Upheld, recommendations

Summary

Mr C had a a temporary dental bridge put in place while he was abroad. He complained that the board delayed in providing appointments after his dentist referred him to the dental institute for a treatment plan to replace it. Mr C said that the delays resulted in additional damage to his teeth, which meant that his preferred treatment plan was no longer possible. In response to the complaint the board said that Mr C had been seen twice within the guaranteed waiting time of 12 weeks for an out-patient appointment.

We confirmed that Mr C's first appointment was within the national waiting time target for new out-patient referrals. Although the institute agreed the treatment plan at this appointment, one of Mr C's teeth then fractured, so his dentist had to refer him there again because it affected the new bridge design. We did not consider that it was reasonable for Mr C to wait a further 13 weeks to have his original treatment plan reviewed, and we upheld his complaint. However, after taking independent advice from our dental adviser, we noted that his tooth could have fractured at any time, even if the new bridge had been in place.

Recommendations

We recommended that the board:

• apologise to Mr C for the delay in his treatment plan being re-assessed; and
• consider reviewing the referral process so that patients who require their original treatment plans to be reviewed are seen in a timely manner.

Summary

Mr C complained on behalf of his late aunt (Mrs A) who was admitted to hospital from her nursing home with sudden pain in her legs. She had been previously diagnosed with dementia (her solicitor held welfare power of attorney) and chronic peripheral vascular disease (a long-term condition where the blood supply to the leg muscles is restricted). Mrs A was prescribed medication for pain and agitation and discharged back to the nursing home the next day. The hospital wrote to her GP and the nursing home detailing her care and said that the vascular surgical team felt that this represented an acute episode of her long term vascular disease, but had decided that surgery was not in her best interests and she should be treated with simple pain relief. They said Mrs A had complained of some pain before discharge and it was decided that this would be better controlled in her normal environment at the nursing home. The nursing home, meanwhile, had identified that Mrs A needed morphine on the day of her discharge and three days later, for the first time, there was an entry in her medical records about palliative care (care purely to prevent or relieve suffering). She was prescribed additional medication for palliative care on the following day, and the nursing home requested more morphine for her. Mrs A died six days after being discharged from hospital.

Mr C said that Mrs A's GP, nursing home and solicitor all knew that she was terminally ill when she was discharged from hospital and that this diagnosis was made while she was a patient there. Mr C said that within a few days of Mrs A being discharged, the GP told Mrs A's solicitor that she had a major inoperable blood clot in one of her main arteries and was being kept comfortable at the nursing home, but that otherwise nothing beneficial could be done and that the 'time-frame' could be days. Mr C also complained that the board failed to provide him with a proper answer about why Mrs A was not immediately referred for palliative care.

After taking independent advice from a medical adviser, who specialises in care of the elderly, we upheld Mr C's complaints. The adviser said that the care and treatment in relation to diagnosis, discharge, communication and record-keeping was below a reasonable standard and impacted adversely on the board's decision-making about palliative care. Mrs A was a vulnerable adult, and we found that the clinicians underestimated her symptoms and their severity and significance, leading to an inaccurate diagnosis and a failure to meet her palliative care needs. We also found that the board failed to provide a detailed explanation of the clinical thinking at the time of Mrs A's discharge to justify their position, which would have added to the distress of Mrs A's family.

Recommendations

We recommended that the board:

• ensure that the failures identified are raised as part of the annual appraisal process of relevant staff;
• review the admission of older adults to assess whether staff have sufficient expertise (such as consultant geriatricians) to assess such patients;
• bring the failures in record-keeping to the attention of relevant staff;
• bring the failures identified in this investigation to the attention of the board's complaints team; and
• apologise for the failures identified this investigation.

Summary

Following a stroke, Mr C's late aunt (Mrs A) was transferred to a hospital for rehabilitation and discharge planning. Mrs A's solicitor had welfare power of attorney for her. Mrs A had a degree of cognitive impairment (a condition that affects the ability to think, concentrate, formulate ideas, reason and remember), which got worse while she was in hospital. Several months later, Mrs A was discharged to a nursing home. Mr C complained about the way the board discharged his aunt, which he said was done too quickly and without input from her family or her advocate, and about the handling of his complaint, including that the board inappropriately contacted Mrs A's solicitor about it.

We took advice on this complaint from one of our medical advisers, who specialises in mental health. Our investigation found that the views of Mrs A and her family were not fed into the decision-making process, contrary to the board’s discharge policy, and that Mrs A was denied the opportunity to visit the nursing home before being discharged there. Her family were not kept updated and there is no evidence that the board made Mrs A, her welfare power of attorney or her family aware of her right to independent advocacy. Finally, the principles underpinning the Adults with Incapacity Act were not adhered to - as Mrs A was unable to give informed consent to treatment or to make reasoned decisions, a certificate of incapacity should have been completed and the interventions being authorised should have been set out in a care plan.

We were satisfied that the board acted properly when they told Mr C that they could not release confidential information about Mrs A without her or her solicitor's consent, because the solicitor had welfare power of attorney. However, our investigation found that early in the complaints process the board were aware of information that brought Mrs A's capacity to consent into question. We were, therefore, critical that they did not make Mr C aware of this until some five months later, after he had obtained and sent Mrs A's consent to his complaining on her behalf. Although the board provided detailed responses to Mr C's concerns, we noted delays and inaccuracies in these (particularly around Mrs A's reaction following her visit to another nursing home).

In relation to the board's handling of Mr C's complaint, we were satisfied that their actions were reasonable in light of the legal advice they received. They carried out several investigations, including having an independent healthcare professional review Mrs A's care. Mr C was disappointed that a senior official was not available to meet him when he arrived at their office (having travelled from abroad), but the board had made no arrangements to meet him at that time. Instead, they met him the following month, and although they withdrew their offer of a teleconference (following legal advice), this was not in itself evidence of maladministration. Finally, the board properly referred Mr C to the council for a response about his concerns relating to the actions of the social workers involved in his aunt's discharge.

Mr C was unhappy that the board had potentially breached confidentiality by seeking comments from Mrs A's solicitor about his complaint. It is not for us to decide whether there has been a legal breach in relation to data protection, but we can consider whether the board's actions were reasonable in the circumstances. Normally, when a family member complains on an individual's behalf, health boards do not directly contact the individual affected by a complaint, rather they would tell the family member they needed to get consent from the individual before the board would look at the complaint. In this case the board contacted the solicitor who was speaking for Mrs A, which was the equivalent of contacting Mrs A herself. Our view was that the existence of a welfare power of attorney did not mean there should be any change to the normal practice, as there are good reasons for that practice and we were aware of no reason why this situation required an unusual approach. We were critical that the board contacted the solicitor about Mr C's complaint, which would not have occurred under ordinary circumstances. We upheld both Mr C's complaints and made recommendations for improvement.

Recommendations

We recommended that the board:

• ensure patients who lack capacity are treated in line with the relevant legislation;
• inform patients with dementia and their families of the right to independent advocacy (and how to access the service) and ensure advocates are given the opportunity to express the views of their clients;
• review their complaints handling procedures in the light of this complaint to ensure that communication with families and/or individuals with welfare power of attorney are appropriate; and
• make a further apology to Mr C in light of the findings of our investigation.

Summary

Ms C complained on behalf of her brother (Mr A). In April 2012, Mr A was admitted to hospital as an emergency suffering from an arteriovenous malformation (AVM - an abnormal collection of blood vessels in the brain where bleeds can occur, and which can be life-threatening). There are three approaches to treat an AVM, two of which the hospital considered, but thought unsuitable. Mr A was then discharged and told that he would be referred to a hospital in England for the third type of treatment. Ms C complained that there was an avoidable delay in providing this.

As part of our investigation, we took independent advice from one of our medical advisers, who is a consultant neurosurgeon. Evidence obtained during the investigation showed that on admission, Mr A's treatment was appropriate and reasonable as were the attempts to address the AVM. We found that the three types of treatment were options (not requirements) and that Mr A's case had been appropriately referred to the English hospital for consideration, although after a long delay. Ultimately, that treatment was also found to be unsuitable, as in the clinicians' view, it could cause more harm than good. (This had not been Ms C's understanding, as she had thought the treatment was essential.)

After careful consideration, although no treatment was ultimately available to Mr A, we upheld the complaint because of the avoidable delays in referring his case on for consideration.

Recommendations

We recommended that the board:

• formally apologise to Ms C and her brother for the delay and confusion over his referral;
• review referrals within the department of neurosurgery and satisfy themselves that these are made in a timely manner and that communication is clear; and
• review the situation in the department of neurosurgery with regard to discharge letters and satisfy themselves that they are typed and issued within appropriate time limits.

Summary

Mr C complained to the medical practice about the treatment that his late wife (Mrs C) received for gout. A GP had prescribed tranquilisers instead of painkillers. After two weeks Mrs C started losing skin on her hands and the GP reduced the medication. Mrs C was later admitted to hospital, where she died, with the cause of death stated as kidney failure and diabetes. Mr C said that his wife should have been admitted to hospital sooner, as she was passing blood.

Although we noted that this was a complex medical case, we upheld Mr C's complaint. After taking independent advice from one of our medical advisers, our investigation found that there was a lack of documentation in the GP records about Mrs C's deterioration in the weeks before she was admitted to hospital. There was also a failure to check her kidney function in view of medication that had been prescribed, and the practice should have referred Mrs C for a specialist opinion or hospital admission sooner.

Recommendations

We recommended that :

• conduct a significant event audit to see if lessons can be learned from this complaint;
• apologise to Mr C for the failings identified in our report; and
• ensure that the GP concerned revises the presentation of acute renal failure and management of hypertension and discusses the case at his next appraisal.

Summary

Mr C complained on behalf of a company who obtained planning consent from the local council to open a food processing site close to their main site, which is on a river estuary. The main site had inherited a deep water outfall from its previous use as sawmills, which was controlled by the Scottish Environment Protection Agency. The company intended, as an interim measure, to transfer effluent by tanker from the secondary site to the main site while a pipeline was constructed between the two. However, this did not prove necessary and from the first day of operations, effluent between the two sites was pumped by pipeline and the trade effluent was never released to the Scottish Water waste water network.

There is provision (process 27) in the arrangements between licensed providers and Scottish Water for a licensed water provider to submit a trader information and allowance form for a 'non-return to sewer' allowance in cases such as this. As Scottish Water do not grant retrospective consent, the licensed provider (in this case, Business Stream) should seek the relevant information from the customer in advance and submit it to Scottish Water for approval. This did not happen here, although the allowance was later given from April 2012. We upheld the complaint that Business Stream unreasonably delayed in advising the company to submit the form, and we made a recommendation about this.

Recommendations

We recommended that Business Stream:

• further consider reimbursing the company for waste water charges for the period from the commencement of their operations at the secondary site until 11 April 2012.

Summary

Mr C, who acts for an organisation in relation to their water costs, complained that following the discovery of a meter that supplied the organisation's office, Business Stream's charging had been inaccurate. The office received water from a private water supply, a water tower, which also supplied other properties. In the past, Business Stream only charged for waste water that the office discharged into the sewerage system. These charges were based on the rateable value of the property.

However, a metered water supply was then discovered. It was originally considered that this only supplied the office Mr C was representing and Business Stream started to charge for water and waste water based on this metered supply. This increased the water charges substantially. Mr C disputed the fact that this meter only supplied the office he represented. This was investigated and it was agreed that this was a back-up supply, which was in fact connected to the water tower and not the office. Business Stream's charging based on their view that the meter only supplied the office was, therefore, inaccurate.

Mr C also said that the landlord of the water tower was paying a fixed waste water charge in relation to the meter, and the organisation he represented was paying a fixed charge and volumetric charge for unmetered waste water supplied from the water tower. Business Stream's view was that it was appropriate that there were two separate fixed waste water charges; one for the back-supply for the water tower and the other for the private supply for the properties supplied by this. Business Stream had contacted Scottish Water who confirmed that there should be waste water charges for both the private supply and the metered supply. We were satisfied that Business Stream had considered the information Mr C had presented to them in relation to this and that they had consulted Scottish Water on this matter. We did not identify any maladministration in relation to Business Stream's decision on this. Where a body have discretion to make this kind of decision, we cannot question that decision if there is no evidence of maladministration.

However, the specific complaint that Mr C asked us to investigate was that, following the discovery of a meter which supplied his premises, Business Stream's charging had been inaccurate. In view of the fact that we found that the charging had been inaccurate, we upheld his complaint.

Recommendations

We recommended that Business Stream:

• issue a written apology for charging the property inaccurately following the discovery of a meter.

Summary

Mr C complained about a bill he had received from Business Stream, and about their handling of his complaint. Mr C had disputed a meter reading, claiming that it was impossible for the amount of water billed to have been used. He had been told that his account would be put on hold. Despite this, Business Stream took full payment of the invoice. Business Stream then failed to investigate the matter, despite repeated requests from Mr C over two years. Neither did they investigate the complaint properly until we prompted them to do so.

We found that the passage of time meant that it was impossible for us to establish whether or not the disputed amount of water had been used. There were, however, significant failings by Business Stream in the way that they handled the complaint. Our recommendation for financial redress was calculated as a percentage of the bill, to reflect the poor service they had provided.

Recommendations

We recommended that Business Stream:

• apologise to Mr and Mrs C for the failings identified in our investigation; and
• pay Mr and Mrs C £450 by way of financial redress for the failings we identified.

Summary

Mr C, who is a prisoner, declared to the prison that he was Jewish and asked to be provided with a kosher diet. The prison told Mr C that he would only be provided with this after he met with a rabbi. Mr C refused to do so and because of that, the prison did not agree to provide him with the kosher diet. In bringing his complaint to us, Mr C said the prison were not allowed to insist that he meet with a rabbi and their refusal was inappropriate.

The prison rules confirm that a prisoner must be treated as having a particular religion, belief or non-belief if they declare so at any time. In addition, the prison rules say that the prisoner is not obliged to give any information about having a particular religion, belief or non-belief. The prison rules also confirm the governor should, as far as practicable, provide a prisoner with food which takes into account their age, health and religious, cultural, dietary or other requirements. We asked the Scottish Prison Service (SPS) to confirm whether any rule or other policy existed that gave prison staff the authority or discretion to assess and test whether a prisoner had shown or was showing evidence of their declared religion. The SPS confirmed that no such rule or policy existed. In light of this information, we concluded that the prison had breached prison rules by insisting that Mr C had to meet with a rabbi before his dietary needs would be met. The prison were not entitled to do so and because of that, we upheld Mr C's complaint.

Recommendations

We recommended that the SPS:

• issue guidance to all prison staff reminding them of the requirements of prison rule 13 and its practical implementation; and
• apologise to Mr C for the failings identified by his complaint.

Summary

Mr C, who is a prisoner, submitted a complaint to the prison prior to his transfer to another establishment. He had escalated the complaint to the internal complaints committee (ICC) but they did not convene until the day after Mr C's transfer, so he was not given the opportunity to attend. He felt that the prison had adequate opportunity to convene the ICC before he left and, failing that, he complained that they did not explore the use of video link facilities to allow him to take part remotely. He said that his requested witnesses were not called to the ICC, but that the chairperson had not recorded that he had considered these requests and deemed the witnesses to be of no relevance or value, as he was required to do under the prison rules. Mr C also noted that the ICC appeared to have had only two members rather than the required three and that the governor did not countersign the complaint form within the 20 day target timeframe.

In responding to our investigation, the prison explained that, although they had been aware of Mr C's transfer several days before the ICC, the chairperson had not been personally aware and the need to prioritise the hearing had been overlooked. They confirmed that the video link facilities at the prison were not operational at that time. They also confirmed that the ICC had three members but the third member left before signing the form. The prison acknowledged that they had not adhered to the rules in considering Mr C's witness requests and accepted that the governor did not sign the complaint form in the required timeframe. They told us that they had emailed managers reminding them to ensure that ICCs have three members. They also confirmed that, since Mr C complained, they had begun logging when complaints are passed back for the governor to sign. They said they would apologise to Mr C for these failings.

We considered it reasonable that a member of staff not directly involved in a prisoner's transfer ie the ICC chairperson, might not have been aware of the impending transfer. We, therefore, understood why this might have been overlooked in the context of the complaints process. We also accepted that video link facilities were not available at that time. However, we were critical of the handling of Mr C's request to call witnesses, of the failure to have the complaint signed off by three ICC members and of the delay in the governor signing off the complaint. We upheld his complaint and asked the prison to provide evidence of the actions that had been taken to address these failings.

Recommendations

We recommended that the Scottish Prison Service:

• apologise to Mr C for the identified failings in the handling of his complaint.