Upheld, recommendations

Summary
Ms C complained about the board's treatment of her wrist injury. She complained that the investigation of her injury and treatment had not been reasonable, and that the treatment had not been undertaken within a reasonable timescale. We upheld both complaints.

We found that a failure to assess Ms C's symptoms from the outset and to treat them with a high level of suspicion had led to failings in her care. We were critical of a number of aspects of the care, including the decision to treat her with a splint initially rather than a cast (whilst acknowledging this may not have impacted upon the healing of Ms C's fracture, we found more consistent immobilisation would have assisted in easing Ms C's pain and discomfort, as throughout the course of her treatment she had splints and casts fitted and removed on several occasions). We also criticised the board's failure to send Ms C for specific wrist x-rays and the decision to discharge her on three occasions without appropriate follow-up care.

In relation to treatment being undertaken within a reasonable timescale, we found that Ms C should have been referred for physiotherapy at around the time she was diagnosed with the fracture. Instead, Ms C did not begin to receive physiotherapy until around six months later after she self-referred. We found this delay may have impacted upon her long term recovery.

Recommendations
We recommended that the board:
• provide a full apology to Ms C for the failures in identified in her treatment;
• review their Minor Injury Wrist and Forearm protocol to ensure that a patient presenting with symptoms potentially indicative of a scaphoid (wrist) fracture are appropriately investigated and managed; and
• ensure staff involved in Ms C's case are made aware of the need to arrange follow-up appointments when necessary, to give consideration toa physiotherapy referral for patients if appropriate, and that the board take these issues into account when reviewing their Minor Injury Wrist and Forearm protocol.
 

Summary
In late 2005, tests revealed that Mr C had elevated liver function tests and he was advised to reduce his alcohol consumption. Mr C's liver function tests became significantly elevated in 2007 and his GP believed that these were consistent with his alcohol history, a view supported by hospital specialists. In 2010, following tests, a hospital specialist diagnosed hepatitis C.

Mr C complained that his GP did not look beyond alcohol misuse as the cause of the abnormal results and that he should have been screened for hepatitis C much earlier. He said that as a result of the failure to do so, he began treatment at an advanced stage of the disease which had impacted adversely on his chances of surviving.

We found that the GP failed to fully investigate Mr C's liver functions abnormalities, particularly in 2007. Although it was impossible to say definitively whether Mr C would have tested positive for hepatitis C earlier than 2010, we found that it was possible he might have and, therefore, an opportunity to make an earlier diagnosis was missed and treatment was potentially delayed.

Recommendations
We recommended that the practice:
• review its management of liver function abnormalities including information provided in referrals; and
• apologise to Mr C for the failures identified.

Summary
Mr C, who is a prisoner, received a copy of his Integrated Case Management (ICM) case conference record. This document records the discussion and outcome at a prisoner’s ICM case conference. This is a meeting where the prisoner and everyone who is involved in supporting them get together to talk about any issues, and about what the prisoner wants to achieve over the next year. Mr C complained to our office because he said that when he received a copy of his case conference record, he did not receive the form that prisoners should receive to sign to say they are happy with the record. This form is called the record of case conference outcomes.

The prison told us Mr C's personal officer gave him a copy of the case conference record and told Mr C to speak with him if he had any concerns. However, there was no written record of this conversation. The prison also said the form had been removed from the most recent version of the ICM case conference document. The ICM guidance manual clearly stated that the prisoner should be provided with the form. The Scottish Prison Service (SPS) also advised us that the most up to date ICM case conference paperwork did include the form.

In light of the information gathered, we upheld Mr C's complaint and recommended that the SPS remind staff involved in the ICM process to provide all prisoners with a copy of the form.

Recommendation
We recommended that the SPS:
• remind staff involved in the ICM process to provide all prisoners with a copy of the appropriate form.
 

Summary
Mr and Mrs C complained about an alleged breach of planning condition in relation to the screening of a landfill site and that they have been left with an open view of the site.

During the investigation we found that a condition attached to the planning consent required screening of the landfill site to be provided at all times.

We found that the council had investigated the matter but had decided, given the work carried out to address the issue of screening, that no further enforcement action would be taken. Although this was a discretionary decision for the council to take, we were concerned that the required screening had been absent for a number of years which amounted to a service failure.

Recommendations
We recommended that the council:
• apologise for the failure to provide screening of the landfill site; and
• consider whether there are any actions they could reasonably take to improve the current situation.

Summary
An MSP complained on behalf of Mrs A about the Scottish Ambulance Service (SAS). Mrs C's husband (Mr A) suffered a heart attack and the SAS were asked to dispatch an ambulance. The ambulance crew gave Mr A aspirin and carried out an ECG (electrocardiograph). It is normal practice for ECG results to be transmitted to the Golden Jubilee Hospital, which provides specialist emergency treatment for heart attack patients. However, on this occasion, the ambulance crew were unable to transmit the results. The paramedic who attended Mr A phoned the Golden Jubilee for advice, as per the protocol for such situations. He was advised that he could take Mr A to the Golden Jubilee if he was having a heart attack, otherwise he should be redirected to a local Accident and Emergency unit.

The paramedic understood that the correct procedure at that time was to take patients to the Vale of Leven Hospital for initial assessment. He did this, but, upon confirmation that Mr A was having a heart attack, staff at the Vale of Leven redirected him to the Golden Jubilee. By the time Mr A arrived at the Golden Jubilee, another patient had arrived and was treated before him. Mr A did not recover from his heart attack and died three weeks later.

We found that the equipment provided in the ambulance was not properly configured and prevented the ambulance crew from transmitting Mr A's ECG results to the Golden Jubilee. The protocol in place at the time of this incident required ambulance crews to take patients showing signs of a heart attack to the Golden Jubilee in the first instance. We found that the paramedic was not aware of the correct protocol and incorrectly decided to take Mr A to the Vale of Leven, delaying his treatment.

Recommendations
We recommended that the Scottish Ambulance Service:
• apologise to Mrs A and her family for the issues highlighted in this decision notice; and
• consider establishing a standard form of words with PCI (Percutaneous Coronary Intervention) centres to avoid any confusion as to what action ambulance crews are being advised to take.

Summary
Ms C enrolled on a professional development course at the college. Shortly after starting, Ms C’s former employer paid fees to the college for the course. Ms C complained that the college did not reasonably communicate changes in course provision, the consequences of which meant she felt that she was due a refund of some of the fees. Ms C also complained that the college did not reasonably communicate the contact details of the course tutor to her, and did not respond reasonably to correspondence about her complaint.

We found from looking at the evidence that the college did not reasonably inform Ms C, in terms of timeliness or detail, about the situation regarding changes in course provision. In addition, the college acknowledged that the change in the course tutor’s contact details was not communicated to Ms C. Therefore, we upheld these complaints.

The college also acknowledged that they took longer than allowed for in their complaints procedure to deal with part of Ms C’s complaint, and that they failed to respond to one of Ms C’s letters. In addition, the college’s responses to Ms C’s complaint letters, specifically about her course fees, were not consistent. Although the college said their complaints procedure was available on their website, it would have been good practice at the end of each stage of the process to inform Ms C of the next stage available to her, and the deadline for accessing that stage. We found from looking at the evidence that the college did not respond reasonably to Ms C’s correspondence and, therefore, we upheld this complaint.

Recommendations
We recommended that the college:
• apologise for not reasonably communicating changes in course provision, or changes in the contact details of the course tutor;
• in future, advise interested parties in writing where a proposed course requires validation by an external body, making clear the schedule, and the consequences if validation is withheld;
• apologise for not responding reasonably to Ms C’s correspondence; and
• review their handling of the complaint, in particular the thoroughness of investigations and the content and consistency of responses, with a view to ensuring they adhere to a transparent, concise and robust complaints procedure to avoid a recurrence of this situation.
 

Summary
Mrs C complained to the board about the treatment her late husband (Mr C) received at Ninewells Hospital in January and February 2011. Mr C had been attending his GP surgery since November 2010 with breathlessness, cough and weight loss. Mr C attended the hospital's A&E department in late January 2011 and after seeing a nurse and a doctor he was sent home and told to wait until the GP referred him to hospital. No medical assistance was given.

Mr C attended the respiratory clinic ten days later where he was x-rayed, weighed and had bloods taken. He was told he did not have cancer. Eight days later, the GP arranged for Mr C to be admitted to hospital that day and a CT scan was carried out two days later. The scan showed evidence of widespread infiltration of the lung, suggestive of malignant disease or infection. As the scan was inconclusive a biopsy of the lung was carried out the following day. The result indicated that Mr C had lung cancer which was rapidly progressing and which was unusual for a non-smoker. It was decided that Mr C should be transferred to a community hospital, where he died two weeks later.

We upheld Mrs C's complaint that her husband was unreasonably turned away from the A&E department when she brought him there when she was concerned at his condition and the lack of urgency shown by his GPs. We also upheld the complaint that when Mr C attended an outpatient appointment he was incorrectly told he 'definitely did not have cancer'.

Recommendations
We recommended that the board:
• remind nursing and clinical staff in A&E of the need to complete nursing and clinical records in accordance with the Nursing and Midwifery Council and General Medical Council guidance; and
• apologise to Mrs C for the failings identified in our investigation.
 

Summary
Mr C complained to us about the board's care and treatment of his late brother (Mr A) prior to his death. Mr A, who was elderly, was due to be admitted to hospital for an endoscopic examination. In anticipation of this, he was given medication the day before, but became very ill and was instead admitted to hospital on the day of the planned procedure, as an emergency. The next day, a Tuesday, Mr A had a colonoscopy and he was then considered ready for discharge in a few days. It was proposed he would be discharged on Friday or Monday, subject to the availability of an ambulance. However, he was returned to his care home by ambulance on the Saturday. Unfortunately, he was returned back to the hospital later that day in a very poor state, and died the next day. Mr C was of the view that his brother was unreasonably discharged from hospital. He also complained that the board's communication with his family was inadequate.

We fully upheld Mr C's complaints. Our investigation showed that there was little information in Mr A's clinical notes and our medical adviser pointed out that nothing at all was noted about his condition on the day that he was discharged. Accordingly, Mr A may well have not been ready and fit for discharge. Similarly, there was very little record of any discussion with Mr A and his family about his care and treatment.

Recommendations
We recommended that the board:
• apologise for the distress caused to Mr C and his brother at the time of Mr A's discharge from hospital;
• formally apologise to Mr C for their failures in communication;
• stress to their staff the importance of effective communication; and
• further review the quality of the content of their clinical notes as they were not held in accordance with relevant guidelines. They should report back to the Ombudsman about the action they take in this regard.
 

Summary
Mrs C complained that when her late husband (Mr C) was being transferred from Ninewells Hospital to his local community hospital his clinical records were not passed on and staff could not administer medication until they received them which was later in the day.

We established that Mr C's records were left in the ambulance and that responsibility for the safekeeping of the records rested with the ambulance service. Our report stated that medical records are important documents and have to be available should clinicians need to review them to obtain details of a patients medical history, medication etc. We were satisfied that in this case the delay was caused by human error. It was discovered shortly after Mr C's arrival that the records were missing and contact was made with the service. They located the records immediately and made arrangements for them to be picked up later in the day and delivered to the hospital. The hospital was content with this arrangement and stated that Mr C was not disadvantaged by the missing records and that he did not require his prescribed medication until after the records had arrived. They also explained that should Mr C have required assistance in the interim period then he would have been assessed by a clinician who would have prescribed appropriate medication if required.

Recommendations
We recommended that the service:
• review their procedures and consider whether measures such as a simple checklist could be completed by staff to ensure that medical records have been collected and delivered when a patient is transferred; and
• apologise to Mrs C for the delay in delivering Mr C's records.
 

Summary
Mr C first visited his GP in September 2009 with pain and swelling in his testicles and was referred to the urology team at the Western General Hospital. He was placed on a waiting list for treatment. He was seen in January 2010 by two specialists who could not agree a diagnosis and referred for a scan which was done in February. In March he was seen by another urologist and told that his problem was not a urology one. Mr C was referred back to the general surgical department and in April 2010 he received a letter telling him that he was on the waiting list to see a consultant.

Mr C telephoned the department to complain about this further delay but was told that nothing could be done. Mr C was seen in July 2010 in the colorectal department and referred for an MRI scan. He was seen again there in September 2010 and a hernia was diagnosed. Mr C was told that due to his other complex health difficulties, the remedial surgery he required would have to be done at another hospital by a specific surgeon. Mr C was seen there in November 2010 and had his surgery in January 2011. Mr C was dissatisfied with the wait for surgery which totalled some 64 weeks and the resultant increase in pain and discomfort he had to endure.

We upheld Mr C's complaint. We found that his wait for surgery had been excessive. There were a number of things that could have been done differently which would have reduced his waiting time. A CT scan was first considered in March 2010, but was not performed until August 2010. Mr C was reviewed by two registrars, who could have discussed his case with a consultant, given there were clear diagnostic difficulties. It was not until November 2010, over a year after Mr C had first been referred, that a consultant took responsibility for the management of his care. We also found the board's responses to Mr C's letters of complaint to be insufficient.

Recommendation
We recommended that the board provide a full apology to Mr C for the delay he experienced when waiting to undergo his operation.