Upheld, recommendations

Summary

Ms C complained on behalf of her child (Child A) about the care and treatment they received at Victoria Hospital. Child A was prescribed various drugs to try to manage their epilepsy (a seizure disorder), including one called phenytoin. Child A later had to be treated in hospital for an overdose of phenytoin. Ms C's main concern was that Child A was not appropriately monitored by the board, which allowed this high level of phenytoin to build up in their blood. Ms C also complained about the board's handling of her complaint.

We took independent medical advice from a consultant paediatrician (a doctor who specialises in child medicine). We found that, when Child A's dose of phenytoin was increased at their clinic review, they were appropriately referred for blood tests to monitor the impact of this increase. However, we found that the clinic review was not appropriately recorded and that there was an unreasonable delay in communicating with her GP about it. We found that the results of Child A's blood tests showed a surprising level of phenytoin in their blood, which should have prompted a clinical review. We also found that appropriate action should then have been taken, which would have been to repeat the blood tests. We upheld this aspect of Ms C's complaint.

Regarding complaints handling, we found that the board delayed in acknowledging Ms C's complaint. We also found that they failed to communicate appropriately with Ms C both during and at the conclusion of their investigation. We upheld this aspect of Ms C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms C for the failure to appropriately monitor child A; for the issue identified with record-keeping and GP communication; and for their communication with Ms C in relation to her complaint. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/leaflets-and-guidance.

What we said should change to put things right in future:

• The results of blood tests carried out to monitor phenytoin levels should be clinically reviewed and actioned appropriately.
• Clinical appointments should be recorded appropriately and actions should be shared with primary care/patients in a timely manner.

In relation to complaints handling, we recommended:

• Updates should be provided to complainants when the twenty working day timescale will not be met; and follow-up correspondence should be responded to appropriately.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

Summary

Mrs C complained about the care and treatment her late husband (Mr A) received at Galloway Community Hospital after he attended the emergency department (ED) with chest pain. Mr A was diagnosed with gastritis (inflammation of the stomach lining) and was discharged home. He died shortly after from a pulmonary embolism (PE, a blood clot in the blood vessel that carries blood from the heart to the lungs). Mrs C was concerned that Mr A was discharged from the ED without a troponin test (a type of blood test to help confirm or exclude damage to the heart) being carried out. Mrs C also questioned why the ED doctor had not suspected a blood clot when they were aware that Mr A had been treated previously for prostate cancer.

The board carried out a critical incident review of Mr A's care and treatment. They found that a repeat electrocardiogram (ECG, a test that records the electrical activity of the heart) should have been performed given abnormalities had been identified and that a troponin test should have been done. In addition, there was no record of family history/other relevant factors. The board said that they would share these findings with the staff involved in order to ensure learning and undertook to source readily available out-of-hours troponin testing at Galloway Community Hospital.

We took independent advice from a consultant in emergency medicine. We did not consider that Mr A's symptoms were indicative of a PE, however, we determined that it was unreasonable to discharge him with a diagnosis of gastritis. We found that Mr A should have been admitted to hospital and that a repeat ECG and troponin test should have been undertaken. We, therefore, upheld Mrs C's complaint. However, we considered that it was unlikely Mr A's outcome would have been different because ECG and troponin testing is not a test for PE.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C for failing to admit Mr A to hospital, arrange a repeat ECG scan, and obtain a blood troponin measurement. The apology should meet the standards set out in the SPSO guidelines on apology available at: https://www.spso.org.uk/leaflets-and-guidance.

What we said should change to put things right in future:

• Staff should ensure in similar circumstances that patients are admitted to hospital.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

Summary

Mrs C complained about the care and treatment that her late husband (Mr A) received when he was admitted to Borders General Hospital and diagnosed with pneumonia (an infection of the lungs). Mr A was discharged from the hospital but later had a CT scan which showed that he had had a stroke. Mr A was readmitted to the hospital but his condition deteriorated and he died several weeks later. Mrs C complained about the medical treatment and nursing care that Mr A received and that the board failed to reasonably monitor his replacement heart valve on a six-monthly basis, as previously agreed.

We took independent advice from a consultant geriatrician (a doctor who specialises in the medicine of the elderly) and a nurse. In relation to Mr A's medical treatment, we found that there had been a lack of continuity during his first admission, which contributed to the fact that the significance of the deterioration in his cognitive function and incontinence was missed, despite the family highlighting this. Whilst much of the communication with his family had been reasonable, there was a failure to listen to the family’s concerns at that time. We also found that it was unreasonable that a CT scan was not carried out during this admission, although we could not say whether or not this would have diagnosed Mr A’s stroke. Therefore, we upheld this aspect of Mrs C's complaint.

In relation to the nursing care, we found that there had been a failure to meet some of Mr A’s basic personal care needs and to assess and manage his ongoing continence problems. Nursing staff also failed to review his cognitive impairment on an ongoing basis and to involve his family in the planning and review of his care. We also found that there was a failure to adequately document his care needs and how they were met on an ongoing basis. We upheld this aspect of Mrs C complaint.

Finally, we found that the board had failed to reasonably monitor Mr A’s replacement heart valve on a six-monthly basis, as previously agreed. We considered that it was unreasonable to plan to follow up a patient with a serious chronic condition, but fail to do so, without any clear explanation. Therefore, we upheld this aspect of Mrs C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C for the failings in relation to Mr A's medical and nursing care and treatment. The apology should meet the standards set out in the SPSO guidelines on apology available at https://www.spso.org.uk/leaflets-and-guidance.

What we said should change to put things right in future:

• Patients admitted to hospital with cognitive impairment should receive CT scanning in line with the Scottish Stroke Care Standards.
• There should be ongoing structured assessment, management and review of patients with cognitive impairment and delirium in hospital settings.
• There should be a structured and comprehensive approach to identifying and reviewing care needs and how these needs will be met during a patient’s stay in hospital. Where appropriate, this should include involving the patient’s family.
• The care needs of patients in relation to continence assessment and management in hospital should be appropriately met.
• The ‘Getting to Know Me’ document should be completed and used to inform a person-centred care plan.
• Patients with a serious chronic condition should have follow-up care as agreed. Where it is decided to stop the follow-up appointments for a patient, the patient should be informed of this and the reasons for this.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

Summary

Mr C was admitted to University Hospital Crosshouse with pain in his side, where he received scans and tests. He was discharged three days later with a diagnosis of non-specific abdominal pain. Mr C was admitted to hospital again a number of months later when he was diagnosed with acute appendicitis (inflammation of the appendix). Mr C complained that there was a failure to diagnose the appendicitis on his first admission.

We took independent advice from a surgeon. We found that there were clear symptoms that Mr C had appendicitis on his first admission. We found that, at a minimum, Mr C should have been alerted to the possibility of appendicitis and made aware of the symptoms to look out for. We upheld this aspect of Mr C's complaint.

Mr C also complained that the board did not provide a reasonable response to his complaint. We found that the response from the board failed to reasonably acknowledge that Mr C had symptoms of appendicitis on his first admission. We also considered that the board's complaint response failed to reasonably explain why Mr C was given a different diagnosis and why no follow-up appointment was arranged. We upheld this aspect of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for failing to diagnose appendicitis; failing to explain why they did not consider a diagnosis of appendicitis was appropriate or issue Mr C with a follow-up appointment; and for stating that Mr C's symptoms on his first admission were not indicative of appendicitis when they were indicative of appendicitis.

What we said should change to put things right in future:

• Feed back the findings of this investigation in a supportive way to the relevant clinical staff and identify how and why the failure occurred, taking into account any supervisory arrangements.
• Where imaging and blood tests indicate appendicitis but the board consider that the clinical picture does not support this, then the patient must be advised of the reasons why the clinical picture does not support this and a follow-up appointment should be arranged to review the patient.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

Summary

Mrs C complained about the care and treatment provided to her late mother (Mrs A) while she was a patient at two different hospitals. Mrs A was admitted to University Hospital Crosshouse with a hip fracture following a fall at home. Mrs A was then transferred to Ayrshire Central Hospital for rehabilitation and physiotherapy. While she was there, Mrs A had a fall and hit her head. Mrs A was then transferred back to University Hospital Crosshouse. Mrs C was concerned about the medical treatment Mrs A received at University Hospital Crosshouse and the nursing care she received at Ayrshire Central Hospital.

Regarding Mrs A’s medical treatment, Mrs C complained about the length of time it took the board to carry out a test to see if Mrs A had deep vein thrombosis (DVT, a blood clot in a vein). We took independent advice from a consultant geriatrician (a doctor who specialises in medicine of the elderly). We found that the board did not consider the cause of Mrs A’s initial fall and that Mrs A was not seen by a geriatrician during her first admission. We found that there was an unreasonable delay in ordering and performing a scan of Mrs A’s leg. When it was suspected that Mrs A had a clot in her leg, Mrs A’s dose of dalteparin (medication that helps to reduce the risk of blood clotting in the legs) was increased from a preventative dose to a treatment dose. Mrs A received clopidogrel (medication to prevent clots that cause strokes and heart attacks) at the same time as the treatment dose of dalteparin. We found that it was unreasonable that Mrs A’s clopidogrel medication was not stopped at the same time that the dose of dalteparin was increased. We upheld this aspect of Mrs C's complaint.

Mrs C had a number of concerns about the nursing care provided to Mrs A, in particular about the communication from nursing staff, that Mrs A’s care needs and preferences were not taken into consideration, that adequate pain relief was not provided to Mrs A, that steps were not taken to prevent her from having another fall and that the action taken by nursing staff following her second fall was not appropriate. We took independent advice from a nursing adviser. We did not find evidence that the communication from nursing staff was unreasonable. We found that the nursing care regarding pain relief, falls prevention, and the action following Mrs A’s second fall was reasonable. However, we found that the board failed to document Mrs A’s care needs and preferences in her assessment and care plan documentation as well as follow the instructions in Mrs A’s “Getting to Know You” document. Therefore, we upheld Mrs C’s complaint. We noted that the board had already acknowledged and apologised that there was a failure to follow the instructions in Mrs A’s “Getting to Know Me” document.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C for the failure to consider the cause of Mrs A's fall, that Mrs A was not seen by a geriatrician, the delay in ordering and performing the scan, the delay in stopping the clopidogrel medication, the failure to follow the instructions in Mrs A's “Getting to Know Me” document and the failure to record Mrs A's care needs and preferences. The apology should meet the standard set out in the SPSO guidelines on apology available at www.spso.org.uk/leaflets-and-guidance.

What we said should change to put things right in future:

• Where a treatment dose of dalteparin is prescribed, appropriate adjustments should be made to any other medication prescribed to the patient. Patients should receive appropriate scans in a timely manner when DVT is suspected. Where patients have fallen and are unable to give an account of the reason for their fall, medical staff should carry out appropriate checks to try and determine the cause of the fall. All patients over the age of 65 presenting with a fragility fracture should have routine access to acute orthogeriatric medical support (orthopaedic care for elderly patients) in line with national guidance.
• Nursing assessments and care plan documentation should clearly document the care needs and preferences of patients.

In relation to complaints handling, we recommended:

• The board's complaints handling system should ensure that failings (and good practice) are identified, and enable learning from complaints to inform service development and improvement.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

Summary

Mr C complained about the outcome of two academic appeals.

We found that the university did not apologise for erroneously telling Mr C which section of the Procedure for Withdrawal and Exclusion of Studies he was being excluded under. We also found that the university's communication with Mr C, following a decision made by the Appeal Committee, was not sufficiently clear.

While the second appeal appeared to have been processed appropriately, it was not clear, even after further enquiries of the university, what had happened following Mr C's first appeal. For this reason we upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for an error with regards to the section of the procedure under which he was excluded from his studies, and for the lack of clarity in relation to the appeals process and decisions following the Appeal Committee's decision. The apology should meet the standards set out in the SPSO guidelines on apology available at https://www.spso.org.uk/leaflets-and-guidance.

What we said should change to put things right in future:

• The university should a) conduct an independent review of how the College Postgraduate Studies Committee's process and decision, following the Appeal Committee's decision, was communicated to Mr C and b) how the process and decision was subsequently expla

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

Summary

Ms C made a number of complaints to the council in relation to breaches of planning control and anti-social behaviour at a neighbouring holiday let property. Ms C complained that the council's response to both her concerns was unreasonable.

We took independent advice from a planning adviser. We found that the council had been slow to respond to a number of breaches of planning control and that their reports were inconsistent in relation to how they assessed planning applications against relevant policies. However, we noted that they had already identified ways to improve their service going forwards, including stopping the use of operational management plans as a planning approval condition. We also found that the council had advised Ms C to contact the police about anti-social behaviour but should have passed these reports to the environmental health department, in line with their planning enforcement charter. Therefore, we upheld both of Ms C's complaints.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms C for failing to pass on her complaints about anti-social behaviour to the relevant service in line with their planning enforcement charter. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/leaflets-and-guidance.

What we said should change to put things right in future:

• It should be clear from planning reports how applications comply with relevant policies.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

Summary

Mr C is the holder of a blue badge which was issued by a different council. When his blue badge did not arrive, Mr C reported this to the issuing council, who subsequently issued a replacement blue badge and cancelled the original one. The original blue badge eventually arrived and Mr C proceeded to use this, unaware that this was the cancelled badge. The City of Edinburgh Council issued Mr C with two penalty charge notices and impounded his car for displaying a cancelled blue badge. The council also observed on three separate occasions that Mr C displayed a valid blue badge, leading them to conclude that he was in possession of two blue badges. Mr C complained that the council wrongly asserted that he was in possession of two blue badges.

We found that the council's blue badge recording systems were insufficient and did not produce consistent information. Therefore, we could not be satisfied that Mr C was in possession of two blue badges. We consided that the council had failed to thoroughly investigate the complaint and, therefore, we upheld Mr C's complaint. We also noted that the council failed to provide us with all the relevant evidence and made a recommendation in light of this.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for failing to thoroughly investigate his complaint and to produce relevant evidence. The apology should meet the standards set out in the SPSO guidelines at: https://www.spso.org.uk/leaflets-and-guidance.

In relation to complaints handling, we recommended:

• The council should respond properly to complaints, taking into account all relevant evidence and should provide all the information relevant to a complaint when responding to enquiries from the SPSO.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

Summary

Mrs C complained that the council failed to take action to address anti-social behaviour at a derelict yard they own, which backs on to her parents' house. She complained that large groups of youths were gathering at night, playing loud music and misusing drugs and alcohol. One of the buildings had been set on fire several times, causing concern because of its proximity to her parents' property.

Mrs C's father (Mr A) had contacted the council on a number of occasions, asking them to take steps to address the problem. After several months without any satisfactory resolution Mrs C complained to the council on her father's behalf, and when she remained dissatisfied with their response she brought her complaint to SPSO.

We found that, until Mrs C complained to them, the council did very little to address the concerns raised by Mr A. They also failed to keep Mr A informed about what action they were taking. We noted that they had taken steps to secure the site, in line with their obligations as landlord, but these steps did little or nothing to prevent access. The council had now taken steps to have buildings on the site demolished and cleared, and although we considered this a positive step, we thought this could have been undertaken much sooner. We upheld Mrs C's complaints.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C and Mr A for not taking action to address their concerns at an earlier stage. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/leaflets-and-guidance.
• Apologise to Mrs C and her father for the shortcomings in their communication. The apology should meet the standards set out inthe SPSO guidelines on apology available at www.spso.org.uk/leaflets-and-guidance.
• Keep Mrs C updated regarding the progress of plans for demolition at the site.

What we said should change to put things right in future:

• Staff should be confident about handling complaints of this nature and understand the measures available to them to address such concerns.
• Where an investigation involves communication across different departments, staff should diarise ahead to check for responses to ensure that matters do not get overlooked.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

Summary

Mr C complained about delays in the council's handling of a breach of planning consent he first reported to them some years ago, but which remained unresolved until recently. The breach involved a complex engineering matter, which the council told him was the cause of the delay, as significant research had been required on the part of the applicant and their architects to identify a workable solution. Regardless, Mr C believed that the timescales involved were unreasonable and questioned whether the council had taken sufficient steps to progress enforcement action.

We took independent advice from a planning professional. We considered that the informal approach taken by the council and the decisions made at each stage to allow informal negotiations were reasonable. However, we did not consider that the council had taken reasonable steps to follow up on proposed action by the applicants at a number of key stages, resulting in months long delays with no apparent progress on several occasions. Given this, we upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for the unreasonable delays in their handling of his reports of a planning breach. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/leaflets-and-guidance.

What we said should change to put things right in future:

• At every stage, planning enforcement action and informal negotiations should be progressed within a reasonable timescale.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.