Upheld, recommendations

Summary
Mrs C attended her GP in January 2010 complaining of abdominal pain. She complained that from then until November 2010 when she was diagnosed as having intra-abdominal cancer, her GP practice failed to either act upon her symptoms or treat them appropriately.

Our clinical adviser found that Mrs C had significant, persistent symptoms which appeared to become worse despite a number of medications related to the gastrointestinal tract. In the adviser's view, this should have prompted a review of the diagnosis especially in the presence of a normal upper abdominal ultrasound and normal endoscopy and sigmoidoscopy (a procedure used to see inside the sigmoid colon and rectum). The adviser added that Mrs C's communications with the practice were clear and concise and that her requests for assistance were specific. Accordingly, the adviser concluded that the management of Mrs C was deficient and we upheld the complaint.

Recommendations
We recommended that the practice:
• formally apologise to Mrs C for their oversights in her management and perform a Significant Event Audit; and
• ensure that the GP discusses this case at their next appraisal.
 

Summary
Mr A was an elderly man with a history of hypertension, aortic aneurism, and chronic kidney disease. Mr A fell while crossing the road and was taken by ambulance to hospital, where he stayed for several days. He was discharged but remained unwell and was admitted again a few days later. He was discharged after several days. Mr A remained unwell and was admitted to another hospital about three weeks later, where he died after three days. His daughter (Mrs C) complained that the care and treatment her father received during and between his second and third admissions was inadequate, that her concerns and information she provided were not recorded or reasonably acted upon during his second and third admissions, and that the board's complaint handling was poor.

Having looked at the clinical records and taken advice from two of our medical advisers we found that Mr A's care and treatment appeared, overall, to have been reasonable. However, we upheld Mrs C's complaints. We identified a number of failings in relation to obtaining Mr A's first admission records, prescribing antihypertensive medication, communication about drug treatment and discharge planning. We also found that the board had acknowledged that information provided by Mrs C was not always recorded.

In addition, our advisers found only limited evidence of communication being recorded, which was below a standard that could reasonably be expected. We also found that, although it was reasonable for the board to have asked different clinicians for their views of Mr A's treatment, more could have been done to integrate their views into a coherent response to Mrs C's complaints. The board should have explained in advance of a meeting with Mrs C why staff responsible for the administration of records were not included, despite Mrs C having asked for them to be present. The note of the meeting should have been checked more carefully to ensure that the correct names were used, as Mr A's name was wrong in two places. In the board's response to Mrs C's final complaint, they should have provided more information about what was done to address the issues raised about Mr A's third admission, and they should have openly acknowledged their failings in handling Mrs C's complaint.

Recommendations
We recommended that the board:
• review their procedure for urgently obtaining clinical notes of patients re-admitted, to reduce the opportunities for the procedure to fail;
• review this case to improve practice on prescribing antihypertensive medication in such circumstances;
• review this case to improve practice on communicating between community and hospital care about drug treatment, and recording such communication in the clinical record;
• review their discharge policy, to ensure it complies with national guidance and that staff act in line with it;
• apologise to Mrs C for staff failing to communicate with her to a reasonable standard about Mr A and for failing to deal with her complaint appropriately; and
• review how they draft responses to complaints, to ensure these are coherent and transparent.
 

Summary
Ms C complained that the council treated her unfairly when administering her council tax account. She said that money continued to be deducted from her pension credit to pay council tax after the council said that they had instructed the Department of Work and Pensions (DWP) to stop this. Ms C also said that she was incorrectly charged for a late payment, and that the council did not give her sufficient information about the years to which the arrears on her account related. Ms C’s complaint included an allegation that the council failed to deal with her complaints according to their complaints procedure.

We upheld all of Ms C’s complaints. When we investigated, the council confirmed that they had told DWP to stop the deductions. However, when DWP told them that this would not be done for some months, the council failed to follow this up despite Ms C complaining again about the continued deductions. We found this delay inappropriate. On the matter of the incorrect charge, the council accepted that Ms C was unlikely to have received the demand notice that resulted in the issue of a warrant for late payment. They also accepted that she was not given enough information about the council’s application to the DWP about deductions to her pension credit and about the unpaid council tax that resulted in this application being made. We noted that the council acknowledged in correspondence with Ms C that there had been delays in dealing with her complaint. As a result of our investigation they also accepted that they should have told Ms C that their response would be delayed.

Recommendations
We recommended that the council:
• apologise to Ms C for all the failings identified;
• apologise for failing to comply with the complaints procedure; and
• take measures to ensure that information is provided to customers when direct deductions are made, and confirm to us what these measures are.
 

Summary
Ms C’s property sits below a property that is leased to the council. She complained that the council failed to take appropriate action when they found out that a pipe had burst in the property above hers and that they failed to properly investigate her complaint. She also complained that the council failed to maintain the property when it was empty and left it without heating in extreme weather conditions.

Our investigation found that, although the council had taken appropriate action to look after the property while it was empty, including taking action to deal with the burst pipe, they had failed to make any contact with Ms C and had provided her with inaccurate information about the action they had taken.

Recommendations
We recommended that the council:
• review the circumstances of this complaint to consider whether there is a need for a written policy or procedure to formalise the action to be taken when dealing with future similar circumstances;
• in circumstances where an owner occupier cannot be contacted by the council, consideration be given to leaving a card for the owner occupier explaining the situation and providing relevant contact details; and
• apologise to Ms C for the inaccurate information provided when responding to her representations and take steps to try to ensure that accurate information is provided when responding to complaints.
 

Summary
Ms C was unhappy with the council’s complaints handling when she complained to them about a social work related matter. She complained that there were delays in the complaints process; that she was not given information about the process, and that there was a delay in providing her with a report from a Complaints Review Committee (CRC).

Our investigation found that when Ms C lodged a formal complaint, the council failed to respond appropriately. They delayed in responding, and in telling her the outcome of the CRC (which the council told us was due to a particular member of staff not being available). We also found that they twice failed to tell Ms C that she could take her concerns to a CRC, despite this being part of the statutory social work complaints process.

Recommendations
We recommended that the council:
• analyse the cause of the delays that occurred in Ms C's case and put in place measures to prevent a recurrence. The council’s analysis should cover all instances of delay, but particularly look at what arrangements are required to ensure that a member of staff’s allocation of different duties does not interfere with the statutory timescales for responding to complaints; and
• remind members of social work staff who are likely to deal with complaints of the requirements of the procedure, in particular with regard to how a formal complaint should be dealt with and what information should be provided to complainants about how to progress their complaints.
 

Summary
Mrs C’s two-year-old daughter was diagnosed with hip dysplasia. Mrs C felt that her GP should have diagnosed this sooner. She complained that the GP had not properly carried out developmental examinations of her daughter during the first year of her life. The board told Mrs C that the GP had reviewed her computer records and felt that they contained a reasonable level of detail for such an examination. No abnormality had been observed. They said that the GP’s usual practice would be to properly examine a baby at such an examination and that hip dysplasia can be difficult to detect in the early stages. The GP apologised for not having written in the parent-held medical records.

Mrs C, however, was dissatisfied that the board had not presented evidence that usual and proper procedures had been followed. She was concerned that the clinician had not noticed the extra skin crease and leg length discrepancy that she believed had always been present. She was also concerned that the board do not carry out further tests on older babies if hip dysplasia is difficult to detect in early stages. She recalled that her older daughter had had an examination at 8-9 months. The board said that records showed that Mrs C’s daughter’s hips were examined at birth and at six weeks, and that these examinations were properly recorded. They advised that the 8-9 month examination was discontinued in 2005, after the introduction of new guidelines. Mrs C was dissatisfied with this response and brought her concerns about the board’s complaint handling to us. We found that the board had not reasonably considered Mrs C's complaints, as they based them only on the GP's recollections. Given this, we upheld Mrs C's complaint.

Recommendation
We recommended that the board:
• apologise to Mrs C that their handling of her complaint was not reasonable.
 

Summary
Ms C complained about the treatment her sister (Mrs A) received following a fall. Mrs A suffered from early onset Alzheimers disease and fell at home injuring her face and chest. She attended an Accident and Emergency unit (A&E) but was discharged without having had x-rays or a CT scan. Ms C complained about what she saw as inadequate investigation of her sister's injuries and a lack of timely pain relief or follow-up treatment. She also complained about the board's complaints handling and the fact that Mrs A was denied access to the Falls Team because she was under 60 years of age, which was apparently the minimum age to be able to access this service.

After taking advice from one of our professional medical advisers we upheld all of Ms C's complaints. Although our adviser confirmed that x-rays and a CT scan were not in fact necessary, we found the board's investigation of Mrs A's injuries inadequate, as they did not follow national Scottish Intercollegiate Guidelines Network (SIGN) guidance on the observation of head injuries. We also found that the board's policy was in fact to allow patients under the age of 60 to access the Falls Team if this was clinically indicated. The policy, however, was not followed on this occasion. We found that the discharge planning process was inadequate and that there were inaccuracies in the board's response to Ms C's complaint.

Recommendations
We recommended that the board:
• apologise to Mrs A's family for the delay in providing her with appropriate pain relief;
• remind staff in A&E of the need to both establish and adequately record the criteria for discharge following head injury contained in SIGN Guidance 110; and
• re-emphasise to complaints handling staff the importance of having an informed clinical review of complaints responses before they are issued.
 

Summary
Mrs C's son (Mr A) was removed from his dental practice’s list of patients. When he attended a new dentist, he was told that he needed at least nine fillings. Mrs C complained that the original dentist had provided inadequate dental treatment to her son resulting in the need for several fillings.

The original dentist maintained that Mr A had poor oral health and said that he only attended for emergency appointments. The dentist said that at such appointments it would not be usual practice to undertake a full check-up, and on the day of attendance they would concentrate on the cause of pain.

We were not able to establish whether the dental decay developed before or after the initial visit to the new practice. We upheld the complaint, however, as we noted that the original practice did not follow Scottish Intercollegiate Guidelines Network (SIGN) guidelines in that they did not take recommended (bitewing) x-rays or carry out a full assessment of Mr A.

Recommendation
We recommended:
• that the dentist takes into account the contents of SIGN 47 for future reference.
 

Summary
Mr C had requested a home visit early in 2010 which was refused. In December 2010 he contacted the practice by email to ask why the visit had been refused and to ask for a copy of the practice policy on home visits.

The practice manager responded five days later by email explaining the policy on home visits. The final paragraph of the emailed letter stated that Mr C's previous email had 'sullied' the patient / doctor relationship and Mr C was to be removed from the list. Mr C complained that the decision to remove him from the GP list without prior warning was unreasonable. We found that it was not appropriate for the practice to have taken the action they did without first giving Mr C a warning and we, therefore, upheld his complaint.

Recommendations
We recommended that the practice:
• apologise to Mr C for the failings identified in this report.

Summary
Mr C complained about care and treatment provided to his wife, Mrs C. Mrs C was admittted to Accident and Emergency at Ayr Hospital in December 2010 after a fall at her home. She had a suspected fracture. After being assessed, it was confirmed that she had a fractured pelvis. She spent the night in an observation ward.

The next day, because she was unable to mobilise and was in a lot of pain, Mrs C was sent for a period of rehabilitation to Biggar Hospital. While there, her condition appeared to deteriorate and late the following day Mrs C was moved back to Ayr Hospital. Shortly afterwards, Mrs C died.

Mr C complained that his wife was not given proper care and treatment and our investigation found that there were unreasonable failings in aspects of her treatment at both hospitals.

Recommendations
We recommended that the board:
• apologise to Mr C for their failings with regard to his late wife's treatment; and
• remind staff involved of the nature of acute medical conditions in terms of the fast tract protocol, with particular reference to the exploration of unresolved issues prior to transfer.