Upheld, recommendations

Summary
Ms C complained about the Scottish Ambulance Service’s (the service) investigation into the circumstances where her late partner's wallet went missing when an ambulance attended to him following a serious accident.

We found that initially it was reasonable for the service to wait for the result of a police investigation into the missing wallet (which concluded that it had most likely been disposed of as clinical waste). However, after receiving the police report it was 40 days before the service wrote to Ms C with this information. This was despite Ms C telephoning during that period asking for updates. We, therefore, upheld her complaint and made recommendations to address these failures. The service also told us that they did not at that time have a lost property procedure but would develop one, so we made no recommendation in respect of this.

Recommendations
We recommended that the service:
• remind staff of their responsibilities to respond to complaints in a timely manner; and
• apologise to Mrs C for the delay in responding to her complaint.

Summary
Mr C underwent a hernia repair and had a testicle removed in January 2011. He later developed a painful swollen lump where his testicle had been. He attended a post-operative review with the consultant surgeon about six weeks after surgery and was advised this was a haematoma (an accumulation of blood) that would decrease over time. However, the lump became bigger and Mr C went to the hospital's accident and emergency unit a few weeks later, where the lump was drained.

In May 2011 Mr C’s GP made an urgent referral for him to be seen again at the hospital. The referral was considered, and re-graded as routine, and Mr C was given a general surgery appointment for August 2011. His GP, however, wrote to the hospital again, and a consultant identified that Mr C should be seen by the surgeon who had operated. He was given an appointment at that clinic for July 2011. Mr C said he would like further surgery to remove the haematoma, and was monitored in relation to this until he was given a date for surgery.

He complained that there was a delay in treating his ongoing difficulties. We found that, although Mr C was initially treated appropriately in his post-operative review, a failure to record full clinical findings after the haematoma was drained meant that a possible opportunity to refer him for a further clinic review had been missed. Although we accepted the board’s general position about the re-grading of referrals, we could not find evidence of why Mr C's initial referral was re-graded as routine. We also found that the board did not appear to operate a mechanism for identifying patients like Mr C who needed to be referred back to their operating surgeon. The board also acknowledged that there had been a delay from the point of referral until the offer of an appointment. In the circumstances we found this to be unreasonable, and upheld Mr C’s complaint.

Recommendations
We recommended that the board:
• review the referral system to ensure when referrals are re-graded the reasons for doing so are clearly documented and communicated; and re-referred patients are routed back to the appropriate consultant; and
• provide a full apology to Mr C for the failings identified.

Summary
Mr C complained about the treatment that his late mother (Mrs A) received in hospital. Mrs A had been admitted for a suspected stroke. A diagnosis of a TIA (transient ischaemic attack or 'mini-stroke') was made and Mrs A was discharged on a Friday to a facility staffed by mental health staff. Mr C and the mental health staff were concerned about Mrs A's condition and tried to arrange for Mrs A to be transferred back to the hospital but were told this could only happen after she had been assessed by a clinician. Mrs A was assessed on the Monday and was transferred back to the hospital, where tests revealed she had suffered a stroke. Mr C complained that Mrs A had not been fit for discharge on the Friday. The board conducted a significant event review which concluded that there was a breakdown in communications and staff at the facility did not follow recognised procedures and made several recommendations. Mr C also complained that the board failed to respond to his requests to meet with senior staff.

After taking advice from two of our advisers, a consultant physician and a senior nurse, we upheld Mr C's complaints. We found that poor record-keeping at the time of transfer contributed to a breakdown in communication between medical and nursing staff about Mrs A's condition, and that the board should have kept Mr C updated about plans for a meeting with staff.

Recommendations
We recommended that the board:
• share our findings with the staff involved and remind them of the importance of completing comprehensive discharge documentation to assist the receiving clinicians;
• apologise to Mr C for the way in which it dealt with his request to meet senior managers; and
• apologise to Mr C for the failings identified during this investigation.

Summary
Mr C, an advocacy worker, complained on behalf of Mr A that his condition was not properly diagnosed and that he was prescribed a named drug inappropriately. He alleged that the consultant concerned had been dismissive and did not review Mr A again as promised.

We obtained advice from one of our medical advisers, who considered Mr A's clinical records. We established that the assessment of Mr A and his treatment were appropriate, as was the drug prescription given to him. However, we also found that follow-up arrangements were far too lengthy given Mr A's presenting symptoms, which were progressive. Our adviser said that arrangements should have been made sooner given that Mr A’s symptoms were unresolved and that the results of a procedure at the hospital required evaluation.

Recommendations
We recommended that the board:
• offer Mr A an apology for their failure to review him at an earlier date; and
• the consultant review his follow-up practice in similar circumstances.

Summary
Ms C complained about the care and treatment provided to her late grandmother (Mrs A), by the board. Mrs A was admitted to hospital in June 2011 because of increased frailty, poor oral and dietary intake and a urine infection. She was discharged in July 2011 and died two weeks later. Ms C complained about the communication between staff and the family during Mrs A's admission to hospital. She said that, given the seriousness of her condition, staff should have been more proactive in updating the family, who only received information when they asked staff directly. Ms C also said that some staff had a negative attitude and were reluctant and ungracious when responding to requests for information. Furthermore, staff failed to make the family aware of the gravity of Mrs A's condition on discharge, which meant that the family were unprepared for her death.

We found that the amount of communication with the family appeared reasonable, but we could not establish with any certainty who prompted the discussions, or the attitude of staff during them. However, we found that the records showed that the quality of communication was variable and that there should have been more consistency in recording discussions with family members. We also found no evidence to show that Ms C and her family were told that Mrs A was likely to be approaching the end of her life.

Recommendations
We recommended that the board:
• bring our findings to the attention of relevant staff to reflect on communication with patients’ carers and families, particularly around end of life issues;
• review how communication is recorded and ensure that staff make accurate and clear records of discussions with patients’ carers and families; and
• apologise for the failures identified.

Summary
Mr C runs a car sales business and uses a building to store vehicles. Scottish Water identified his premises as a gap site and made arrangements for a meter to be fitted to begin charging for water. A fitter visited the premises and installed the meter above a sink in the building. Business Stream were then contacted to set up a business account for Mr C.

During a cold spell, the meter's fittings burst and flooded the premises, causing damage. Mr C complained that he received no prior notice that he would require a water meter or that it would be fitted in his premises. He said he was not given the opportunity to choose a licensed provider for his water account. He also complained that the meter was fitted incorrectly, and that he was given no information about his responsibilities for its maintenance. Mr C submitted an insurance claim, but this was rejected on the basis that the meter was installed correctly and the problem had been caused by extreme weather.

Business Stream acknowledged that Mr C was not given notice of Scottish Water's arrival to fit the meter, but said that this was not possible as Scottish Water would not have the customer's details at that point. They explained that it was Mr C's responsibility to maintain the meter and to protect it from the cold weather. This information is held in their terms and conditions on their website.

We found that Scottish Water did not properly follow the correct process for supplying newly identified gap sites. Customers should be contacted in advance and given the opportunity to choose their preferred licensed provider. This did not happen in Mr C's case. With regard to the burst water meter, whilst it is not for this office to determine whether the unit was installed correctly, we did not consider it reasonable to expect Mr C to visit Business Stream's website in order to look up their terms and conditions for specific details as to how to maintain the meter. We felt that this information could have been provided at the point of installation. We also upheld Mr C's complaint that Business Stream's handling of his complaint was poor.

Recommendations
We recommended that Business Stream:
• apologise to Mr C for the issues highlighted in our decision letter;
• take steps to ensure that customers are provided with information regarding maintenance of water meters either at the point of installation or when their account is opened;
• share our decision with Scottish Water to ensure that the central marketing agency's procedure for allocating gap sites identified by them is properly followed; and
• pay Mr C a sum equivalent to the total of his initial insurance claim plus any fees incurred for the disconnection of his water supply.

Summary
Ms C suffers from a rare blood disorder. In 2009, she was diagnosed with mini-strokes, and prescribed medication. Tests, however, later showed that these were not the cause and clinicians decided that migraine (severe headache) was more likely. Ms C was prescribed aspirin for the long term and was taken off the initial medication. In 2009, Ms C was taken off aspirin, although it is not clear from her medical records when exactly this happened or why. She continued to experience symptoms and was admitted to hospital in 2010 having suffered a stroke.

Ms C complained that the investigations and treatment for her symptoms were inadequate. She said that the clinicians were not sufficiently alert to the symptoms and implications of the blood disorder she had, and failed to act on her prolonged symptoms. In particular, Ms C was concerned about the decisions to discontinue medication including aspirin.

We took advice from specialist neurology (nervous system) and haemotology (blood disease) advisers. They found that the board's investigations of Ms C's symptoms were appropriate and thorough, and that it was reasonable to offer treatment on the basis of migraine as the probable cause of symptoms. It appeared, however, that one of the clinicians involved decided to discontinue aspirin, but had failed to record why. Our advisers both said that continuing aspirin would have reduced the risk of future stroke.

We concluded that the decision to discontinue aspirin was poor practice and that the failure to record this decision and the reasoning behind it was not reasonable. For this reason, although other aspects of Ms C's care and treatment were appropriate, we upheld her complaint and made recommendations to address the failures identified.

Recommendations
We recommended that the board:
• review their arrangements to discontinue prescribed medication to patients to ensure this is properly recorded and reasons provided;
• draw this investigation and its findings to the attention of the clinicians involved; and
• apologise to Ms C for the failures highlighted.

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.