Upheld, recommendations

Summary
Mrs C complained about the care and treatment provided to her late husband, Mr C, and about the way in which the board handled her complaint.

Mrs C said that her husband was diagnosed as having prostate cancer in November 2006. She said that this was confirmed by a biopsy but that complications arose. She said that Mr C rang the hospital for advice about being unable to pass urine but he was wrongly referred back to his GP. As this was over the weekend, his GP was unavailable.

Generally, things appeared to settle by mid 2007, but, Mrs C said, from April 2007 her husband was complainaning of rectal bleeding, which continued until his death. Mrs C said this was raised at every meeting with clinical staff but the cause was suggested to be haemorrhoids.

In late 2008, Mr C was diagnosed with cancer of the liver and given hormone replacement therapy. Mrs C complained that by the end of 2009, he was suffering considerable pain and discomfort and that the quality of his life reduced significantly. She said that there was no coordinated plan for his treatment and that despite frequent requests for help there was no sense of urgency on the part of clinicians. She alleged that what action points there were, were not implemented. She complained that by 2010 there was a dramatic decline in her husband's condition and he was moved to Ninewells Hospital but again, she said that there was no coordinated plan and that Oncology and Urology failed to work together. She alleged that any treatment for Mr C was merely reactive.

After her husband died, Mrs C raised these matters as a formal complaint. She said that the time taken to deal with the complaint was too long and that the responses she recieved failed to answer her concerns. We fully upheld these complaints and also those about the care and treatment of her husband.

Recommendations
We recommended that the board:
• confirm to the Ombudsman the procedures for cover of absent consultant staff to ensure that continuity of care is maintained;
• remind oncology staff to involve urology staff in the management of catheterised patients; and
• highlight to the urology department that regular renal function measurement is required as part of the monitoring of patients with symptoms of prostatism and potential obstruction.
 

Summary
In early 2011, Mr C complained to the board about the length of time he was told he would have to wait on the waiting list for a psychological assessment. He had already been on the waiting list for over nine months and was told it would be another eight to ten months before he would be seen.

The board apologised to Mr C for the length of time that he would have to wait before treatment and told him that the problem was caused by the departure from post of one of the psychologists. They hoped to recruit a replacement as soon as possible and the manager had been working with the psychological department to reduce the waiting times as quickly as possible.

Mr C complained to us and we found that in 2008 the Scottish Government issued guidance to health boards so that they could take action to be best placed to meet new waiting time targets of 18 weeks from referral to treatment due to take effect from 2014. We found that the board failed to demonstrate to us that they had taken action in accordance with the guidance and that Mr C had waited too long for an appointment.

Recommendations
We recommended that the board:
• develop an action plan to deliver aspects of the 'Matrix' (the 2008 Scottish Government guide to delivering evidence-based psychological therapies) which are relevant to the situation in their area; and
• apologise to Mr C for the unreasonable delay he had on the psychological therapy waiting list.
 

Summary
Miss C suffered from abdominal pain and attended A&E on three occasions between July and August 2008. Appendicitis was suspected, but Miss C's symptoms settled and she was discharged after a short admission on the first two occasions. On the third admission, her symptoms did not settle and a laparoscopy was carried out to diagnose the cause of her pain. During the procedure, her appendix was removed and she was noted to have an inflamed uterus and fallopian tubes. Miss C continued to have recurrent abdominal pain following surgery.

Miss C complained that, at a routine doctor's appointment in 2010 she was told that she had been diagnosed with Pelvic Inflammatory Disease (PID) in August 2008. She had not been made aware of this diagnosis and complained that she had not been treated for it. She also questioned why her appendix had been removed.

We found that a provisional diagnosis of PID was made during the laparoscopy in August 2008. Miss C was treated empirically for PID with a course of antibiotics. We were satisfied that the removal of her appendix was in line with standard practice during laparoscopies. However, we found no evidence of Miss C being informed of her presumed diagnosis of PID or of another diagnosis that was also made at the time. Whilst treatment was clearly provided for her PID, we concluded that the combination of antibiotics used and the dosages prescribed were not in line with guidelines on the treatment of this condition. Furthermore, there was no evidence of any treatment being provided for Miss C's other condition.

Recommendations
We recommended that the board:
• review their procedure for obtaining patient consent to ensure that it is in line with the Scottish Government's Good Practice Guide for Health Professionals in NHS Scotland;
• provide the Ombudsman with details of any action they have taken, or propose to take, to ensure that patients are provided with information about the surgical team's findings;
• review their approach to treating patients with PID to ensure that the medication used is in line with the guidance in the Royal College of Obstetricians and Gynaecologists' document, Management of Acute Pelvic Inflammatory Disease;
• ensure that any future treatment that Miss C receives for PID is in line with the guidance in the above document; and
• apologise to Miss C for the issues highlighted in this decision letter.
 

Summary
Mr and Mrs C complained about the games area in a new community campus beside their home. They were unhappy about light spillage from the floodlighting for the games area into their garden. In particular, they complained about the council's failure to take enforcement action on a planning condition about light spillage from the community campus. The planning condition for the campus said that there should be no light spillage beyond the boundaries of the site to the satisfaction of the planning authority.

We were satisfied from the evidence we saw that light spillage from the games area had occurred. Planning authorities have a general discretion to take enforcement action against any breach of planning control if they consider such action appropriate. We did not consider that the council had taken satisfactory steps to mitigate the effects of the floodlighting and to address Mr and Mrs C’s complaints about this matter. Although the light levels in Mr and Mrs C’s garden had been measured, this was done by staff from the facilities management group contracted by the council to manage and run the facility, and not by council staff.

Our planning adviser commented that the use of terms such as ‘to the satisfaction of the planning authority’ had been discouraged in the Scottish Government Planning Circular 4/1998 – ‘The Use of Conditions in Planning Permissions’.

Mr and Mrs C were also unhappy that the council had failed to take action in response to their complaints about antisocial behaviour by users of the games area. The Centre Manager confirmed that Mr C had contacted him about this eight to ten times during two months in 2010. We found that the council had taken action to try to prevent balls going into their garden and had put up signs asking customers to mind their language.

However, the Centre Manager also stated that he did not have a record of each time Mr and Mrs C made a complaint. It was clear that management staff at the campus did not adequately record their complaints about noise/swearing and the balls coming into the garden. There was no evidence that the council established the facts and determined whether the behaviour complained of constituted antisocial behaviour. There was also no evidence that consideration was given to referring the matter to the council’s Antisocial Investigations Team.

When Mr and Mrs C made a written complaint to the council about this, they were told that they needed to notify the council of incidents at the time so that management staff at the campus could investigate and deal with the matter. The council also delayed in responding to their written complaints about the matter. In view of all of these failings, we upheld the complaints.

Recommendations
We recommended that the council:
• remind staff that, in line with Scottish Government planning circular 4/1998, they should not use phrases such as ‘to the satisfaction of the planning authority’ in planning conditions for matters such as floodlighting. in such cases, specific and detailed plans should be sought from developers, and subsequent planning conditions should be worded to ensure compliance with these plans;
• take all reasonable action to enforce the planning condition;
• review their guidance on obtaining statistical evidence relating to a condition of planning consent from staff employed by the operators of the site to which the condition applies;
• remind the relevant staff involved in the case that complaints of this nature should be clearly recorded and investigated where appropriate;
• give consideration to taking further action to try to resolve the matter and/or referring the matter to the council’s antisocial investigations team; and
• apologise to Mr and Mrs C for the failings identified.
 

Summary
In August 2009 Mrs C attended her GP complaining of a lump in her left breast. She was examined and asked to return for a follow up appointment a week later. She was seen by a different GP at the review appointment and was advised that the lump was most likely a cyst. She was told to monitor the lump over the course of a few menstrual cycles. No follow-up appointment was made. Mrs C said that the lump increased in size and she returned to her GP practice in August 2010. She was seen by a third GP, who was concerned by the lump and referred her to a breast clinic for further investigation. The lump was found to be cancerous. Each of the three GPs described the lump as being in a different location and the Practice concluded that different lumps had been examined.

Mrs C maintained that she had had the same lump since August 2009 and that it had increased in size. She complained that the first GP incorrectly noted the lump as being in her right breast, and that she should have been referred to the breast clinic by the second GP. Although it was not possible for us to confirm whether there had been three different lumps, or if the same lump had been described differently, we upheld both of Mrs C's complaints, as we found the first GP's record-keeping to be poor and possibly inaccurate. We found that the treatment plan proposed by the second GP was not in line with good practice guidance and that Mrs C could have been referred to the breast clinic significantly earlier, or had it confirmed whether her lump was just a cyst.

Recommendations
We recommend that the practice:
• add a note to Mrs C's records clarifying that she attended her examination on 14 August 2009 complaining of a lump in her left breast;
• draw their staff's attention to the guidance in SIGN 84 and the Scottish Primary Care Cancer Group's publication: Scottish referral guidelines for suspected cancer; and
• apologise to Mrs C for the failings identified by our investigation.

 When this report was first published on 21 September 2011, it was incorrectly categorised as being about Greater and Glasgow and Clyde NHS Board. This was due to an administrative error which we discovered on 22 September 2011, and for which we apologise.

Summary
Mr C owns a flat in a tenement block in central Edinburgh which he lets out. In March and September 2008 the council served two statutory repairs notices on owners of the block under section 24(1) of The City of Edinburgh District Council Confirmation Order Act 1991. Mr C was unaware of the notices until about a week before the works were due to start. He complained that the council failed to serve notice on him of the repairs. Our investigation established that this was the case and that in drawing down the list of owners to be served, Mr C's flat was wrongly numbered.

Summary
Mr C complained that the council had effectively recommended a tradesperson by giving him a trader's contact details. He was also concerned about the way the council handled his subsequent complaint. When we investigated this, the council said that they did not have a written policy on recommendations, as their standard practice was that they did not make these. We decided that this position was in fact undermined when they provided Mr C with contact details for a particular trader. Whether the council chose to refer to this as a 'recommendation' or not, we took the view that members of the public are likely to consider a trader suggested by an authoritative body such as the council as, effectively, having been recommended. On the complaint handling, we found that the council suitably investigated Mr C's concerns about his consumer complaint. However, they did not look at his concerns about the 'recommendation'. Instead they took the view that a complaint would only be accepted where 'there is evidence of service failure or maladministration on the part of the council'. We found that this was not supported by their complaints process. The council should have been able to investigate and respond to his concerns that their consumer adviser provided him with the trader's contact details.

Summary
Mr C complained that the council failed to respond to his written complaint about a road layout. Our investigation found that the council had contacted Mr C to discuss his concerns. The officer who spoke to him said the matter would be dealt with the following week. Mr C said he was happy with this and the council closed their complaint file. When we looked at the correspondence, however, it became clear that as a result of the discussion the officer thought that Mr C was complaining about problems in a different place. The officer, therefore, arranged for work to be carried out in an area that was not mentioned in Mr C's original letter. As Mr C had said during the discussion that he was happy the work was going to be done, the complaint was closed without replying to the original point. We, therefore, found that the council had not answered Mr C's complaint. We also noted that it would have, in any case, been appropriate to respond in writing to complete matters. Had this been done it is possible that the misunderstanding could have been resolved then. As a result of this we upheld the complaint and recommended that the council respond to the points raised in his letter. The council have now done so.

Summary
Mr C was a new patient at the practice and his medical records had not yet arrived. While the practice was waiting for them, Mr C asked for additional medication. When he did not receive this, he complained about how the practice had dealt with his request. We found that they had not in fact properly actioned it. We recommended that the practice apologise to Mr C and carry out a significant event analysis to identify the problem and prevent a recurrence.

Recommendations
We recommend that the medical practice:
• apologise to Mr C for the way they dealt with his request; and
• conduct an Significant Event Analysis of this incident.

Summary
Mr C raised concerns about a telephone consultation that he had with his GP. He was suffering from severe lower back pain. He told us that he believed that he should have had a home visit as he was admitted to hospital later that evening with Cauda Equina Syndrome (a disabling condition caused by compression of the nerves of the spine). Although our investigation found that the GP's management plan was reasonable, we found that her notes of the consultation were limited. Our medical adviser told us that in the circumstances a physical examination of Mr C was required. As this should have been carried out at his home, we upheld Mr C's complaint that the GP's telephone assessment of his condition was inadequate. We did, however, recognise that it was possible that the outcome would have been the same, even had the physical examination taken place.