Upheld, recommendations

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 former 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.

We considered that the practice should have asked Mr C if he was having any problems with his breathing when they were reviewing his medication and that they should have recorded his response to this in the medical records. As there was no evidence in Mr C's medical records that they had done so, we upheld his complaint.

Recommendations

We recommended that the practice:

• apologise to Mr C for failing to record whether they had asked if he was having any problems with his breathing when they reviewed his medication.

Summary

Mr C raised a complaint about how a dental practice had handled his representations about treatment that he had received by a dentist at the practice. Although it was difficult to establish the exact sequence of events after Mr C complained, our investigation found that the practice had not handled his complaint in line with their complaints procedure and we upheld his complaint.

Recommendations

We recommended that the practice:

• review their procedures to ensure they deal with complaints in accordance with the NHS complaints procedure; and
• apologise to Mr C for their handling of this complaint.

Summary

Mr C's mother (Mrs A) collapsed at home, and was taken to hospital as an emergency. She was transferred to a ward at 15:50 and was assessed at 23:00. Early the next morning there was a marked deterioration in Mrs A's condition, and she was suspected to have suffered a stroke. Mrs A's condition continued to decline and she died that evening.

Mr C complained about his mother's care and treatment and questioned whether she was given any treatment when she was initially admitted to hospital. He was unhappy that she was not properly assessed until late at night by which time, he said, her condition had deteriorated and she had become confused. He was concerned that her anticoagulant medication (used to prevent blood from clotting) had been stopped and considered that this could have led to her stroke. Mr C was also concerned that in responding to his complaint, the board said that cancer could have been a contributing cause to Mrs A's death. He complained that this possibility had never been raised with him before.

Our investigation took account of all the available information, including the complaints correspondence and the relevant clinical records. We also obtained independent medical advice from a consultant in acute medicine for older people. We found that the board had maintained that they had treated Mrs A reasonably and had discussed the possibility of an underlying diagnosis of cancer with Mr C. However, on reviewing the case notes, the adviser was concerned that Mrs A was not provided with treatment until some ten hours after her admission. He said that the treatment, when provided, was reasonable but it had not been timely. He noted, however, that even if Mrs A had been treated earlier it was unlikely that her condition and prognosis would have changed. He also said that stopping her anticoagulants had been the correct thing to do in the circumstances. With regard to the underlying diagnosis of cancer, the adviser said that a discussion with Mr C was recorded in the notes but this was unclear about the precise language used, and whether or not the term 'malignancy' had been understood.

The advice received during the investigation confirmed that Mrs A's treatment had been reasonable. However, for it to be appropriate it would have to be both reasonable and timely. As it was not, we upheld Mr C's complaint.

Recommendations

We recommended that the board:

• apologise for the delay which occurred; and
• review the guidelines published by the Society of Acute Medicine, particularly section AF-505, to ensure that more timely assessment of acute admissions occurs in the future.

Summary

Mrs C complained to the university that she was being bullied and harassed. She said that she was unable to continue with her studies for a considerable period and was signed off by her GP. She complained to us that the university had not followed their procedures in investigating her complaint of bullying nor offered her reasonable care in terms of their mental wellbeing policy.

Our investigation found that the university should have dealt with the complaint of bullying under their dealing with harassment policy but did not do so. It was investigated under the student disciplinary code and no evidence was found to discipline any student. At the next two stages of the complaints procedure, the university acknowledged that the best approach had not been followed, but did not uphold the complaint that bullying and harassment had not been dealt with properly. Our investigation concluded that there had been confusion over which procedure should have been followed and that the university had failed to fully investigate the harassment allegation.

We also upheld the complaint that the university failed to offer reasonable care in terms of their mental wellbeing policy, as the university investigated the complaint of harassment as a potential student code of conduct matter. They did not give due regard to Mrs C as a potential victim of harassment and to the potential harmful effect on her wellbeing. There was no evidence of the university offering her support and practical assistance as outlined in the mental wellbeing policy.

Recommendations

We recommended that the university:

• apologise to Mrs C for failing to conduct an adequate investigation into her complaint of bullying; for not following its policy on dealing with personal harassment, and for failing to offer reasonable care in terms of their mental wellbeing policy; and
• share the outcome of the investigation with relevant staff and remind them of of the importance of following the dealing with harassment policy and the mental wellbeing policy.

Summary

Miss C complained about the way in which the university handled her application for Recognised Prior Learning (RPL - a process in which skills and knowledge gained outside formal learning are assessed and granted formal recognition) when she was accepted onto a course. She said that their handling of her application was unnecessarily protracted and flawed. She also complained about the way her complaint about this was handled.

We upheld both Miss C's complaints. During our investigation we found that the university had failed to follow their RPL guidelines, as Miss C should have been provided with a named RPL adviser to support her in making the application. We found no evidence that she was told who her adviser was. Nor was there evidence that she had been provided with written support materials, which the guidance in place at that time identified as essential elements of the RPL support system. We also found that, while the assessor of any RPL claim should not normally be the RPL adviser, in this case the person the university identified as the RPL adviser had also assessed the claim, contrary to their guidance. Although we found that the identified assessor had not formally notified Miss C of the decision on her application, nor had it been considered by the assessment board as it should have been, we were satisfied that the university had written to her explaining why she did not meet the RPL criteria. Nevertheless we considered that, as correspondence became protracted, there was a failure to adequately explain the exemptions that the university were prepared to grant, and any right of appeal that Miss C might have had.

Miss C also complained that her complaint was not adequately considered. She said that the university's formal response diminished the substance of her complaint, and that they failed to offer mediation in line with their complaints procedure. We found that the university had acted in line with their complaints procedure in not offering Miss C mediation. Given the detailed email correspondence and meetings with staff that had already taken place to try to resolve the issues informally, we considered that by the time Miss C made her formal complaint, the opportunity to resolve the matter informally through mediation had passed. However, we found that the response to Miss C's formal complaint, although it largely upheld her concerns, did not adequately explain the university's decision and any remedial action taken to avoid this happening again. We were also critical at the way in which Miss C's formal appeal against the decision was handled, as it was considered by the same person who made the decision on the complaint. We noted that, under the complaints procedure, any appeal should have been considered by the complaints appeal panel. We made a number of recommendations to address the failings identified in our investigation.

Recommendations

We recommended that the university:

• ensure that all relevant staff are aware of the RPL process and, in particular, the need to ensure that students are adequately supported when making such an application;
• ensure that students are appropriately advised of all rights of appeal in relation to RPL within the revised policy and when advising them of the decision;
• ensure that, should Miss C decide to re-register for the doctoral course, any further RPL application from her is assessed in line with their revised policy and at no financial cost to Miss C;
• ensure that formal complaints are handled in line with their complaints procedure: in particular, that the investigation is thorough and the response adequately addresses the issues raised; and
• provide Miss C with a formal apology for the failings identified.

Summary

Mr C complained that, as an employer, he was not kept fully informed of what he needed to do to qualify for a Skills Development Scotland (SDS) scheme incentive and receive the payment that he expected for employing a young person. Our investigation found that there was a lack of clear and consistent written communication from the college to Mr C about the scheme and its requirements, and we upheld the complaint.

We also upheld the complaint that the college had not conducted an adequate investigation into Mr C's complaint as, although they considered all the information they held, contradictions in communications were not explored fully and they did not ask Mr C for all his evidence.

Recommendations

We recommended that the college:

• after discussion with SDS, provide their partner employers with clear summary information on SDS schemes for 2013-2014; and
• apologise to Mr C for failing to conduct an adequate investigation into his complaint.

Summary
Mrs C had been a patient of a dentist at the practice for 20 years. She visited him complaining of toothache and a history of loosening teeth, and he referred her for a specialist assessment, mainly to discuss an implant and bridge. The specialist she attended told Mrs C that she had chronic adult periodontal disease (a condition involving infections of the gums and bone that surround and support the teeth). This had resulted in significant bone loss, and she also had a chronic infection. The specialist suggested a number of options for dealing with the problem but warned that the damage done would be difficult to address.

Mrs C complained that her dentist did not identify or treat her for periodontal disease and that, as a consequence, her teeth and gums had deteriorated to the extent that it would be difficult to maintain her remaining teeth or deal with the problem with which she had been left.

As part of our investigation, we obtained independent advice from one of our dental advisers. Our adviser confirmed that the dental records made by Mrs C's dentist were minimal and that there was no explicit diagnosis or treatment plan. There was no evidence that he had told her that she had serious periodontal disease or that she had been given any preventative advice. Given Mrs C's symptoms, we found that the dentist should have at least carried out a basic periodontal examination and taken x-rays, but he did not do so.

Recommendations
We recommended that the dentist:
• apologise to Mrs C for his failure in this matter; and
• discuss this matter at his next professional appraisal and provide evidence that he has done so.

When this report was first published on 27 March 2013, it was incorrectly categorised as being about Greater Glasgow and Clyde NHS Board. This was due to an administrative error which we discovered on 9 April 2013, and for which we apologise.

Summary

Business Stream issued a large water bill to Ms C in 2011. Her bills were normally around one-tenth of the amount for which she was billed, so she queried the amount with Business Stream. They advised her to look for a leak on her premises, which she did, but no leak was found. Ms C's plumber later found a leak on pipework outside her business premises.

Ms C felt that she was unfairly being held liable for the charges associated with the leak. She complained that she did not use the water that had caused her meter readings to run high and felt that she should not have to check and maintain Business Stream's equipment. She acknowledged that Business Stream had applied a credit to her account, but did not consider that this went far enough to reduce the amount owed.

We found that the leak was located on pipework for which Scottish Water were responsible. Their leakage allowance policy says that, under such circumstances, the customer should receive a credit equal to 100 percent of the difference between their average daily usage before the leak and their average daily usage during the period of the leak. The allowance is only paid over a period of six months, which they say should be ample time to detect and repair a leak.

The leakage allowance was applied to Ms C's account for the six months before the leak was identified and repaired. Business Stream also acknowledged that they failed to read her meter over a twelve month period, and offered a further credit of 50 percent of her water charges in light of this.

Our investigation found that, had Ms C's meter been read in line with Business Stream's normal procedures, the leak would have been identified and the leakage allowance would have covered the entire period of the leak. We agreed that Ms C was being unfairly financially penalised by Business Stream's failure to carry out their routine meter read and upheld her complaint.

Recommendations

We recommended that Business Stream:

• review Ms C's case with a view to applying an extended leakage allowance to reflect the impact of their failure to read her meter.

Summary

Mr C, a former teacher, complained that the Scottish Qualifications Authority (SQA) did not respond reasonably to complaints that he and his school submitted about examinations. We upheld Mr C's complaint, as we found that the SQA's initial responses did not adequately address the complaints raised, and there was a significant delay in providing an appropriate response to the points Mr C had raised. In addition, the SQA should have informed the school that there would be a delay in responding to one of their letters because the matters raised were to be discussed at a meeting.

However, before Mr C complained to us, the SQA had reminded relevant staff that they should ensure that they provided appropriate information in response to all incoming enquiries and complaints. They had also reminded staff of the importance of adhering to the timescales set out in their customer complaints process. We, therefore, only made one recommendation.

Recommendations

We recommended that the Scottish Qualifications Authority:

• issue a written apology to Mr C for failing to adequately address the issues raised in their responses to the initial correspondence and the delays in responding to some of the complaints.

Summary

Mr C, who is a prisoner, complained to the prison about a delay in receiving correspondence from his solicitor. The complaint was resolved to his satisfaction, but he was unhappy with the time taken to respond. The prison rules say that, at stage one, a manager should offer to discuss the complaint within 48 hours of receipt, and respond within five days. They also say that the governor should issue a stage two response within 20 working days. Our investigation found that none of these timescales were adhered to in Mr C's case and he was not sent a holding letter to explain the delay.

Mr C also complained that he was not told about or invited to the complaint hearing at stage two, despite having indicated his wish to attend. The prison rules allow for prisoners to attend hearings and make representations if they so wish. We noted that Mr C had said on his complaint form that he wanted to attend the hearing. He was not noted as being at the hearing and, in the absence of any evidence that an invitation was issued and declined, we concluded that the prison had failed to facilitate his request. In the circumstances, we upheld this complaint.

Recommendations

We recommended that the Scottish Prison Service:

• remind staff to ensure that they respond to complaints within the relevant timescales set out in Rules 122-124; and
• remind staff to ensure that, where prisoners ask to attend an internal complaints committee hearing, arrangements are made to facilitate this, as per Rule 123(5)(a).