Upheld, recommendations

Summary

Mr C complained about the care and treatment given to his late wife (Mrs C). He said that Mrs C had initially been taken into hospital with a urinary tract infection. The following month, she was transferred to another hospital for rehabilitation and physiotherapy. Later that month she was noted to have red heels, with a blister on one of them. Mrs C was discharged home shortly afterwards and Mr C said that at that time she had pressure sores. Mrs C died some six months later.

Mr C complained that his wife suffered from pressure sores while in the care of the board. He said that she was inadequately nursed and that this contributed to her death. In our investigation we took all the relevant information into account including the board's file of correspondence and Mrs C's clinical notes. We also obtained independent nursing advice about Mrs C's care and treatment.

We upheld all Mr C's complaints. Our investigation found that there was no reason not to discharge Mrs C home with dressings on her feet. However, there was also no evidence to suggest that a wound chart was completed before discharge, which would have assisted community nurses to plan their care for Mrs C. Community nurses were also not told that Mrs C's heels needed dressing and we found that communication between the hospital and the community nurses was poor. Similarly, record-keeping was below a satisfactory standard.

Recommendations

We recommended that the board:

• emphasise to the staff concerned in this case the importance and necessity of keeping properly recorded notes and of using the tools that are available to them to assist in the care and treatment of patients (eg a wound chart);
• apologise to Mr C for their failures in this matter. Also, that the apology makes specific reference to the poor treatment given to Mrs C while she was at home; and
• provide evidence to the Ombudsman about how they assure themselves that the discharge planning standards/policies relating to communication have been addressed

Summary

Mr C complained about the care and treatment received from his dentist, including that: a root canal treatment was not completed properly; despite requesting a white filling the filling provided was grey; the dentist allowed bleach from a syringe to spill on to Mr C's suit and allowed the syringe to fall on to Mr C's thigh.

We upheld Mr C's complaint. Our investigation, which included taking independent dental advice, found that the root canal treatment (a deep filling of the root of a tooth) was not completed properly. Our adviser said that the dentist should have used a rubber dam, which would have protected Mr C's gums from the hypochlorite (bleach) used during the treatment. The adviser was also of the opinion that, although the end result could be deemed acceptable, the root filling was slightly short of the tip of the root canal. She was also concerned at the lack of detail in the dental notes, including a failure to document the working lengths of the canals or what substance was used to wash them out.

On the matter of the type of filling used, the adviser stated that it would be normal practice within the NHS to use an amalgam (grey or silver) filling. She said that white fillings can be provided but that this would be on a private basis. The adviser also commented that it is considered best practice to restore a root filled tooth with a crown (a metal and/or porcelain restoration made in a laboratory which covers the tooth) and that all the various options should have been discussed with Mr C. However, we found no evidence that this was done. Overall, the dental adviser was concerned that the standard of the records did not conform to that expected by the General Dental Council or the Faculty of General Dental Practice (UK).

On the matter of the incident with the syringe, the dentist acknowledged that this had happened but he could not at the time of the investigation, some two years after the incident, recall exactly what had happened. He acknowledged that the bleach had damaged Mr C's trousers, and that Mr C had complained about it. The dentist said that he apologised to Mr C at the time and offered a compensatory payment, which Mr C accepted. In the circumstances, we took no further action on this element of the complaint.

Recommendations

We recommended that the dentist:

• reviews his practice in carrying out root canal treatments with particular regard to the use of rubber dams - this to be discussed at his next annual appraisal;
• reviews the standard of his record-keeping with particular regard to the level of detail of the treatments undertaken and discussions on treatment options and consent - this to be discussed at his next annual appraisal; and
• issues a written apology for the failings identified.

Summary

Miss C had her tonsils removed. After the procedure, she was in a great deal of pain and unable to eat and drink. Five days after the procedure, she went to see her GP about these symptoms. Miss C said that her GP just looked at the back of her throat and did not take her temperature or carry out any other tests. Miss C also said that her GP suggested she should go to the ear nose and throat (ENT) ward if she had any further problems, although her understanding was that she could not do this. The GP diagnosed post-operative pain and muscle spasm and prescribed strong analgesia (pain relief) and anti-inflammatory gargles (solutions used to treat throat conditions).

We upheld Miss C's complaint and made two recommendations. Our investigation found that, while the GP's diagnosis and the medication prescribed were reasonable, his advice to attend ENT was not helpful.

Recommendations

We recommended that the practice:

• review their actions in light of the findings; and
• apologise to Miss C for the failings identified.

Summary

Mr C'’s property was flooded with sewage during heavy rain when a pipe was blocked by inappropriate items that had been flushed into it. His insurance company covered the costs of the damage to his property and Scottish Water reimbursed his insurance excess. Mr C assumed that was the end of the matter. However, when he renewed his household insurance, Mr C'’s insurers informed him that Scottish Water had denied responsibility and the claim had been held against him. He said that this resulted in the loss of his no claims discount and in his insurance premiums increasing.

We cannot establish legal liability, nor can we award compensation. Only a court can look at legal liability between individuals and organisations. However, we can consider complaints about the handling of an insurance claim if we find it was not handled properly. We might make recommendations to put things right if we find that the claim could have been handled better or a more detailed explanation should have been offered.

We upheld Mr C's complaints. Scottish Water had failed to take into account the fact that Mr C's neighbour had told them about potential flooding the day before Mr C’'s property was flooded. When they referred the insurance claim to their claims handlers, Scottish Water did not tell them about the call from Mr C’'s neighbour. Although the claims handlers said that this information would not have changed their decision, we considered that Scottish Water should have made them aware of this so that they could make a fully informed decision.

Under their Guaranteed Service Standard scheme, on occasions Scottish Water will make a payment to customers who are flooded internally from a sewer. In Mr C'’s case, Scottish Water told us that they had not made a payment, because the flooding was external to his property. We told them that Mr C’'s garage had been flooded and it formed part of an extension to his house. In view of this, Scottish Water issued a Guaranteed Service Standard payment to him.

Mr C also complained that it was three weeks before Scottish Water cleaned the area after the flooding. Although we found that Scottish Water’s contractors cleaned up the area five days after the sewage flood, it was clear from the evidence that Mr C and his wife (Mrs C) did not consider that this was done satisfactorily. In their response to us, Scottish Water said that they were unaware of any dissatisfaction with the initial clean-up until they were contacted nearly four weeks later. However, we found evidence that on the day that the initial clean-up was done Mrs C asked for the area to be cleaned again. No action was taken on this until Mr and Mrs C again reported their dissatisfaction nearly three weeks later. We found this delay unacceptable.

Recommendations

We recommended that Scottish Water:

• issue a written apology to Mr C for failing to initially inform their claims handlers of the call his neighbour made to them the day before his property was flooded;
• issue a written apology to Mr C for the delay in carrying out a satisfactory clean-up after the sewage flood; and
• review this case in order to identify how they can prevent similar delays from occurring.

Summary

Mr C received planning permission to build two semi-detached properties in the grounds of his former home. When creating the plans for the development, he obtained plans held by Scottish Water which showed that a water main ran through the site. Mr C based the location of his development on the plans he had obtained, ensuring that his properties would not be built over the water main. However, he later found that the south east corner of his properties were built over the mains pipe. Scottish Water told him that he would have to pay for the pipe to be diverted. However, Mr C considered that this was unreasonable, given that he built the properties according to plans provided by Scottish Water, which turned out to be inaccurate.

Our investigation found that Scottish Water are legally obliged to supply plans of their water infrastructure that are reasonably accurate. Scottish Water told us that, generally, their plans should be accurate to within a two metre tolerance. However, there may be some inaccuracy. With this in mind, they issue a disclaimer with any requested plans which highlights the developer's responsibility to ensure they know the precise location of any local water mains. Scottish Water told us that the pipe was two metres out from the location shown on the plans. They considered this to be within a reasonable tolerance.

Mr C found the pipe when digging the foundations of the properties. He sought advice as to what he should do, but did not contact Scottish Water. He said that the pipe was substantially more than two metres from the location shown on the plans.

We examined the plans provided to Mr C and subsequent drawings from a Scottish Water representative who plotted the accurate location of the water main. We found that the pipe was roughly 8.5 metres out from the location suggested in the plans. The evidence presented to us also suggested that Mr C's plans did not include the disclaimer regarding accuracy.

We found that Scottish Water failed in their obligations to supply reasonably accurate information. Whilst acknowledging Mr C's responsibility as developer to check where the pipe was, we considered it reasonable for him not to do so on this occasion, given the apparent distance from his proposed site as shown on the plans. That said, Mr C had an opportunity upon finding the pipe to avoid the situation he found himself in. As such, we could not ignore his responsibilities entirely. We recommended that Scottish Water and Mr C split the cost of diverting the water main.

Recommendations

We recommended that Scottish Water:

• contribute 50 percent of the cost of diverting the water main from under Mr C's property.

Summary

Ms C occupied business premises in April 2004. She complained that in 2011 she received a telephone call from Business Stream telling her that she would be receiving a bill from them for water charges for the year March 2010 - 11. She complained that this was unreasonable as it was the first time Business Stream had ever contacted her.

Our investigation found that although Business Stream are the default provider as part of the water industry's regulatory regime, they were under no obligation to identify, or to identify quickly, premises where there was no licensed provider. However, in Ms C’s case it had been identified in March 2010 that Business Stream would act in default as her provider, but she was not told about this until a year later. We took the view that this was too long and upheld the complaint.

Recommendations

We recommended that Business Stream Ltd:

• apologise to Ms C for their initial failure to respond properly to her query about water services until June 2011
• waive the first of the penalty charges (plus VAT) that was levied on Ms C's account in May 2011

Summary

Ms C owns a property that she rents to a tenant. In December 2010, the tenant complained of intermittent water supply and low water pressure. During an initial telephone conversation with the tenant, Scottish Water found that the water pressure had returned. However, the problem recurred in January 2011. Scottish Water attended the property and found that the water pressure met the minimum standard of one bar of pressure. As such, they took no further action. Ms C continued to raise concerns about the issue as her tenant continued to complain of loss of water and low pressure.

In March 2011, Scottish Water arranged for a pressure flow test to be carried out, to assess the water pressure over a 24 hour period. Further investigations and complaints from other residents in the street led to the conclusion that there was a burst on the water main. In July 2011 a temporary solution was found pending refurbishment of the water main. Ms C complained that Scottish Water delayed in dealing with the problem, resulting in her losing rental income and other expenses. She also said that their communication was poor throughout her dealings with them.

Our investigation found that locating the source of the problem was not straightforward. However, Scottish Water did not respond to Ms C's reports of low water pressure in line with their general service standards, and a number of short delays contributed to a significant overall delay. We accepted independent advice from our adviser on water matters that water pressure can vary throughout the day depending on demand, and as such, a reading of one bar of pressure may be lower at peak times. It took ten weeks for Scottish Water to order the pressure flow test, despite numerous contacts from Ms C explaining that the low pressure problem persisted. We considered this should have been done sooner. We were also critical of Scottish Water's communication, which was often delayed and contained little useful information about what was being done to resolve the problem.

Recommendations

We recommended that Scottish Water:

• apologise to Ms C for the issues highlighted in our investigation;
• make a payment to Ms C of £120 in line with their general service standards;
• consider making a further payment to Ms C in recognition of the time and trouble and expense incurred as a result of the low water pressure problem; and
• take steps to ensure their staff work in line with their customer service standards - Pressure Reference Map, which sets out the process that should be followed to achieve the 5 day service standard.

Summary

In 2008, Ms C wanted to create a driveway into her property. She asked the council for advice, and they wrote to her with this saying that planning permission was not needed. They outlined the circumstances in which it would be needed and who she should contact should she wish to have the kerb dropped. Based on that advice Ms C created the driveway. More than two and a half years later the council contacted her to say that they wanted her to either purchase a piece of land at the edge of the road (which they owned and which she had used in creating the driveway) or re-instate it. Ms C complained to the council but remained dissatisfied with their response and complained to us.

We found that in 2008 the council had not explained to her that they had responded in their role as planning authority, and that she also needed to get the consent of the council in a different role as owner of the piece of land. We upheld Ms C's complaints.

Recommendations

We recommended that the council:

• apologise to Ms C; and
• consider waiving their administration charges for any sale of the land.

Summary

Mr C, who has a history of physical and mental health conditions, was in prison outside Scotland. On release, he travelled to Scotland, where he approached a council for assistance with homelessness and housing issues. A few weeks after he arrived, Mr C was arrested and sent to prison. He was released from the prison on licence around a year later. Mr C's licence was revoked within a few weeks and he was returned to prison. Mr C complained that the council unreasonably failed to comply with their statutory and procedural responsibilities for housing him, in the lead up to and after his release from prison.

We found from the evidence that the council did not know that Mr C was due to arrive in Scotland, and we did not find any failings by the council in the lead up to his first release. Neither did we find any failings in their handling of Mr C's application for more permanent housing on his first release. In addition, we did not find any failings in how the council dealt with Mr C's homelessness and housing situation in the lead up to, and following, his second release.

However, we did uphold Mr C's complaint about how the council dealt with his homelessness situation after his first release. They had a duty to identify accommodation that was appropriate to Mr C's needs. They had to do so reasonably, and in line with relevant legislation and guidance. In our view, their actions were unacceptable, as the temporary accommodation was unsuitable. It also appeared that council staff were confused about how to deal with Mr C's case; there was a contradiction between council records and the view of a GP who specialises in dealing with people who are homeless, and there was delay in processing Mr C's homelessness application. We made recommendations to address the failings identified.

Recommendations

We recommended that the council:

• apologise to Mr C for failing to deal with his homelessness situation appropriately;
• provide us with an outline of how they would deal with a similar situation in future, to ensure that the same failings are not repeated; and
• ensure that records of contact with homelessness practice GPs accurately note their comments about applicants, ideally supported with a written statement from the GP.

Summary

Mrs C complained that the health board unreasonably failed to provide a home podiatry visit for her elderly father (Mr A). Podiatry is the branch of medicine related to disorders of the foot, ankle and lower extremity.

Mrs C also complained that there was unreasonable failure to maintain Mr A's feet to an acceptable standard and to make a referral to a specialist team when required. Mrs C had concerns about the method of making home visits, about comments in some of the notes, and said there were unreasonable delays and a failure to answer her questions during the complaints process.

Mr A had a significant history of multiple illnesses, including insulin dependent diabetes and mobility problems. These were made worse in cold weather. As is standard for diabetics within the NHS, Mr A had had a podiatry assessment and was receiving regular podiatry treatment - usually attending his local clinic. However, in early December 2010 there had been heavy snowfalls and he was unable to attend a scheduled appointment. Mrs C telephoned the clinic to ask for a home visit. She said she found the attitude of the staff members she spoke to unacceptable, and that she was told that a visit would not be arranged or at least not for some weeks.

Mrs C was concerned about this arrangement as her father had had previous problems with diabetic ulcers on his feet and was complaining of a sore right foot. She spoke with the service director, and a home visit was arranged for the next day. Mr A received several treatments at home during December 2010. He was referred to the specialist team at the end of December and seen the next day. He was immediately admitted to hospital for treatment of an infected diabetic ulcer on his toe. Mr A was discharged in mid January 2011. He was readmitted five days later and died in hospital in February 2011. The primary cause of death was sepsis (infection).

Our investigation included taking independent advice from a podiatrist and a physician, and we upheld all Mrs C's complaints. The podiatrist said that although in general Mr A's feet had been maintained to a reasonable standard, by early December 2010 it should have been clear to the podiatrists that the ulcer was not healing and Mr A should have been referred to the specialist team at that stage. The podiatry adviser also found fault with the general lack of detail in the notes and said that there were some subjective rather than objective comments.

Having seen Mr A's medical records, the physician adviser said that although sepsis was the primary cause of Mr A's death it was not directly caused by the infected toe. However, Mr A had been treated for some time with antibiotics to try to address the infection in his toe. Although this was appropriate treatment, use of antibiotics in this way can kill off the natural pathogens (bacteria) within the digestive system. This can pre-dispose a patient to contracting Clostridium Difficile infection, which is what happened to Mr A. Such infection can produce a range of symptoms from diarrhoea to severe and overwhelming infection, particularly in a patient such as Mr A, with other significant medical problems. Therefore, although the infected toe did not directly lead to Mr A's death, it was a factor in it.

Recommendations

We recommended that the board:

• apologise for the deficiencies identified in our investigation;
• report on their review of the process for home visits;
• review the standard of podiatry notes; and
• provide awareness training on SIGN 116 (guidelines on the management of diabetes).