Upheld, recommendations

Summary

Ms C complained about the treatment her daughter (Miss A) had received from the Child and Adolescent Mental Health Service (CAMHS). She said that they had not responded soon enough when she and her daughter had expressed concerns about Miss A. Miss A experienced a significant deterioration in her eating behaviour, which coincided with a planned break from treatment, and a change in treatment staff. Ms C told us that she was concerned about her daughter's behaviour and weight loss, and while the staff did respond, by the time Miss A was referred to a specialist unit, she had to be hospitalised for re-feeding before she could receive treatment for her eating disorder. She felt that this significant deterioration in her daughter's health could have been avoided.

As part of our investigation, we sought independent advice from one of our medical advisers. Having taken this advice, we upheld Ms C's complaint on the basis that, while community-based approaches to eating disorders can be effective, they require a strong working relationship between family and staff. This should be in place before the situation becomes critical. Given the absence of such a relationship, the community-based approach was unlikely to be effective in Miss A's case. The absence of a risk assessment also meant that there was less scope for staff to correctly assess the situation when it became critical, and act accordingly. The family had to wait for over a month before Miss A was referred to a specialist unit, and during this time her weight loss continued and her condition deteriorated. We agreed that this could have been avoided if an eating disorder risk assessment had been in place.

Recommendations

We recommended that the board:

• develop a clear CAMHS protocol about the risk assessment of eating disorders;
• consider developing clear CAMHS guidelines on what situations merit priority and specialist referral; and
• provide information which will assure the Ombudsman that systems are in place within the CAMHS team to ensure that handover (including risk assessment) between health professionals is robust and documented to the standards required.

Summary

Ms C has type 2 diabetes. In July and August 2012 she attended, or was admitted to, hospital five times with swollen, painful legs. Deep venous thrombosis (DVT - a blood clot in a vein) was discounted and she was ultimately diagnosed as having cellulitis with some pitting oedema (an indentation on the skin that persists for some time after the release of pressure). After her last discharge, her GP advised her to stop taking the medication she had been prescribed, as she had neither DVT or cellulitis. He prescribed diuretic tablets (drugs that enable the body to get rid of excess fluid) which, Ms C said, remedied the problem. Ms C complained that the board failed properly to diagnose her condition and that she had been wrongly treated for cellulitis. She said that if the correct diagnosis had been made earlier, she would have improved sooner and spared unnecessary pain.

As part of our investigation, we obtained independent advice from one of our medical advisers. We carefully considered all the complaints correspondence and Ms C's relevant clinical records. The adviser said that, while the treatment given to Ms C was not unreasonable, overall there appeared to be a lack of clinical awareness. He said that although, throughout, she had pitting oedema, which indicated that diuretic therapy should be tried, it was not. The adviser said that if this had been tried earlier, it would likely have resolved Ms C's problem.

Recommendations

We recommended that the board:

• apologise to Ms C for failing to appropriately assess and treat her; and
• conduct a critical incident review into the circumstances in this case.

Summary

Miss C owed the university money because she had withdrawn from her course. She complained to the university about the way that a debt agency working on their behalf handled the recovery of her debt. She also complained that the university had not dealt adequately with her complaints and that communication from them was inappropriate.

We upheld Miss C's complaints. Our investigation found that she had raised several concerns with the university about the agency's handling of the debt recovery, but the university declined to respond to these and told her to continue dealing directly with the agency. We also found that the university's handling of Miss C's complaint was poor. We found that they failed to confirm receipt of her communications, missed agreed deadlines and provided inconsistent information. In addition, they sent communications to Miss C at an incorrect address and email account, even though she had provided the correct information.

Recommendations

We recommended that the university:

• apologise to Miss C for instructing her to continue to deal with the debt recovery agency;
• take appropriate action to reach an agreement with Miss C about repayment of the outstanding fees;
• apologise to Miss C for their unreasonable handling of her complaint;
• share our decision letter with relevant staff to remind them of the importance of timely responses to complaints, and of the need to explain and apologise to complainants if exceptional circumstances create delays in response; and
• review their procedures for assuring that external agencies acting on the university's behalf meet the relevant service standards, including putting in place monitoring arrangements.

Summary

Ms C complained that Business Stream had acted inappropriately in charging extra when a meter was discovered to be connected to her premises, in not notifying her earlier that there was a meter and in taking money from her account without prior notification.

During our investigation we found that, due to an error, Business Stream had failed to take action when they were notified that a meter was in place. The error was not identified until a few years later. Business Stream accepted that the change from an unmetered service to a full metered service had resulted in an increase in water charges. In line with legislation, they could backdate this for five years, but as a gesture of goodwill they decided to phase in the metered charges over a three year period rather than charging Ms C immediately for them. We found no evidence that Business Stream had failed to adhere to the direct debit guarantee, but we were concerned that Ms C's account was not changed to a metered service when Business Stream were first notified that there was a meter and that when the error was discovered they failed to contact Ms C.

Recommendations

We recommended that Business Stream:

• apologise to Ms C for the failure to take action in 2009 following notification that a meter had been installed at the property and and their failure to contact her when the error was discovered.

Summary

Mr C, who is a prisoner, complained that the prison did not properly test a powder found in his cell for the presence of drugs. Mr C said the powder was protein powder that he purchased through the prison. He asked for another sample of the protein powder to be tested, and for a sample of the powder that tested positive for drugs to be provided to his lawyer so that it could be tested independently.

In responding to our investigation, the prison advised us that they tested the powder found in Mr C's cell in line with the Scottish Prison Service's drug testing policy. However, the policy says that the prison is required to complete appropriate paperwork, and in Mr C's case, the prison did not do that. We also found that they failed to action Mr C's request that the positive powder be retained for his lawyer, and misled him by indicating that a sample of the protein powder provided by him had been sent away for testing, when it had not. Because of this, we were unable to determine with certainty whether the powder found in Mr C's cell had been tested properly by the prison and so we upheld his complaint.

Recommendations

We recommended that the Scottish Prison Service:

• in light of the failings identified, review the circumstances of Mr C's case with a view to determining whether appropriate corrective action should be taken;
• consider enhancing the presumptive drug testing policy by considering whether it would be appropriate for a prisoner to be present when the substance found in their possession is being tested for the presence of drugs; and
• issue a reminder to all prison establishments advising them of the obligation to adhere to the requirements of the presumptive drug testing policy.

Summary

Mr C, who is a prisoner, complained that there was an unreasonable delay in the prison referring him for a generic assessment (which identifies whether or not a prisoner should participate in offending behaviour programmes). In Mr C's case, in January 2012 the risk management team (RMT) considered whether he was suitable for progression to less secure prison conditions. They decided that he was not but said that he would be considered again at a later date. In November that year, another RMT considered Mr C's progression and again did not support this. However, the RMT said he should be referred for a generic assessment. Mr C complained that there was an unreasonable delay in the prison identifying him for that assessment.

The decision on whether to refer a prisoner for a generic assessment is a decision the prison is entitled to take. We cannot question a decision like that unless there is evidence of poor administration. In investigating Mr C's complaint, we found that the information available to the RMT in January was the same as that available in November. We recognised that members of both RMTs may have been different, but considered that Mr C could have been referred for a generic assessment in January. We took the view that the RMT unreasonably failed to exercise its discretion in January 2012 by not identifying Mr C for a generic assessment at that time. Because of this, we agreed that there was an unreasonable delay in referring him and upheld his complaint.

Recommendations

We recommended that the Scottish Prison Service:

• remind RMT members of the importance of identifying within a reasonable timescale the steps individual prisoners will be required to take in an effort to prepare for progression to less secure conditions.

Summary

Mr C lives close to a holiday chalet park. The park was first granted planning consent in 1985 but various amendments were later granted. In July 2010 the operator submitted an application to the council for retrospective planning consent. This was granted in March 2011, subject to four conditions.

In October 2011, Mr C contacted the council’s planning services, complaining that the park operator had delayed in complying with three of the four conditions and about an error in the other condition. Six months later, dissatisfied with the council's lack of action, Mr C tried to pursue a complaint through the council's corporate complaints procedure. He was dissatisfied with the handling of the complaint, and complained to us. At that time further matters of alleged unauthorised activity at the chalet park had arisen, but as Mr C had not pursued these with the council as a complaint, we could not look at those.

Our investigation upheld all three of Mr C's complaints, namely that there had been: unreasonable delay or failure to enforce planning conditions; a failure to adequately respond to Mr C's complaints and an unreasonable failure to investigate Mr C's subsequent complaints adequately. We upheld the last complaint because we found that Mr C's complaint to the council had not been dealt with. This was because the council had said that their corporate complaints procedures excluded matters about live planning applications, although this was not the case here.

Recommendations

We recommended that the council:

• reach a decision on the information received on a particular date from the agent;
• respond, without breaching confidentiality, to confirm the action they have taken with the owner in response to Mr C's reports of breaches of the planning conditions; and
• review the content of their enforcement charter and procedures on complaints to remove inconsistencies.

Summary

Mrs C complained that when her husband (Mr C) was airlifted to hospital after a heart attack, there was unreasonable delay in transferring him from the air transport into the hospital and in assessing his condition.

We upheld both Mrs C's complaints. Our investigation found that there was no ambulance available to transfer Mr C into the hospital. The health board and Scottish Ambulance Service were in the process of finalising a protocol under which patients could be transferred on a trolley in such circumstances. However, when Mr C was taken ill the protocol had not been finally agreed or adopted although the equipment required - such as a trolley and protective clothing and equipment - was available.

Our investigation identified that responsibility for a patient remains with the service until the patient is received in hospital. The ambulance staff involved in transporting Mr C were paramedics and provided evidence that they had offered to take clinical responsibility for transferring Mr C on a trolley. However, this offer was declined by a nurse from the hospital who was also there. It was about 40 minutes before an ambulance was available to transfer Mr C. In view of the offer made by the paramedics, we considered that it was unreasonable for Mr C to have had to wait this long.

With regard to the assessment of Mr C's condition, our independent adviser noted that she would not necessarily expect to find notes of an assessment made while a patient was the responsibility of another body. However, although we noted that responsibility remained with the service until Mr C was received at the hospital, the board had in fact indicated in their response that the nurse had assessed Mr C's condition. We found no evidence, however, that any such assessment was made.

Recommendations

We recommended that the hospital:

• apologise for the distress caused by the failings identifed; and
• ensure that all staff are aware of the amended policy for manual transfer of patients when ambulances are not available, in order to expedite transfer, assessment and treatment of patients.

Summary

Mr C complained that, when he attended a hospital clinic appointment, the doctor carried out a procedure without Mr C's consent. He said that he told the doctor that he could look at the problem only, but not take any action. He said that the doctor ignored his wishes.

When we investigated this, the board explained that the doctor and the health care assistant who were present were of the opinion that Mr C had agreed to the procedure. We found, however, that the doctor had not strictly adhered to the board's informed consent policy and had not explained what the procedure entailed, or recorded that Mr C had agreed to the procedure. We upheld Mr C's complaint and made a recommendation about this.

Recommendations

We recommended that the board:

• apologise to Mr C for the failure to obtain his informed consent.

Summary

Mr C had been prescribed nitrofurantoin (an antibiotic drug used to treat bacterial infection) for a number of years for a recurring infection. He was then diagnosed with pulmonary fibrosis (a rare condition causing scarring of the lungs), which is a known side effect of nitrofurantoin and the drug was stopped. He complained that his medical practice failed to review his long-term prescriptions of nitrofurantoin appropriately.

The British National Formulary (BNF) provides national guidance for healthcare professionals about the prescribing of medicines. The BNF entry for nitrofurantoin says that lung and liver function should be monitored where someone had been prescribed this long-term. In addition, the General Medical Council (GMC) provide prescribing guidance, which says doctors should ensure that they are familiar with the BNF guidance for medicines they prescribe.

Our investigation found that during medication reviews the practice should have consulted the BNF to look up the long-term effects of the drug that they were prescribing. They should also have asked Mr C if he was having any problems with his breathing and recorded his response to this in the medical records. There was no evidence in Mr C's medical records that they had done so. Mr C also complained that the practice failed to consider the possible implications when he presented several times with breathing or chest problems. We obtained independent medical advice on this and found that the practice had acted reasonably in response to the symptoms Mr C presented with. However, in view of the fact that the practice had failed to consult the BNF about nitrofurantoin, they were not aware of the possible implications of taking the drug on a long-term basis. We, therefore, upheld both complaints.

Recommendations

We recommended that the practice:

• apologise Mr C for the failure to consult the BNF during medication reviews or at any other time to look up the long-term effects of nitrofurantoin.