it had still not been completed four months after that. They explained that the facilitators were new to delivering the programme, and writing reports, and that this had impacted on timescales. In addition, before a decision could be reached on whether Mr C was required to undertake further programme work, his completed report needed to be considered by the prison's programmes case management board (PCMB).

As Mr C's case is due to be considered by the parole board in early 2014, we agreed the delay in completing his report was unreasonable. We upheld his complaint and made recommendations.

Recommendations

We recommended that the SPS:

• complete Mr C's report as a matter of urgency and ensure it is ready to be considered by the PCMB without further delay; and
• prioritise Mr C's access to any further programme work that may be identified by the PCMB.

Summary

Mr C complained to the council about a statutory notice that had been served on his property, and for which the council had told him he was now liable. He was unhappy at having to pay as he said he and his solicitors had tried to find out more from the council about this, both before he bought the property and since, without success. He had a lot of communication with the council about this, and was also unhappy with the advice they gave to solicitors acting on his behalf and how they handled his complaint. He was dissatisfied with the council's responses and complained to us.

We found that the council's responses did not reasonably address his complaints, that their responses to his enquiries about the matter had been unreasonable, and they did not make clear what an apology they provided was related to. Given this, we upheld the complaint.

Recommendations

We recommended that the council:

• apologise unambiguously to Mr C for the poor standard of their communication with him;
• reflect on how the situation came about that Mr C was advised that a manager would be made aware of his contacts and would return calls as a matter of urgency at a time when he had been on holiday, and whether action requires to be taken to ensure this cannot be repeated; and
• remind all staff to ensure that all matters raised by complainants are clearly acknowledged and responded to at all stages of the process.

Summary

Ms C had complained to the council about antisocial noise in her building. This had been a problem for some time and she felt that the council had failed to address the underlying issue. A flat that was the source of some of the noise was owned privately with a high turnover of tenants, and Ms C said that this contributed to the ineffectiveness of the council's approach as she felt that it had been addressed on a 'tenant-by-tenant' basis, rather than as a continuing issue. She was also dissatisfied with the way that the council handled her complaint and their responses, and she raised her complaints with us. We explained that we did not have the legal power to address the alleged antisocial behaviour on her behalf. However, we did consider the way that the council had handled her complaints.

Although Ms C questioned the council's reasons for handling matters in a certain way, this in itself, does not automatically mean that they mishandled her complaint. For example, the council had provided explanations and, although Ms C did not agree with them, these had explained the council's position. When we reviewed the correspondence, however, we felt that it indicated that the long-term problems had had a significant and distressing effect on Ms C. We took the view that the council's responses did not appear to have taken this into account, and we noted that there were delays in replying. We found they had also failed to keep Ms C updated about how matters were being progressed and so, on balance, we agreed that the council failed to deal with her complaint appropriately.

Recommendations

We recommended that the council:

• reflect on their complaints handling at stages one and three, and advise the Ombudsman of any action taken (over and above their new complaints process) to ensure that in future complaints will be handled more appropriately; and
• apologise to Ms C for not keeping her informed of what was happening about her complaint.