Upheld, recommendations

Summary

Mr C contacted the council's environmental services about a spillage of domestic heating oil (kerosene) in the area near to his home. Mr C had the spillage completely cleaned from his property but his neighbour did not. Mr C was concerned about the potential for recontamination of his property, and about the smell of kerosene, from his neighbour's land. He contacted the council, asking them to take action to deal with his neighbour's failure to have the spilt kerosene cleaned up. The council said that the clean-up was the insurance company's responsibility. Mr C was not satisfied with the council's response to his concerns and brought his complaint to us.

We took independent advice from an environmental health adviser. We found that Mr C's complaint of smell from the kerosene spillage at his neighbour's property could potentially have been deemed a statutory nuisance. The council were unable to provide us with evidence that they had carried out a robust investigation into Mr C's complaint of smell, to determine if it was valid. Instead, it appeared that the council relied on a report prepared by environmental specialists working for Mr C's insurers, in relation to the clean-up at his property. We also found that what the council told Mr C about the matter was, on occasion, at odds with their internal communication. We upheld Mr C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for their failure to respond reasonably to his reports of kerosene contamination at a neighbouring property. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/leaflets-and-guidance.
• Carry out a robust investigation into Mr C's reports of kerosene contamination at a neighbouring property, with specific reference to both the potential for recontamination of his property, and smell affecting the reasonable enjoyment of his premises.

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

• Share our decision letter with environmental services staff, who should reflect on their handling of Mr C's reports of kerosene contamination at a neighbouring property, with reference to the adviser's observation that nuisance can include having reasonable enjoyment of premises impeded or restricted.

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 council on behalf of his mother (Mrs A) who is a council tenant. Mr C said that her property had been in a state of disrepair with issues including repeated boiler breakdowns, faulty electrics, persistent roof leaks and draughty windows. Mrs A had been reporting and complaining about these issues for a number of years but the council had only recently brought the property up to a reasonable state of repair. Mr C considered that the time taken to repair the property and provide a final response to Mrs A's complaints had been unreasonable.

We found that Mrs A had been complaining to the council, about a number of similar repair issues, for several years. There were a number of repairs mentioned in the complaints correspondence which were not recorded on the council's repair log, meaning it was difficult to assess whether these were completed within a reasonable timescale. The council told us that they did not record the outcomes of their inspections. This meant that it was very difficult to assess the ongoing condition of the property or evidence whether or not the faults being reported persisted throughout the period in question, or only required repair later in the process due to damage or deterioration.

We considered it was likely that there were unreasonable delays on the part of the council. Additionally, the reason we were unable to confirm this was due to insufficient record-keeping. We also found that the council's complaints handling had been unreasonable as they delayed in referring Mrs A to ourselves. Therefore, we upheld both of Mr C's complaints.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs A for failing to appropriately handle the repairs to her property and to both her and Mr C for the failures in complaints handling. 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 repair log should be a full and accurate record of all repairs completed.
• A clear record should be made of repair inspections, detailing the inspector's findings.

In relation to complaints handling, we recommended:

• All complaints should be handled and progressed in line with the complaints policy.

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 that the council unreasonably applied their Unacceptable Customer Behaviour Policy (UCBP, a policy that outlines how an organisation will approach situations where the behaviour of individuals using their service becomes unacceptable, including any actions the organistion will take to restrict contact from the individuals concerned). The council decided to apply their UCBP on the basis that the correspondence received from Mr C placed an unreasonable demand on the business of the council. They confirmed that they would still accept Freedom of Information (FOI) requests.

We found that the council were unable to provide enough evidence to support their decision to apply the policy. We noted that the correspondence recorded from Mr C was mainly based under FOI requests which the council had stated that they did not take into consideration when deciding to implement their UCBP. We also noted that the council were unable to access some correspondence as they had been issued to members of staff who had since left the council. We upheld Mr C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for unreasonably applying their Unacceptable Customer Behaviour Policy. The apology should meet the standards set out in the SPSO guidelines on apology available at https://www.spso.org.uk/leaflets-and-guidance.
• Clarify and review the status of the restriction of access under the UCBP.
• Respond to Mr C's emails providing him with the information he requested where they are able to do so and where they have not previously provided it.

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

• The council should take steps to ensure that when correspondence is received it is identified and recorded at the outset which part of the correspondence relates to FOI and non-FOI.
• The council should take steps to ensure that when the UCBP is implemented the correspondence which this refers to is identified and highlighted to the customer.

In relation to complaints handling, we recommended:

• The council should establish how they can retain access to emails issued by customers to members of staff, who leave the employment of the council to ensure that evidence they rely on is retained for the purpose of complaints investigations.

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 that the ambulance service failed to send an ambulance to him when he phoned to report that he had suffered a collapse at home. When he received a call back from an ambulance service clinical adviser, Mr C reported that he had suffered flashing lights, neck stiffness, headaches for the past three weeks, and that he now also had pins and needles in his right hand side. The ambulance service said that Mr C's reported symptoms did not meet the criteria for an emergency ambulance. However, as Mr C had symptoms for a number of weeks, he did require a medical review and it was agreed that Mr C's sister would transport him to hospital.

We took independent advice from a paramedic and listened to the audio recordings of the phone calls. We found that Mr C's symptoms did not warrant the dispatch of an emergency ambulance and that it was appropriate to arrange for the clinical adviser to phone him back to obtain further information. We found evidence that a number of assumptions had been made by the clinical adviser. At no time did Mr C state that he had had the pins and needles for two weeks but rather that the problems had just started. We found that the clinical adviser did not adequately question Mr C or his sister about how manageable it would be to transport Mr C to hospital, should he suffer another collapse. We also found that insufficient weight had been taken of the severity of Mr C's headache, the visual disturbances, and neck stiffness. We found that it would have been advisable to have dispatched an ambulance crew who would have carried out a face-to-face assessment in Mr C's home and determined the appropriate way to progress matters. We upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C that assumptions had been made regarding his reported symptoms. The apology should reach 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:

• In carrying out clinical assessments the clinical adviser should give sufficient weight to red flag signs and not make assumptions about the reported symptoms.

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 on behalf of her late husband (Mr A) that the ambulance service failed to transfer Mr A to hospital in an appropriately safe manner. Mr A had recently been diagnosed with a cancerous tumour on his femur (thigh bone) and was at risk of fracture. While being admitted to hospital for pain management, Mr A sustained a fractured femur while he transferred himself from a trolley cot to a hospital trolley. Mrs C was also concerned that the ambulance crew did not stay with Mr A in the accident and emergency department until he was attended to by hospital staff and did not complete an incident report regarding the fracture.

We took independent advice from a paramedic clinical team leader. We found that good practice should have dictated the use of transfer equipment or, as a minimum, the supporting of Mr A's leg during his efforts to self-mobilise. We also considered that the ambulcance crew should not have left Mr A in hospital without ensuring treatment had commenced and should have completed an incident report regarding the fracture. Therefore, we upheld Mrs C's complaint.

Mrs C also complained about how the ambulance service handled her complaint. We found that there was an unreasonable delay in responding to the complaint and a failure to keep her updated. We also noted that Mrs C only received a copy of the internal investigation report document. No formal, personalised complaint response letter was issued and she was not informed of her right to appproach us with her complaint. We upheld Mrs C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C for failing to adhere to best practice when transferring Mr A to the hospital trolley; failing to stay with Mr A until active treatment commenced; and failing to complete an incident report in line with protocol.
• Apologise to Mrs C for failing to respond to her complaint within 20 working days; failing to proactively inform her of the delay and keep her updated; and failing to issue a formal, personalised written response (including details of her right to approach the SPSO). 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 ambulance service should demonstrate organisational learning to try to prevent similar future failings – they should complete and share with staff an anonymised case study highlighting the identified failings in this case.

In relation to complaints handling, we recommended:

• The ambulance service should ensure their complaints investigations comply with the requirements of the NHS Scotland model Complaints Handling Procedure – they should highlight these requirements to complaints handling staff.

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 board unreasonably discharged her from a community mental health team. She believed that she was discharged due to the absence of her usual community psychiatric nurse (CPN), who had been off work for a number of months at the time of discharge. Mrs C said that she had not been regularly seen or supported during this absence, only receiving two appointments, the focus of which were her discharge from services. While complaining to the board, she also became aware that her previous diagnosis of bipolar disorder (a mental health condition marked by alternating periods of elation and depression) had been changed to a possible diagnosis of borderline personality disorder (BPD, a disorder of mood and how a person interacts with others). Mrs C complained that she had never been informed of this change and that the board failed to communicate with her appropriately.

We took independent advice from a CPN. We found no evidence to suggest that Mrs C's discharge was related to staffing issues. Prior to the CPN's absence, she had a clear care plan in place and was being seen around every two weeks. One of the aims of the plan was to explore a possible alternative diagnosis of BPD. There was also recorded agreement that any future discharge would be clearly planned in advance and communicated, to ensure that this happened in a supportive manner. We considered that the overall decison to discharge Mrs C was reasonable. However, the adviser explained that, under Scottish Government guidance, the board should have implemented an Integrated Care Pathway (ICP) which would define the care and support offered to people with personality disorders. We noted that it did not appear that the board had an ICP in place for BPD.

We also found that there was a lack of continuity in the support provided to Mrs  C once her CPN was absent. Prior to discharge, Mrs C had been without support for around four months, despite her care plan stipulating that she would be seen every two weeks. The adviser noted that the care plan should have been updated to reflect the CPN's absence but this did not happen. They also confirmed that, while Mrs C was aware that a diagnosis of BPD was being considered, no formal diagnosis had been given. However, they noted that Mrs C had now been referred back to the board for the specific purpose of reaching a clear diagnosis.

Overall we found that the decision to discharge Mrs C was reasonable. However, the manner that this was handled and communicated to Mrs C was not in line with the agreed care plan or relevant guidance. Therefore, we upheld both of Mrs C's complaints.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C for failing to appropriately handle her discharge and failing to clearly communicate her change of diagnosis. 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 board should have an ICP to guide care provision for patients with BPD.
• Care plans should be reviewed and appropriately amended when a member of staff is absent from work long-term to ensure consistency of care.

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 husband (Mr  A) at Ninewells Hospital. Mr A was resident in a care home and had Alzheimer's disease. He was referred to the emergency department by his GP as he was suffering from hip pain and could not bear weight. The GP asked that staff at the hospital rule out bony injury as a cause of Mr A's symptoms. X-rays were carried out and Mr A was discharged back to the care home after staff found no significant changes from previous x-rays. Four days later, an emergency referral was made for Mr A and he was admitted to hospital. Subsequent tests showed that Mr A had an abscess (a painful swelling caused by a build-up of pus) in his hip. It was determined that he was not suitable for surgery and Mr A was referred to the palliative (end of life) care team. Mr A died in hospital a few days later. Mrs C complained that Mr A's care in the emergency department was unreasonable and that there had been confusion over his palliative care referral. She also complained about how the board handled her complaint.

We took independent advice from an acute care consultant and from an emergency medicine consultant. The advice highlighted that Mr A's pain and inability to straighten his leg should have prompted further action by the staff who saw him in the emergency department. However, there was no indication that earlier treatment would have changed the outcome for Mr A. We also found that national guidance from the Scottish Intercollegiate Guidelines Network (SIGN) in SIGN 111 recommended tests that could have identified Mr A's infection earlier and that the care he received fell short of what he required as a patient with dementia. Therefore, we found that the care and treatment Mr A received was unreasonable and upheld this aspect of Mrs C's complaint.

In relation to communication around palliative care arrangements, we found that the board had identified failings and had apologised to Mrs C. Therefore, we upheld this aspect of Mrs C's complaint but made no recommendations as we considered that this had been adequately dealt with by the board.

Finally, we found that Mrs C had not been kept properly updated during the complaints process, which exceeded the 20 working day timescale set out in the board's complaints handling procedure. 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 decision to discharge Mr A without further investigation of the cause of his hip pain and for the failings in the handling of her complaint. 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:

• Emergency department staff should take appropriate account of patients' cognitive impairments given that these make them more vulnerable to healthcare associated harm.
• SIGN 111 should be followed for patients with suspected hip fracture.

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, who works for an advocacy and support agency, complained on behalf of her client (Mrs A) that the consent process followed for an above knee amputation of Mrs A's leg was unreasonable. Mrs A had been admitted to Balfour Hospital for treatment of severe chronic leg ulcers and amputation was planned when other options were exhausted.

We took independent advice from a consultant physician. Although we found that Mrs A had been fully aware of the plan for surgery and had discussed this with staff on the ward, we found that the consent form had not been signed until the day of the procedure. We also found that there was a lack of evidence in both the medical records and the consent form to confirm that the risks and benefits of the surgery were appropriately discussed with Mrs A. The advice we received highlighted that this did not follow national guidance on consent and that, while Mrs A's post-operative care was appropriate, her delirium had not been monitored using the appropriate test. We upheld Ms C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs A that the consent process for her above the knee amputation was unreasonable. 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 consent process should follow national guidelines. Consent should be taken, where possible, prior to the day of surgery and what is discussed as part of the consent taking process, including risks and benefits, should be documented.
• Where appropriate, patients should be tested for post-operative delirium.

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 treatment he received at the Royal Infirmary Edinburgh after suffering a head injury. He raised concerns that the board had failed to identify a fracture to his skull on his first attendance, as they did not carry out a CT scan until he was referred back to hospital by his GP two days after being discharged.

This case was very similar to a complaint we had recently upheld (201508264). In that case, we recommended that the board carry out an audit of similar head injury cases treated at the hospital. As the audit was still in progress at the time of Mr C's complaint, we asked the board to include his case in their consideration. They did so, and repeated what they had told Mr C in their response to his complaint - that they considered the treatment he received was appropriate. They also maintained this position in response to enquiries we made throughout our investigation.

We took independent advice from a consultant in emergency medicine. The adviser told us that the board's failure to carry out a CT scan on Mr C's first admission was unreasonable as the board had recorded that Mr C had a severe and persisting headache and Mr C had suffered a fall from a height greater than one metre. Under guidance from the Scottish Intercollegiate Guidelines Network  (SIGN) and the board's protocol in place at that time, this should have led to a CT scan being arranged. We also found that the board had failed to carry out enough observations of Mr C's level of consciousness. In particular, the board had failed to record that Mr C was reviewed by an experienced doctor before being discharged. SIGN guidelines specify that an experienced doctor should review all head injury patients before they are discharged to ensure that six specific criteria are met. However, this failling had since been remedied by a new procedure implemented following case 201508264.

We were also concerned that, despite a number of these failings being a repetition of those highlighted in case 201508264, the board had failed to identify the failings, either in response to Mr C's complaint, as part of the audit they carried out into his care or when responding to our enquiries. For these reasons, we upheld this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for failing to provide appropriate treatment for his head injury. 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:

• All staff should follow the protocols in place with regards to patients with head injuries.

In relation to complaints handling, we recommended:

• The board's investigations at all stages should identify failures in care and, where failings are identified, make proportionate changes to avoid similar mistakes in future.

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 care and treatment his late wife (Mrs A) received while she was a patient in Wishaw General Hospital. Mr C was concerned about both the medical and nursing care Mrs A received, and about the way that the board handled his complaint.

In regards to Mrs A's medical treatment, Mr C questioned the length of time a central line (a tube placed by needle into a large, central vein of the body to administer drugs or take blood samples) was in place. Mr C also complained that there was an unreasonable delay by medical staff in reviewing blood test results, and subsequently in Mrs A receiving antibiotics. Mr C believed that, because of poor treatment, Mrs A was denied the opportunity of starting chemotherapy treatment.

We took independent advice from a consultant general surgeon with experience in oncology (cancer treatment) We found that, following Mrs A's admission surgery and further investigations being carried out, it was confirmed that she had extensive, incurable cancer and all further treatment was to be palliative (end of life care). We considered that the length of time Mrs A's central line was in place and the actions of medical staff in prioritising the alleviation of Mrs A's severe pain was reasonable. However, we found that there was a significant delay of several hours in reviewing Mrs A's blood test results and starting appropriate antibiotics. While we found that it was unlikely that the delay in starting antibiotics significantly changed Mrs A's outcome, given her underlying condition and poor prognosis, the delay was unacceptable. Therefore, we upheld this aspect of Mr  C's complaint. The board had already acknowledged that there was an unacceptable delay, due to a breakdown in communication involving both junior and senior doctors, and had noted that this has been addressed with staff.

In relation to Mrs A's nursing care, Mr C was concerned over elements of record- keeping and the frequency and recording of some of Mrs A's observations by nursing staff. We took independent advice from a nurse. We found that certain aspects of Mrs A's nursing care were good however, both advisers noted failings in the quality of the completion of some of Mrs A's records and in the frequency of her observations. Therefore, we upheld this aspect of Mr C's complaint. The board had already acknowledged that these issues were unacceptable and noted that they had apologised and taken action.

Finally, Mr C was dissatisfied with the board's response to the concerns he and his family raised about Mrs A's care and treatment. In relation to a meeting which was held to discuss Mr C's concerns, we identified certain aspects that we found to be unreasonable. For this reason, we considered that the board had not responded reasonably to Mr C's complaint. We upheld this aspect of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C and his family for the failings identified including a breakdown in communication causing a significant delay in reviewing Mrs  A's blood test results and starting appropriate antibiotics failings by nursing staff in record keeping; and a failure to respond to concerns raised by Mr C and his family following a meeting. 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:

• Current practices and processes and the working relationship between junior and senior doctors should be improved to minimise the risk of a future similar event occurring. Ensure that the importance of effective handover is emphasised as part of a junior doctor's induction. Ensure appropriate timescales are in place for requesting, performing and documenting results, and actions taken, for investigations such as blood tests.
• Nursing observations should be carried out in line with the board's Medical  Early Warning flowchart and the scoring system should be accurately applied. Nursing care charts and care bundles should be completed accurately and in line with the Nursing and Midwifery Council's guidance on record-keeping. The board should reissue relevant staff with their central line care policy and provide appropriate education to staff to support this. Also, senior nurses should routinely audit compliance with the central line maintenance bundle.

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.