Upheld, recommendations

Summary

Mrs C was assaulted, and was taken by ambulance to a hospital accident and emergency department (A&E) with two police officers in attendance. She complained that she was not fully examined and that no tests were done to assess whether or not she had a head injury, which meant that her concussion was undiagnosed. She said that this has caused her ongoing health problems.

Mrs C was discharged into the care of the police officers who took her to the police station to make her statement and then took her home. When she later applied for copies of her notes from the incident she took issue with the lack of detail in them. Mrs C complained to the board but was not satisfied with the response she received. She was unhappy that later statements made by the nurse and doctor who saw her on the night indicated that she had been uncooperative and possibly under the influence of alcohol.

Our investigation included taking independent advice from one of our medical advisers. We found that there was a disparity between the notes made at the time of the events and the later statements made by the staff who attended Mrs C. The A&E unit is a GP-led unit and on the night in question was staffed by a nurse practitioner (a specially qualified senior nurse) and an on-call GP. We found that the notes made at the time by the nurse and the GP did not record all the injuries Mrs C had suffered, as recorded by the Scottish Ambulance Service staff who took her to hospital. Nor did any of the notes taken at the time refer to Mrs C as being uncooperative or under the influence of alcohol. However, after Mrs C complained to the board, the nurse and GP were asked for statements and both then referred to her as being uncooperative, possibly due to alcohol intake. The GP said that it was because Mrs C was not cooperating that he was unable to conduct a full examination and assessment of her condition.

Our adviser found that the lack of information in the notes taken at the time did not give a full picture of Mrs C's condition on the night in question. However, he was of the view that with the information now known - that Mrs C had concussion - the management of her condition would have been the same even had the concussion been diagnosed at the time. Mrs C was discharged with a small amount of medication and with advice to return to A&E if her condition worsened. The adviser said that this would have been appropriate. He was also of the view that Mrs C's ongoing problems would probably have occurred even had the concussion been diagnosed at the time. We did, however, uphold Mrs C's complaint because no valid reason was recorded in the notes for the GP not having conducted a full assessment and examination at the time.

Recommendations

We recommended that the board:

• apologise for the failings identified during our investigation; and
• review a sample of notes to establish the quality of record-keeping of the staff involved.

Summary

Mr C's late wife (Mrs C) was diagnosed with cancer in June 2011. He complained that staff at the practice failed to take account of the seriousness of her condition and to take follow-up action. Mr C raised concerns about the way in which his wife's medication was given; a failure to document phone conversations; a failure to admit Mrs C to hospital when a provisional diagnosis of gastroenteritis (inflammation of the stomach and intestines) was made; and a failure to monitor her calcium levels. Mr C complained that, by the time Mrs C was admitted to hospital in October 2011, she was hallucinating. He believed that his wife had suffered more than she needed to as a consequence of the practice's failures or inaction.

In considering Mr C's complaint, we obtained independent advice from one of our medical advisers. Our investigation found that once Mrs C was diagnosed with cancer, her care was primarily the responsibility of the hospital and hospital staff. It was clear from hospital records that the practice was kept up to date with Mrs C's condition, and it was also clear that when requested, the practice took appropriate action. Our adviser confirmed that, in his experience, not all patients wanted to hear further from their GP, or to discuss matters with them, at what can be a busy and difficult time.

On the matter of administration of medication, we found that although Mr C was unhappy that his wife was given her medication in tablet rather than liquid form, the adviser said that there was no record on file confirming that this was required.

On the issue of Mrs C's non-admission to hospital when gastroenteritis was suspected, the adviser said that the records confirmed that this was discussed with Mr and Mrs C and it was noted that she was 'OK' to stay at home. Mr and Mrs C were given advice that if her condition worsened, they should phone NHS 24.

We found that Mrs C's calcium levels were not taken, and as she was vomiting, the adviser was of the view that when completing blood tests, this test should also have been carried out. He said that if her calcium levels were high, it might then have been possible to reduce them, and in turn this might have led to a reduction in Mrs C's sickness.

Recommendations

We recommended that the practice:

• apologise to Mr C for the failure to monitor Mrs C's calcium levels.

Summary

Miss C attended the dental practice complaining of pain in her lower left five tooth. She said that she specifically pointed this out to her dentist. The dentist recorded in the notes that the lower left seven tooth was mobile with a discharge of pus coming from the buccal aspect (cheek side of the tooth). The dentist then extracted the lower left seven tooth.

After around 20 minutes, Miss C returned to the practice and complained that the wrong tooth had been extracted. The dentist recorded that the lower left five tooth was mobile and then removed it. The dentist also recorded that she had apologised to Miss C and explained that the lower left seven tooth was not treatable by any means other than extraction.

In her complaint to us, Miss C understood that the dentist said she would not charge her for this extraction. Our investigation found that the notes completed at the time said that the lower left seven tooth was to be extracted, so we could not say for sure whether the wrong tooth was extracted. However, Miss C clearly thought that it was the lower left five tooth that was to be extracted. We found that the dentist did not obtain consent appropriately and did not communicate with Miss C effectively.

In responding to Miss C's complaint, the dental practice said that the dentist was aware of the crucial importance of securing valid consent prior to any treatment and would not have proceeded with the removal of the lower left seven tooth unless she believed that Miss C understood and agreed to this treatment. We concluded, however, that this was not the case and upheld Miss C's complaint that the practice had provided incorrect explanations as to why the tooth had been removed.

Recommendations

We recommended that the practice:

• issue a written apology for the failure to obtain consent appropriately for the extraction of the tooth and for failing to communicate effectively with Miss C; and
• make the dentist aware of our finding on this matter.

Summary

Mr C's house sustained water damage when Scottish Water carried out work to replace a valve in his area. Mr C was not notified that the water supply would be shut off, and when it was turned back on, dirty water was forced through his bathroom tap at high pressure, soaking the room and seeping through the floor to the ceiling and walls below. Mr C complained about the lack of notice that the water was to be turned off and about Scottish Water's handling of his claim for the cost of redecorating the affected areas of his house.

Scottish Water investigated Mr C's claim and concluded that a tap must have been left on in the bathroom. They accepted that he was not notified that the water was to be turned off, but explained that there had been no plan to turn the water off in his street. Arrangements had been made to set up a diversion of the water supply so that his street was not affected, but a valve was left shut in error and around 200 properties were unexpectedly left without water. Whilst no notification was given that the water would be shut off, we accepted that there should have been no reason to notify Mr C, as it was not foreseen that the valve would be left shut.

Mr C's redecoration claim was rejected based on information provided by Scottish Water to their insurers. Scottish Water told the insurers that their investigation had concluded that Mr C must have left a tap on and that this was the cause of the water flooding his property. We found Scottish Water's conclusions to be supported by the evidence available to them. That said, we considered that Scottish Water's error with the shut valve would also have contributed to the flooding, as Mr C's water supply should not have been interrupted on that day. We found that Scottish Water failed to tell their insurers about their mistake and the impact that it had, as well as other information that may have been relevant to the determination of liability.

Recommendations

We recommended that Scottish Water:

• resubmit Mr C's claim to their insurers for consideration with full details of the circumstances surrounding the damage to his property.

Summary

In May 2011, Ms C received a bill from a reading of a meter that did not belong to her. Business Stream apologised to her for this in October 2011 and confirmed that they had wrongly billed her for this meter. They said they were crediting her account with £20 in recognition of a failure in service standards to reply. However, Business Stream then credited the wrong account and continued to invoice her for the wrong meter. Ms C complained by email, phone and letter to Business Stream over the next year. When she brought her complaint to us, she said that the matter was unresolved and Business Stream had not responded to her recent correspondence.

Our investigation found that Business Stream had written to Ms C in July 2012, confirming that she had been wrongly invoiced and that all charges for this meter would be credited back to her account. Business Stream told us that they were now satisfied that the billing was on the correct meter and the charges were correct. However, there had been a long delay in resolving the matter, and we did not consider that Business Stream had provided Ms C with a clear explanation of how her current account balance had been calculated. Also, we found that Business Stream delayed in replying to Ms C’s correspondence, and had not compensated her in accordance with their complaints procedure for the failure to reply to correspondence.

Recommendations

We recommended that Business Stream Ltd:

• apologise for the long delay in resolving the matter;
• set out clearly in writing how Ms C's current account balance has been calculated;
• pay £20 for the delay in responding, in line with service standards; and
• pay a further £20 for the delay in responding, again in line with service standards.

Summary

Mrs C runs a small business. She complained about the way her bills had been handled by Business Stream. Mrs C was told in June 2011 that she had not been paying enough for her water and had a backlog of debt. Since then, the amount for which she is being billed has doubled.

Until 2009, Mrs C paid for water based on the rateable value of the property. A Scottish Government decision meant that from 1 April 2009 all businesses began paying for water, based on the amount they used. To allow businesses to adapt to this, the move to the new charging system was phased, with only 30 percent of the bill in the first year being based on usage and this moved to 100 percent on 1 April 2011. As part of the new scheme, Business Stream are required to read the meters to ensure actual meter readings twice per year. Mrs C received bills from 1 April 2009 until 10 June 2011 based on estimated readings. When the first meter reading was made, it was shown that the business had used considerably more water than had been estimated. Mrs C queried this and it was found that there had been an error and this bill was reduced. However, she was still left with a debt and it became clear that due to the change from rateable value to charging by usage, Mrs C was facing considerably larger bills.

Our investigation found that Business Stream had made a mistake when they first read Mrs C's meter. However, they were now calculating bills correctly. We also considered the Scottish Government policy. The aim of the phased period was to allow businesses time to adjust and to take any action they could to reduce their water usage prior to the bills being solely charged on usage. We found, however, that Business Stream had failed to read the meter for nearly two years. This meant that Mrs C had not been able to take any action or to prepare for the increase in bills. Even although the bills were now correct, we upheld her complaint that Business Stream failed to handle the billing appropriately. However, as the water had been used, we were not able to recommend a change to the amount billed. We did consider it unfair that Mrs C had not been able to prepare for the change in the way her bills were calculated and made a recommendation about this.

Recommendations

We recommended that Business Stream Ltd:

• apologise for the delay in reading the meter; and
• review Mrs C's account and ensure no payment charge relating to the debt from the period of 1 April 2009 to 10 June 2011 remains. Any future payment plan agreed between Mrs C and Business Stream should fully reflect that Business Stream's failing prevented Mrs C from taking any mitigating action and, in particular, should allow for an extended repayment period.

Summary

Mr C, who is a prisoner, complained that the Scottish Prison Service (SPS) failed to make appropriate arrangements for him to attend his brother’s funeral. In replying to his complaint, the SPS said that they had been told that the funeral was on a particular day, and that they had booked an escort to take him to the funeral on that day. They said that Mr C had later told them that the funeral was the day before, but as he only told them this on the morning of the funeral they were unable to arrange an escort for him to attend.

The prison rules are clear - they say that the governor of a prison may grant escorted day absence for a prisoner to attend the funeral of a near relative on the written application of the prisoner, providing the governor is satisfied that the purpose of the application is genuine and appropriate. During our investigation, the SPS sent us evidence that indicated that they might have received the wrong information about the day of the funeral from Mr C’s family. However, there was no evidence that Mr C was asked to make a written application for escorted day absence in line with the prison rules. We found that the problem might have been prevented and that he might have been able to attend his brother’s funeral had he been asked to submit a written application.

Recommendations

We recommended that the Scottish Prison Service:

• take steps to ensure that the procedure for granting escorted day absence is in line with the prison rules and the relevant Direction by Scottish Ministers; and
• apologise to Mr C for the failure to adhere to the prison rules on escorted day absence in relation to his brother’s funeral.

Summary

Mr and Mrs C have a teenage son with a disability. They were unhappy with the council’s handling of an assessment of their need for an increased respite service and said there was poor communication. They complained to the council’s social work service. Their complaint was fully upheld and three recommendations were made and implemented, one on a limited basis. Mr and Mrs C were not satisfied and made a request that their complaint be taken to a complaints review committee (CRC). When that request was not met they complained to us about the council’s failure to meet their request and failure to communicate with them.

We upheld both elements of Mr and Mrs C's complaint. Our investigation found that there had been an unacceptable delay in convening the CRC because the council lacked a full panel of appropriately qualified persons. There had also been continuing poor communication by the council in telling Mr and Mrs C about the reasons for this delay.

Recommendations

We recommended that the council:

• convene a CRC at the earliest opportunity; and
• keep Mr and Mrs C informed of progress in convening the CRC.

Summary

Mr C raised a number of issues about the housing association's handling of his complaint about dampness in his property. In particular, Mr C complained that the housing association had been aware of the problem before they let the property, and that there had been delays in carrying out repairs.

During our investigation we found that before letting the property the association were aware that there was a small area of dampness in a cupboard. They had initially believed this to be a minor issue and had taken action to try to address it. It turned out that the problem in fact related to the whole building, but there was no evidence that the association had been aware of this before letting the property. Once this was known about, as a minority owner within the building the housing association had taken action to try to obtain agreement from the other owners to allow works to be carried out. However, we were concerned at the length of time Mr C had lived with the problem.

The association accepted that he had suffered inconvenience and had offered compensation for this and for the delay in carrying out a repair. We were also concerned that there was no written record of the accompanied viewing that Mr C had of the property before it was let to him. This would have detailed what issues, if any, had been brought to Mr C's attention.

Recommendations

We recommended that the association:

• give further consideration to Mr C's request for housing points should his property show further signs of internal dampness, because of the apparent uncertainty about the completion of the external repairs; and
• retain a note of the accompanied viewing of the property, where a void inspection is not being carried out.

Summary

Mrs C complained that the medical practice had unreasonably removed her name from the list of patients who were entitled to receive the flu vaccination. She said she had been told to wait in the chance there was a surplus of flu vaccinations. Mrs C, who has a medical history of non-hodgkin’s lymphoma (a cancer which affects certain cells in the lymphatic system) was in remission but had received the flu vaccination for many years previously. Mrs C then purchased the vaccination privately. She also contacted her haematologist (a specialist concerned with the study of blood and blood-related disorders) who wrote to the practice. As a result, Mrs C was reinstated to the list of patients entitled to receive the vaccination.

The practice explained that Mrs C's condition was stable in 2011. She was not receiving immunosuppressant therapy (treatment to suppress immune response) and did not satisfy the criteria for groups who require the vaccination. Mrs C's records did not contain a marker that would have highlighted her eligibility for the vaccination and the GP who was reviewing patients on the list had used her clinical judgement and decided not to allow Mrs C the vaccination.

We upheld Mrs C's complaint. Our investigation found that the GP was entitled to decide whether individual patients satisfied the criteria for the vaccination and had used her clinical judgement. Our medical adviser explained, however, that although Mrs C was not on immunosuppressant therapy at the time, her past history of lymphoma made it likely that she would be prone to infections. The adviser felt that most GPs would cover such patients using immunisations such as the flu vaccination. We found that the practice could have taken a more proactive role when they told Mrs C that she was not going to have the vaccine. They could also have made contact with the haematologist themselves when Mrs C reported her concerns or have offered her a face-to-face meeting to discuss the matter in more detail.

Recommendations

We recommended that the practice:

• apologise to Mrs C for the failure to take her circumstances fully into account; and
• consider holding a significant event analysis in order to establish if there were any missed learning opportunities.