Upheld, recommendations

Summary
Ms C is an advocate for the sister of the late Mr A. Ms C complained that the care and treatment that two medical practices provided to Mr A was unreasonable.

Mr A had attended the first practice until March 2010, when he changed his registration to the second practice. At the time of the events complained about, the practices were independent of each other. The second practice has since taken over management of the first practice.

Mr A began to attend his GP at the first practice in July 2009, reporting recurring bouts of diarrhoea. Blood tests suggested that he had an infection of helicobacter pylori (a bacteria commonly found in the stomachs of middle-aged people which has been linked to ulcers and some stomach cancers). Mr A was treated with three different types of antibiotics and was advised to eat a bland diet. He continued to report symptoms of altered bowel habit, and then weight loss, as his food and drink options became more limited.

Mr A was eventually referred to hospital in February 2010, and was diagnosed the following month with Mantle Cell Lymphoma (MCL - a cancer of the white blood cells). He was treated by both his local NHS board and the specialist team at another board. In June 2011, he was told that his test results were clear.

In August 2011, however, Mr A's symptoms returned and he again visited a GP, this time at the second practice. Tests initially suggested that the MCL had returned. However, after a liver biopsy (where a sample of tissue is taken for examination in the laboratory), Mr A was told that he had a second type of cancer, incurable small cell lung cancer. This had already spread to his liver. Mr A died some three weeks later.

As part of our investigation, we took independent advice from a medical adviser. We found that in July 2009 the North East Scotland Cancer Co-ordinating and Advisory Group had issued guidance for GPs on the action to take and when to take it, when patients reported symptoms suspicious of cancer. A symptom that should have triggered an urgent referral to a specialist colorectal surgeon (a specialist in disorders of the stomach and bowel) was where a patient reported altered bowel habit for more than six weeks. Mr A had reported his symptoms for some seven months before he was referred. Even then, he was given only a routine referral to a general surgeon, rather than the urgent specialist referral described in the guidance. We upheld Ms C's complaint and made recommendations to address these failings.

Recommendations
We recommended that the practice:

• apologise for the failings identified;
• review a sample of clinical records from all GPs at both practices to assess the standard of record-keeping in line with General Medical Council guidance, and if deficiencies are found these are to be discussed at the GP(s) annual appraisal(s) and if necessary appropriate training to be undertaken; and
• ensure that all GPs in both practices are aware of and take cognisance of the local guidance on urgent referral of symptoms suspicious of cancer.

Summary

Mr C complained about root canal treatment that he had received. He told us that after it he was left with periodic pain for two years, and that he had to pay for corrective work to be carried out by a new dentist.

After taking independent advice from a dental adviser, we upheld Mr C's complaint. Our investigation found that the standard of treatment he received was inadequate. The adviser said that an x-ray taken after the treatment showed that the dentist had not completely filled the root canal, leaving space that could then act as a possible further source of infection, and that led to Mr C's problems. We also found that there was a lack of information in the dental records and no record of any discussion with Mr C of the options, risks or warnings given in advance of treatment. In addition, there was no evidence that x-rays taken had been graded or that any report on the x-rays was written.

Recommendations
We recommended that the dentist:

• apologise to Mr C for the failings identified in this case;
• refund the cost of treatment required by Mr C from another dental practice;
• ensure that dental records are in accordance with General Dental Council standards; and
• provide the Ombudsman with an undertaking that she would address the concerns raised in this complaint through her continuing professional development.

Summary
Mrs C complained about the care and treatment that her father (Mr A) received from the board during the four months it took to provide a definitive diagnosis of pancreatic cancer (cancer of the pancreas - a gland in the digestive system). Mr A had been attending his medical practice, and they referred him to hospital for a range of tests. When the test results indicated the possibility of pancreatic cancer, Mr A was referred on an urgent suspected cancer pathway (a route into further treatments which are not available to GPs directly) for a scan. Following this, his case was discussed at a team meeting, and he was referred on for another specialist scan. The results of this test were reviewed at further team meetings, which identified a need for a specialist form of endoscopy (a medical procedure where a tube-like instrument is put into the body to look inside). Mr A had to wait four weeks for this test, and was given a final diagnosis of pancreatic cancer four months after he first attended his GP. During his hospital visits, he was seen by a clinical nurse specialist three times, but never had a clinic appointment with a consultant.

We obtained independent advice on this complaint from two medical advisers. Their advice indicated that pancreatic cancer is difficult to diagnose, so it took several tests to get a diagnosis. In Mr A's case, there were no significant delays in delivering the tests or results. However, we upheld Mrs C's complaint as our investigation found that the lack of contact with a consultant indicated a lack of good patient care. Mr A's needs and concerns were not kept at the heart of the process, and this made it more difficult for him and his family to accept the apparently slow progress in reaching a diagnosis.

Recommendations
We recommended that the board:

• conduct a significant event analysis around the substance of this complaint, particularly in relation to the conduct and role of doctors and specialist nurse practitioner in the delivery of diagnostic service, taking into account our advisers' concerns on this issue;
• ensure that the findings of this complaint become a significant part of the relevant consultant's next appraisal; and
• issue an apology to Mr A for failing to provide him with appropriate care and attention while he was undergoing diagnostic tests.

Summary
Miss C had gastric band surgery (surgery to fit a band around the top of the stomach to help weight loss) some years ago, but was not offered supporting lifestyle therapy sessions at the time and did not achieve the weight-loss that had been expected. After moving to another area, Miss C sought further surgery through her new health board. As the board did not have a bariatric (obesity) service at that time, she was referred to another health board, and funding was approved for surgery and supporting therapy sessions. Surgery was agreed pending completion of the therapy sessions, but the specialist left and Miss C was referred back to her local board, who by that time had the facility to provide the required treatment.
 
Miss C was again identified as a suitable candidate for surgery, which was to happen when she completed the therapy sessions. However, the lack of a suitable dietician meant that the therapy sessions could not be completed, and so surgery could not go ahead. Miss C complained that the board referred her for surgery without ensuring that all the necessary services were in place.

We accepted that surgery could not go ahead without a fully funded multi-disciplinary service being in place, consisting of surgical staff, psychology and dietetics. Initially, Miss C was referred to a board that had such a service, but was referred back to her own board when the service was disbanded.

Our investigation found that Miss C was accepted there as a candidate for surgery and that, although there was still no bariatric service in place, a surgical place was allocated to her from an allocation set aside for patients on a pilot diabetes project. The board gave three separate reasons as to why Miss C did not receive her surgery: she failed to attend therapy sessions; there was no suitably qualified dietician available; and there was no fully-funded multi-disciplinary unit. We found that the board had agreed to allow Miss C another chance to take the therapy sessions and that there was a dietician in place, although they were not funded to work as part of a multi-disciplinary team. With regard to the lack of a multi-disciplinary team, we found that the board were able to provide this service to patients on the diabetes project, but not to those requiring surgery outwith that project. We considered that the board failed to look at Miss C's case by taking all her needs into account. Having agreed that she was suitable for the therapy sessions and surgery and that funding would be made available for this, they should have followed through on their agreement and funded the dietetic input that was required. We concluded that this was an administrative failing, which meant that Miss C could not access the support services that would have completed the assessment of her suitability for surgery.
 

Recommendations
We recommended that the board:

• prioritise the completion of Miss C's assessment and therapy sessions in line with the National Planning Forum's guidance;
• ensure that full multi-disciplinary funding is made available for the completion of Miss C's therapy sessions and any surgical treatment that she may subsequently be approved for in line with the clinical advisory panel's approval;
• apologise to Miss C for the delay in progressing her case; and
• provide the Ombudsman with details of how they intend to meet the requirements for multi-disciplinary assessment and treatment of patients in line with the National Planning Forum's guidance.

Summary
Mr C complained that he had not received adequate feedback from the college during his studies. As part of his complaint he said that as he had been unable to progress with his studies he had to enrol on his chosen course at another college. This meant that he had to undertake work he had already completed and had lost his student funding.

To investigate this complaint we made several enquiries to the college as well as considering information from Mr C. We also looked at the college complaints and assessment procedures. We carefully considered all the available information and found that the college had not followed its published procedures for giving students feedback. We asked the college about Mr C being unable to progress to the next year of his course. The college explained, and we saw evidence, that they had in fact offered him the opportunity to continue his studies with them.

We found that the college had not addressed one of Mr C's complaints. We also found that their record-keeping for his complaints was poor as they were unable to produce a report that they said had been written. This was contrary to their published procedure which said that they would keep accurate and complete records of all complaints received and the resulting correspondence, interviews and actions.

Recommendation
We recommended that the college:

• remind staff to ensure that all individual complaints are addressed, and of the need to keep accurate records in line with the college complaints procedure.

Summary
Mr C complained about the way he was treated by a prison officer in the reception area of a prison he was visiting.

He was unhappy with the prison's complaints handling, and in particular, felt the prison failed to investigate his complaint appropriately. He was also unhappy because the prison had not interviewed independent witnesses that he had identified.

The prison told us that, on receiving Mr C's complaint, a manager had been instructed to carry out enquiries. This involved interviewing the member of staff complained about and viewing closed circuit television footage. The prison said other members of staff were also interviewed. However, the prison could not provide us with evidence to support this. Following our enquiries, the investigating manager provided a statement instead.

We upheld Mr C's complaint, as we were concerned that the prison had not taken steps to interview the independent witnesses that Mr C identified in his complaint. Although the prison has discretion to decide whether or not to interview such witnesses, they should have explained to Mr C why they did not do so.

In addition, the prison told us that it was not normal practice to interview members of the public in relation to incidents. However, in our view, we considered that the prison should consider whether interviewing independent witnesses may or may not bring something new to the investigation, just as they would when deciding whether to interview members of staff who have witnessed an event. Doing so would ensure that investigations are seen to be fair and balanced, and that decisions are based on as much relevant evidence as possible.

Recommendation
We recommended that Scottish Prison Service:

• issue a proper apology to Mr C for the failings identified by our investigation.

   

Summary

Mr C, who is a prisoner, uses a mobility aid and has a heart condition. He complained that, despite having a disability, he was double cuffed (a more secure method of handcuffing) when being escorted from a holding cell to court. In response to the complaint, the escort service acknowledged that a risk assessment should have been carried out, but said that they could not be certain whether or not Mr C had been double handcuffed. In addition, they told Mr C that they would take further action to develop guidance for staff on how to deal with prisoners who have disabilities in such circumstances. 

We were unable to clearly establish what happened in relation to Mr C being handcuffed, but we upheld his complaint, as there was a failure to document that a risk assessment had been carried out to show that he had been safely and securely escorted.

Recommendations
We recommended that Scottish Prison Service:

• consider recording on a prisoner's record, after a prisoner has been escorted, the type of handcuffing style that has been used; and
• provide the Ombudsman with a copy of the new protocol on how staff should deal with prisoners who have disabilities.

Summary

Mrs C complained that the council failed to follow procedure when dealing with a noise nuisance complaint against her. She said the council did not provide her with a statement of complaint and did not allow her to read and sign their summary of the interview. She said she was not allowed to make her own statement or provide evidence to the council and that they decided to issue her with a written warning before they interviewed her. Mrs C also complained that the council failed to acknowledge or investigate equalities issues that she raised with them.

We upheld both of Mrs C's complaints. Our investigation showed that the information recorded at the time of the interview was very brief and that subsequent notes contained incorrect information on the complaint and failed to specify key details, including the actual times the incidents were alleged to have taken place. We, therefore, concluded that the council failed to provide Mrs C with the required details of the complaint against her. The evidence also suggested that Mrs C was not given the opportunity to read or sign a statement or summary of the interview. We noted, however, that Mrs C was given some opportunity to provide her version of events to council officers during the interview and that there was no evidence to suggest that she was not allowed to provide evidence to the council. There was also no evidence to suggest that the council decided to issue Mrs C with a written warning before the time of the interview. On the equalities matter, our investigation found that the council did acknowledge the equalities issues Mrs C raised but failed to take appropriate steps to investigate her concerns.

Recommendations

We recommended that the council:

• provide Mrs C with a written apology for unreasonably failing to follow their procedure when dealing with the noise nuisance complaint by failing to provide her with the required details of the complaint, and not giving her the opportunity to read or sign a statement or summary of an interview;
• feed back the failings identified in the noise nuisance issue to the staff involved;
• provide Mrs C with a written apology for failing to take appropriate steps to investigate the equalities issues; and
• feed back the failings identified in the equalities issue to the staff involved.
   

Summary
Ms C complained that the council failed to provide her with an adequate repairs service to her council property. She said that, since moving into her home in 2007, she had reported numerous problems requiring attention. She said that the quality of the repairs carried out by the council was inadequate and the repairs appointment service was poor.
 

Our investigation found that over the five years concerned there were some occasions when the council cancelled repairs appointments and others where they were unable to gain access to Ms C's property. Given the time period involved, the number of occasions where appointments were not kept, by either party, did not seem unreasonable. We noted that the council had explained that they had raised the issue of timescales for appointments with their staff, that further training would be provided and that they apologised for their failings in this area. They had also advised staff to ensure that all future repair work involved a suitable appointment to minimise disruption, and highlighted the need for better communication. In terms of the quality of the repairs, however, the evidence suggested that over an 18-month period there were numerous occasions when Ms C reported unsatisfactory repairs or inadequacies in the repairs service. We were concerned that the council did not appear to have a record of these reported concerns, when Ms C's emails clearly showed that she had made them aware of the issues at the time. Although we noted that in their responses to Ms C's formal complaint the council expressed concerns about the length of time it took for some repairs to be done and that they had highlighted this with staff, we upheld the complaint as the evidence suggested that the council did fail to provide Ms C with an adequate repairs service over this period.

In our decision on this case, we made reference to remedial action that the council said they had taken as a result of Ms C's formal complaint. When we asked them to provide evidence of some of this, they indicated that they could not do so. Where a council has investigated a complaint and found failings in the service provided, we would expect them to keep records of any remedial action taken and so we addressed this in our recommendations.

Recommendations
We recommended that the council:

• provide Ms C with a written apology for failing to provide an adequate repairs service;
• feed back our decision on this complaint to the staff involved;
• take steps to ensure that in future all reports of inadequate repairs are logged on their systems; and
• take steps to ensure that in future they keep documentary evidence of any remedial action taken as a result of their investigation of a complaint.
   

Summary
Mr and Mrs C complained that an alleged incident of bullying involving their daughter was not handled according to procedure, and that the council failed to fully deal with their complaint. Mr and Mrs C said that neither the school nor the council had followed their own policy in handling the alleged incident. They also said that they had only been told about the incident five weeks after the alleged event, and their daughter said that it had not been discussed with her. An inaccurate letter about bullying had also been kept on their daughter's file.
 

We upheld Mr and Mrs C's complaints. Our investigation found that the alleged incident was not investigated, the parents were not informed promptly and evidence was not gathered as laid out in both the council's and the school's anti-bullying policies. The school had also not reviewed its policy, as set out in the council's policy. We found that the council's investigation into the matter was inadequate as, although they acknowledged there were significant faults in the process followed by the school, they upheld the decision to retain the disputed letter on file. The evidence provided by the school did not demonstrate that they had followed policy. Additionally the council did not refer Mr and Mrs C to their complaints process, nor explain the stages and timelines they would work to.

Recommendations
We recommended that the council:

• apologise to Mr and Mrs C for failing to ensure that the anti-bullying policy was followed;
• share the outcome of the investigation with the school;
• review the decision to retain the letter about bullying on Mr and Mrs C's daughter's file;
• consider how they monitor the implementation of council policies; and
• apologise to Mr and Mrs C for the way in which their complaint was handled.