Upheld, recommendations

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.

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.