Upheld, recommendations

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.
 

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.