Upheld, recommendations

Summary
Mr and Mrs C complained about the care and treatment that their eleven year old son (Master A) received for chest problems at a hospital's emergency department assessment unit. They said that it was unacceptable that the board took the time they did to diagnose Master A's tuberculosis (an infectious lung disease). Master A had four visits to the hospital in about six months, the last of which was a review appointment at a clinic, which was scheduled at his second visit to the emergency department.

We found from looking at the medical records, and taking advice from one of our medical advisers that in their own review of this case the board found that a consultant's comment on an x-ray report should have raised the possibility of a diagnosis of tuberculosis. However, due to administrative problems within the hospital this was not followed up. Although the review said that the administrative problems were being addressed, we found that the board's response to Mr and Mrs C's complaint said the same thing, eighteen months later. We saw no evidence that the matter had yet been satisfactorily resolved.

The board said they regretted that a diagnosis of tuberculosis was not reached earlier. Our medical adviser took the view that Master A's review appointment at the clinic should have been arranged sooner. Our adviser also said that tuberculosis should have been excluded or diagnosed around the time of Master A's third visit to the emergency department, and certainly by the time of the review appointment at the clinic. The delay led to a progression in Master A's condition. As the evidence indicated that it was unacceptable that the board took the time they did to diagnose Master A's illness, we upheld the complaint.

Recommendations
We recommended that the board:
• apologise to Master A and his family for the delay in diagnosing his illness;
• review the August 2009 emergency department assessment unit visit, in the light of the Ombudsman's adviser's comments, to ensure that a differential diagnosis of tuberculosis is considered in children with symptoms and examination/investigation results such as those present in Master A; and
• provide the Ombudsman with a copy of their action plan to take forward the learning points from Master A's case. The action plan should address the issues raised in 2009 and 2011 about the problems with filing timeously the emergency department assessment unit records in a child's hospital case records.

Summary
Mr C complained that his 14-year-old son (Master A) had six baby teeth extracted by his dentist. At the time the family were told that this was necessary to allow room for his adult teeth to come through. Master A also had an adult molar removed, again to allow space for the rest of his adult teeth to come through. Mr C has now learned that his son has a congenital problem (a condition present at birth) that means he has no further adult teeth to come through. Mr C said that the dentist was wrong to have extracted the teeth when there was no clinical need to do so.

We upheld Mr C's complaints. We found that overall there was a lack of documentation to show what the dentist discussed with him. Although there was no evidence about whether it was clinically appropriate to have extracted Master A's baby teeth, we found that the dentist should have sought specialist orthodontic advice before carrying out the procedure. We found that the adult tooth which was extracted had been heavily filled. However, while it may have been appropriate for the dentist to have extracted it, there was no evidence that a treatment plan had been carried out or that informed consent had been obtained.

Recommendations
We recommended that the practice:
• apologise for the failure to obtain an orthodontic opinion prior to the extraction of Master A's baby teeth and for failing to explain his reasons for doing so; and
• apologise for the failure to produce a treatment plan for the extraction and for not obtaining informed consent for the extraction.

Summary
Mrs C complained about treatment she received from a dental practice. She had had a replacement bridge fitted which caused her difficulties. The practice and Mrs C had different views about what had happened. Mrs C said her dentist had advised her to have the bridge replaced, but the practice said that Mrs C had expressed dissatisfaction with her original bridge and had made several requests for it to be replaced. When we looked at the written records, these did not show that Mrs C had been fully informed of the risks of having her bridgework replaced. On this basis we upheld the complaint as we found that Mrs C had not been able to give fully informed consent to the procedure.

Mrs C also complained that the bridge was inadequate. It fractured, fell out on several occasions and Mrs C developed abscesses. We found that the practice had replaced the old single-unit bridge with a bridge in two parts, which was not in the original approved treatment plan. After taking advice from our dental adviser, we found some aspects of the work unsatisfactory, in particular that Mrs C's bite was not properly assessed at the fitting stage, the bridge had to be re-fixed a number of times and the porcelain had fractured. We also upheld this complaint.

Finally, although we recognised that the practice had refunded Mrs C the cost of the bridge and referred her for specialist treatment, we found that they had failed to correct the work, as Mrs C has continued to experience numerous difficulties.

Recommendations
We recommended that the practice:
• provide evidence to the Ombudsman that they take steps to ensure patients give fully informed consent by advising them of potential risks with
• undertake and meet the cost of any further treatment as laid out within the suggested treatment plan in the specialist's letter.

Summary
Mrs C lives in a council owned sheltered housing complex. Through an advocate, she complained to us that she was the victim of vandalism and pranks by staff. She said that her mail and electricity had been tampered with as a prank and a window had been vandalised. Mrs C was dissatisfied with the council's investigation into her complaints and failure, in her view, to take disciplinary action against the staff concerned.

While we recognised that Mrs C was disappointed with the council's handling of the matter, we explained that the outcome she wanted (ie disciplinary action against staff) was not something we could achieve. She confirmed that she understood this but nevertheless asked us to investigate and do what we could for her. We asked the council to send us copies of the records of complaints made by Mrs C, or on her behalf by her advocate, over the last 18 months, and details of the investigations undertaken by staff and the council into the individual reports. We also asked for documents relating to the investigation into Mrs C's complaint.

Our investigation found that Mrs C had complained about various issues over a number of years. Some of the complaints related to service failure (for example, a failure by sheltered housing staff to test the pull cord in her home). Some were about her heating and some were of a more personal nature and related to issues of theft (a police matter) and about the staff in the sheltered housing complex. Our investigation confirmed that the council had investigated all the complaints that Mrs C had made about repairs in her home, in some cases on a number of occasions, and they had taken appropriate action by offering to either carry out repairs or provide a replacement. The council showed us that they arranged for a clerk of works to check Mrs C's windows and were satisfied that these did not need repair or replacement as they were functioning properly. The electricity had also been checked and no faults had been identified, and Mrs C's heating system was working effectively.

However, we did find fault and upheld the complaint because of the failings in the way the council handled Mrs C's complaints. There was a lack of records of staff interviews. It was evident that council officers had visited Mrs C on a number of occasions to discuss her concerns and to explain that no further action being taken because of a lack of evidence. However, Mrs C is elderly and the council were providing her with an element of care. There was a lack of evidence that the sheltered housing staff had been interviewed about her complaints, which would have provided a more balanced picture of the situation. In response to our investigation, the area manager recognised this failing and we welcomed the steps he took to make relevant changes to the council's procedures.

We also found fault in some stages of the complaints handling, as there was a failure to progress the complaint to the next stage, and in the advice given to Mrs C about the statutory right of review of her complaint by a social work complaints review committee. We made two recommendations to the council about their complaints handling.

Recommendations
We recommended that the council:
• review the procedures for investigation of service complaints to ensure that staff are interviewed as part of the process and that this is recorded; and
• review the information provided to staff about complaints handling and sending standard letters, to ensure that there is clear advice to staff about when it is appropriate to escalate a complaint to the next stage and when it is appropriate to send a letter with standard phrasing.

Summary
Mrs C was referred for orthodontic treatment by her dentist in 2008. She was first seen by a restorative dentistry consultant in February 2009 for hygiene therapy as she had severe gum disease. She was then referred to orthodontics, and was seen in December 2009. She was referred to see a specialist about orthognathic (jaw) surgery as she wanted to undergo this form of treatment, but was not seen until January 2011.

Following this assessment, Mrs C was placed on the waiting list for surgery, and seen again in September 2011, when she was advised that her gum disease and level of oral hygiene were not sufficiently stable for surgery at that time. A treatment plan was put in place to continue to treat Mrs C's gum disease. Mrs C had also been advised previously to give up smoking, as this would affect her oral health and hygiene.

Mrs C complained to us that the board failed to provide her with treatment for her dental problems within a reasonable time. We upheld her complaint as our investigation found that her wait to see a orthognathic specialist was unreasonable. We noted that the board had implemented evening clinics to tackle the long waiting lists, and that they had experienced a shortage of qualified staff. We found, however, that the board could make further efforts to reduce waiting times within the orthodontic/orthognathic department, and we made a recommendation about this. We did not, however, find that the delay itself had adversely affected the state of Mrs C's teeth, as her oral heath and hygiene needed to be addressed before surgical treatment could begin.

Recommendation
We recommended that the board:
• implement an action plan to reduce the current waiting lists for treatment within the orthodontic/ orthognathic department.

Summary
Mr C complained about statements that he alleges an officer made to another prisoner. The prison could not investigate these complaints as the officer was not at work, however, they agreed to write to Mr C after the officer returned to duty.

Mr C complained about the prison's complaints handling. He said that the prison failed to write to him following the officer's return to duty, and that he had to pursue the matter himself. He also complained that the response he received differed to the response issued on the same day to the other prisoner.

We upheld both complaints with recommendations. We considered that the prison should have progressed the handling of Mr C's complaint. We also considered that the information provided to the other prisoner was relevant to Mr C's complaint and should also have been shared with him.

Recommendations
We recommended that the Scottish Prison Service:
• ensure they put systems in place to track the follow-up of commitments they have chosen to give;
• apologise to Mr C for failing to honour the commitment they gave to revert to him following an officer's return to duty;
• provide Mr C with a fuller response communicating all relevant available information; and
• apologise for failing to provide all relevant available information in the first instance.

Summary
Mr C had problems with his hip and used a walking aid. He fell while walking with a friend in the city centre. The police, who attended to Mr C first, called an ambulance. Mr C complained that the ambulance crew did not provide adequate care and treatment to him. Specifically Mr C said that the ambulance crew did not give him pain relief despite his requests; did not properly assess the injury to his leg; and did not take him to hospital despite his requests. Four days after falling in the city centre, Mr C fell at home and was taken to hospital, where he was diagnosed with a broken leg. Mr C felt that the break happened when he fell in the city centre.

We found from looking at the records, and taking advice from one of our professional medical advisers, that there was anecdotal evidence that Mr C did ask for pain relief. However, our adviser said it would not have been appropriate to administer it in the specific circumstances. We also found that the ambulance crew's record of the assessment of Mr C was inadequate and, given subsequent events, appeared to have been deficient. There was anecdotal evidence that Mr C did ask to be taken to hospital. We found the decision not to take Mr C to hospital was correct, based on the assessment carried out by the ambulance crew. However, given that the assessment was deficient, that decision could be questioned. Therefore, given the failings identified, we concluded that the ambulance crew did not provide adequate care and treatment to Mr C, and we upheld his complaint.

Recommendations
We recommended that the service:
• apologise to Mr C for the failure of the ambulance crew to provide him with adequate care and treatment; and
• ensure the ambulance crew refresh their knowledge of the relevant sections of the UK Ambulance Service Clinical Practice Guidelines relating to limb injury and pain management.

Summary
Ms C was injured when there was an accident involving the stair lift on which she was being transported by a member of the Scottish Ambulance Service (the Service) to a hospital appointment. She complained that, following the accident, she reported the matter to the receptionist at the clinic and was told that someone (apparently the lead nurse of the clinic) would come to see her. This did not happen before Ms C was collected again by the Service for transport home.

Ms C also complained that despite being in pain from her injuries no hospital staff came to check her over. She also said that when the board responded to her complaints the letters contained inaccurate information, including referring to her injuries being caused when she was 'putting her aunt onto the stair lift' and that she had been 'walking with the consultant' within the clinic. Ms C was in fact in a wheelchair the whole time she was in the clinic on this day.

We upheld all of Ms C's complaints and made relevant recommendations. The board acknowledged that the incident had occurred (while Ms C was in the care of the Service) and that Ms C had made hospital staff aware that it had happened. Although a member of staff checked with the Service that they knew about the matter, no action was taken to report it within the hospital's own policy on accidents. The board had not referred in their response to the failure of the lead nurse to come to speak to Ms C while she was in the clinic.

On the matter of Ms C not being checked over, the board said that the consultant that Ms C was there to see recalled Ms C mentioning that she had had an accident but not that she had been injured and/or was in pain. They also said that none of the other staff had any recollection either of Ms C saying she was in pain or that she seemed to be in pain. Although there was no conclusive evidence to support either version of events, we found that although aware that there had been an accident, there was little evidence to suggest that staff had taken steps to find out how Ms C was after it happened. On balance, therefore, we took the view that little or no effort had been made by staff to establish the extent of Ms C's injuries and/or pain.

On the issue of their complaint response, the board acknowledged that there were errors in two letters. In particular, the chief executive said that the comment about Ms C walking within the clinic was based on the recollections of staff from a previous visit to the clinic by Ms C. The chief executive accepted that on the day in question Ms C was in a wheelchair the whole time she was in the clinic.

Recommendations
We recommended that the board:
• apologise to Ms C for the failures identified; and
• review the policy and procedures for reporting accidents and ensure that all staff are aware of the policy and their responsibilities within it.

Summary
Mr C was left without water from Christmas Day 2010 until 14 January 2011. He said that when he telephoned Scottish Water, the message he received was that as his pipes were frozen, Scottish Water would not attend. He, therefore, arranged to have the matter dealt with himself, only to be advised that the toby (a water stopcock) was also frozen, and like the pipes was set too high. The toby was the responsibility of Scottish Water and was understood to be a contributing factor.

Scottish Water took no action on the toby until 19 September 2011. In the meantime, on 8 September 2011, Mr C submitted a claim for compensation for the time he was without water but this was rejected as Scottish Water took the view that it was out of time. Mr C complained that this was unfair as he had initially been told that the problem was for him to resolve and he had since discovered that this was not the case because of the problem with the toby.

After an investigation which confirmed the facts, it was confirmed that Scottish Water missed the opportunity to alert Mr C to the possibility of making a claim when they became aware of the problem with the toby in January 2011. We found that the decision to refuse to consider Mr C’s claim was unreasonable, and we upheld the complaint.

Recommendation
We recommended that Scottish Water:
• makes the complainant a payment of a specified amount in recognition of the time he was without water.

Summary
Mr C complained to the council about an incident involving his granddaughter, where a misunderstanding amongst social services staff left her unsupervised during an outing. A Social Work Complaints Review Committee (CRC) was subsequently convened to consider the complaint.

Mr C then complained to this office that he did not receive a copy of the Social Work Services' report to the CRC members until two days before the hearing. The submissions for both parties to the complaint are required to be issued to the CRC members at least seven days before the hearing. Our enquiries revealed that the council wrote to the members, appending all submissions, four days before the hearing. They were unable to explain why this had happened and, in the circumstances, we upheld the complaint.

Recommendations
We recommended that the council:
• apologise to Mr C for the delay in issuing the relevant papers in advance of the CRC hearing; and
• remind staff of the importance of adhering to the relevant timescales when arranging CRC hearings.