Upheld, recommendations

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.

Summary

A firm of solicitors (Firm C), raised a complaint on behalf of their client (Mrs A) that, during an examination under anaesthetic, a consultant had carried out a rectal examination without her knowledge or consent. She only found out about this when she received a copy of her medical records. When Firm C raised concerns about this with the board, they passed the correspondence to the consultant (who no longer worked for the board), who responded to Mrs A directly. The board subsequently accepted the consultant's response as their response to the complaint and did not investigate the complaint through their complaints handling procedure.

We took independent advice from a consultant in obstetrics and gynaecology (the medical specialty that deals with pregnancy, childbirth, and the post-partum period and the health of the female reproductive systems and the breasts). We found that it was not routine practice to perform a rectal examination as part of the examination Mrs A was having conducted. The Royal College of Obstetricians and Gynaecologists guidance on Obtaining Valid Consent states that procedures should not fall out-with that which the patient consented to, unless there is an unanticipated emergency. We found that Mrs A should have been aware that a rectal examination was a possibility prior to the procedure and consented as such. In the absence of consent, it was not reasonable for a rectal examination to be carried out. We upheld the complaint.

We also had concerns about the way in which Firm C's concerns had been handled. Firm C had clearly raised a complaint and our view was that the board should have investigated and responded to this in line with their complaints handling procedure. We made recommendations regarding this.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs A for conducting a rectal examination on her without her knowledge or consent and for failing to consider her complaint through the complaints handling procedure. 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:

• Ensure that clinical staff in the Obstetrics and Gynaecology department are aware of the Royal College of Obstetricians and Gynaecologists guidance on Obtaining Valid Consent.
• Consideration should be given to a discussion about consent at the departmental induction for doctors and/or a training session.

In relation to complaints handling, we recommended:

• Complaints handling staff should be aware of the board's complaints handling procedure and how to recognise a complaint.

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 compained about the care and treatment that her husband (Mr A) had received during a number of admissions to Hairmyres Hospital. Mr A had initially been admitted with abdominal pain, and he was found to have a stone in his urinary tract and some thickened loops of small bowel. His pain decreased and, after review by the urologist (a doctor who specialises in the male and female urinary tract, and the male reproductive organs) and general surgeons, he was discharged home.

Mr A was readmitted three weeks later with similar symptoms and required surgery. During his stay he had thromnophlebitis (inflammation of a vein related to a blood clot) in his arm and it was felt that he should have his blood thinned with warfarin (a medication used to thin the blood and prevent blood clots). He was then discharged home, but was readmitted five days later because he had very high Internalised Normalised Ratio (INR - the higher the number, the longer the takes the blood to clot).

Mrs C complained that the board failed to provide reasonable treatment to Mr A.

We took independent advice from a consultant general surgeon. We found that it had been reasonable to discharge Mr A following his first admission. However, when he was readmitted he was prescribed warfarin outside of the guidance for anticoagulation (blood thinning), as thrombophlebitis is not an indication for anticoagulation. The justification for this had not been clearly recorded. We found that, whilst it had not been unreasonable to give Mr A warfarin, the clinical reasons for this should have been clinically documented.

We also found that there was some confusion about the dose of warfarin that Mr A should take at home. We found that Mr A's readmission with high INR could have been avoided by ensuring that his anticoagulation was stable before discharge. We found that the board's anticoagulation guidelines needed to be updated. In addition, we found that a blood sample had gone missing when Mr A was in hospital, and that he had to have this sample retaken. In view of these failings, we upheld Mrs C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr A for the failings in relation to the warfarin he received. 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 use of warfarin or similar medication should have clear and acceptable justification and any exception for clinical reasons should be documented and accessible.
• Review the pathway of blood tests to minimise the risk of losing samples.

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 she received at Wishaw General Hospital. Following a heart attack, Mrs C attended the hospital on a number of occasions in the period whilst she waited for heart surgery. She was unhappy with the way the board managed her condition in this period and the way the board coordinated her care.

We took independent advice from an emergency medicine consultant, an acute physician and a consultant cardiologist (a doctor who specialises in finding, treating and preventing diseases of the heart and blood vessels).

Mrs C firstly raised concern that the board failed to investigate her symptoms and provide her with appropriate treatment. We found that, during the first admission, Mrs C was diagnosed with an acute coronary syndrome (symptoms attributed to obstruction of the coronary arteries). Mrs C also had hyperglycaemia (high blood glucose) but was not prescribed insulin. The adviser noted that tight blood glucose control is important in acute coronary syndrome and considered that the board failed to monitor Mrs C's blood glucose levels appropriately and failed to prescribe insulin. We also concluded that there had been a delay in Mrs C being reviewed by a cardiologist and that a GRACE score (which takes into account a patient's age, heart rate, systolic blood pressure, kidney function, signs of heart failure, as well as other parameters in order to calculate the risk of in hospital death) should have been calculated earlier as this can inform the need for angiography (a type of x-ray used to check the blood vessels). In relation to a later hospital admission, we considered that it was unreasonable for the board to have discharged Mrs C without assessment by a senior physician, in view of her medical history and presenting symptoms. We upheld this aspect of Mrs C's complaint.

Mrs C also complained that the board failed to coordinate her surgery with another NHS organisation that was involved in her care. The board acknowledged that there was a lack of detail in the documentation of the conversation between their medical staff and the staff from the other organisation. We found a number of points in Mrs C's care where the communication with the other organisation could have been better. We upheld this aspect of Mrs C's complaint.

Finally, Mrs C complained that the board failed to investigate her complaint reasonably. The board acknowledged that they had not addressed all the issues raised in her complaint letter. We considered that since Mrs C's original complaint spanned two NHS organisations, and the co-ordination and communication involved between each, the board should have worked more closely with the other organisation and issued a single complaint response. 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 failing to provide reasonable care and treatment; unreasonably discharging her without assessment by a senior physician; failing to coordinate her care with another board reasonably; and not fully responding 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:

• Where a patient presents with an acute coronary syndrome and has hyperglycaemia, close monitoring of blood glucose levels should be a routine part of acute coronary syndrome management. Insulin should be prescribed for patients who require insulin and adm
• Patients who have been diagnosed with an acute coronary syndrome should be reviewed by a cardiologist within a reasonable timescale. In line with guidelines, patients should be risk assessed for future adverse cardiovascular events and the timing of coron

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