Upheld, recommendations

Summary

Mr C complained about reinstatement works at the site of a former opencast mine. Mr C accesses his home via a road that runs adjacent to the site and he complained that the council unreasonably considered a development to be permitted when it did not satisfy the correct requirements. When Mr C first raised his concerns, the council maintained their position about the planning status of the land, until the council reversed their view two years later. Mr C also complained that they failed to consider the risk of flooding when granting the works permitted development status. He said that access to his home was sometimes impossible as flood water remained on his access road and did not drain away as previously. Finally, Mr C felt that the council's handling of his complaint was unreasonable.

We took independent advice from a chartered town planner. We found that the council had been presented with sufficient information around the time of Mr C's initial concerns to determine that planning consent was required. Instead they determined that the proposed works constituted permitted development. It was only two years later after protracted correspondence that they accepted there had been an error. Therefore, a number of processes and consultations, which should have occurred, did not. We considered the fact that, had the works been properly assessed, the council should have explicitly considered the use of their powers in relation to flooding. We also found that Mr C had been given incorrect information regarding the role of the Scottish Environment Protection Agency (SEPA).

In dealing with Mr C's complaint we found that there was very extensive correspondence; however, there had been some delays in the council responding and Mr C and he was not always kept updated. For these reasons, we upheld all of Mr C's complaints.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for failing to correctly assess the development; providing incorrect advice regarding SEPA's role; and failing to explicitly consider the use of their powers in relation to flooding. 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:

• Proposed development should be assessed in line with applicable planning legislation, guidance, circulars and policy.
• Potential flood issues should be properly assessed.

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 father (Mr A) received at the Royal Alexandra Hospital. In particular, Mr C complained about an unreasonable delay in diagnosing and treating Mr A's metastatic melanoma (skin cancer that has spread). Mr C also complained about a failure to communicate clearly from the outset to Mr A that he was suspected to have cancer.

We took independent advice from a plastic surgeon. We found that appropriate investigations were carried out into Mr A's condition. However, we found that Mr A's treatment plan should have been discussed by the multi-disciplinary team when there were concerning findings from his full body scan. We also found that it would have been appropriate for Mr A to have been offered a scan. We upheld this aspect of the complaint.

We found that discussions with Mr A about his condition were not recorded. The board acknowledged failings in their record-keeping and outlined steps that they had taken to address this. We upheld the complaint and we have asked the board to provide evidence of the action that they said they have taken to address this.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for the delay in referring Mr A to the regional multi-disciplinary team to discuss his treatment plan; for not offering a scan and for the failure to properly document discussions with Mr A in which he was told he might have cancer.

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

• High risk cases of melanoma should be discussed by the regional multi-disciplinary team before surgical treatment is carried out.

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 complained that the dentist failed to provide her with a reasonable standard of dental care and treatment. Ms C attended the dentist over a number of months, concerned about a number of issues. Ms C had experienced pain in one of her teeth which she subsequently discovered had a crack in it. She said that the dentist failed to investigate this appropriately. As a result, Ms C said an adjoining tooth was extracted, and she was unreasonably prescribed three courses of antibiotics before the cracked tooth was extracted. Ms C also had to receive root canal treatment on another tooth which had an infection Ms C said that as a result of the failings, she was in pain for months and needed to get veneers or implants to close the gap at the front of her mouth because she could not eat or smile.

We took independent advice from two dentists. We found that there were significant failings around record-keeping, the prescription of antibiotics, and the management of two teeth. We also found that the dentist was not in a position to appropriately monitor any potential decay progression, which was unreasonable. However, we did not find that the extractions were unnecessary. On balance, we found that the care and treatment Ms C received was unreasonable and therefore. we upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms C for failing to follow relevant guidelines and standards. The apology should comply with the SPSO guidelines on making an apology, available at https://www.spso.org.uk/leaflets-and-guidance.

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

• Records should meet the relevant standards and the dentist should become fully aware of and comply with the requirements of these standards.
• Ensure that the approach to patient care is in line with professional guidance (including key skills in primary dental care and management of acute dental problems) and complies with the new guidance due in 2018 in relation to x-rays (Ionising Radiation (Medical Exposure) Regulations).

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 complained that the board unreasonably failed to identify her hip fracture. Following a referral to Ninewells hospital, Ms C was reviewed by a consultant orthopaedic and trauma surgeon who considered that she had strained a ligament in her knee. She was then referred for physiotherapy for mobilisation and rehabilitation. Ms C was reviewed over the following months and developed progressively worsening pain. A subsequent x-ray identified a hip fracture.

We took independent advice from a consultant orthopaedic surgeon and a physiotherapist. Ms C noted that no x-ray was performed at the consultation with the surgeon. The board said that an appropriate examination was carried out, and that this examination gave no indication that an x-ray was required. The orthopaedic surgeon adviser said that the examination was not recorded in sufficient detail in Ms C's medical record, and that it provided inadequate evidence that a hip fracture was excluded.

Ms C also raised concern about the subsequent physiotherapy appointments. The physiotherapist adviser considered that, throughout the physiotherapy sessions, there were indications that the initial diagnosis of ligament strain of the knee may have been incorrect. We found that there was a failure to re-evaluate the situation in light of Ms C's increasing pain and deteriorating mobility. We considered that this contributed to the delay in identifying the hip fracture. Finally, we found that there was failings in recording of assessments and pain scores during these appointments. However, we noted that the board had acknowledged this failing and had taken steps to address this.

Overall, we found that the board unreasonably failed to identify Ms C's hip fracture and upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms C for unreasonably failing to identify her hip fracture and for the failings in record-keeping.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 carry out full and appropriate examinations and assessments, and record these in contemporary records.

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 that his father (Mr A) received at Perth Royal Infirmary following a fall. Mr C was concerned that a fracture was not identified until Mr A had been in hospital for eight days. Whilst in hospital, Mr A also suffered a period of delirium. Mr C complained about communication issues and the way that Mr A had been transferred between wards at the hospital. Finally, Mr C also considered that the board had not handled his complaint reasonably.

We took independent advice from an emergency department consultant, an acute care consultant and a nursing adviser. We found that there was no documentation of an examination of Mr A's neck in the emergency department. As the x-rays that were taken had been difficult to interpret, further action should have been taken to rule out fracture, or clear reasons should have been recorded for not doing this. We considered that there were opportunities to diagnose the fracture at an earlier stage. In regards to Mr A's delirium, we found that the care he received was reasonable, although there was some areas where practice could be improved.

In relation to communication issues and transfers within the hospital, we found that nursing notes indicated that Mr A was in pain but that this information did not appear to have been shared with medical staff. We also found that Mr C had not been kept properly updated regarding Mr A's moves within the hospital. We noted that Mr A's moves had been reasonable however, on one occasion, he was transferred during a meal which was inappropriate.

In relation to complaints handling, we found that the board had not addressed Mr C's concerns about the delay in diagnosing Mr A's fracture in their response and that Mr C was not kept appropriately updated during the complaints process.

We upheld all of Mr C's complaints. However, we noted that the board identified some failings in their consideration of this case and had apologised for these.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for the delay in diagnosing the fracture; for not fully addressing his concerns; and for not keeping him updated during the complaint process. 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:

• Medical staff should keep comprehensive medical records.
• Where x-rays are inadequate, consideration should be given to further imaging or discussion with the on call radiologist. If this is not considered necessary, the rationale should be clearly documented in the medical records.
• There should be a mechanism in place for nursing staff to make medical staff aware of issues with continuing pain. Consideration should be given to unitary records and reviewing how nursing/medical staff communicate during formal handovers.
• Consider the adoption of Health Improvement Scotland's 'Think Delirium' as a means to try to reduce delirium in hospital and manage it appropriately, particularly liaising with relatives.

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 her late husband (Mr A) had been taken to the wrong hospital by the ambulance service. Mrs C explained that, when Mr A became ill, she recognised signs of a stroke and called an ambulance. She said she thought that, according to the protocol in place at the time, Mr A should have been admitted to the Hyper Acute Stroke Unit at a particular hospital. He was taken to a different hospital and Mrs C felt that this had had an impact on the treatment he was given.

We took independent advice from a paramedic. We found that, on the basis of the information given by Mrs C in the emergency call, the ambulance crew should have suspected a stroke and on this basis should have taken Mr A to the stroke unit at the hospital where Mrs C thought he should have gone. We, therefore, upheld this complaint. We noted that the ambulance service had carried out stroke education since the events of this complaint; however we recommended that they carry out an audit to confirm that patients are being taken to the correct hospital. We also noted that the ambulance crew had failed to document a test they carried out, and we made a recommendation on this point.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C for unreasonably taking Mr A to the hospital they did, rather than the specialist stroke unit elsewhere.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:

• Tests carried out by ambulance crews when attending a patient should be documented.
• In similar situations, suspected stroke patients should routinely be taken to the Hyper Acute Stroke Unit, as opposed to the local emergency department in line with protocol.

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 provided to his father (Mr A) at the Western General Hospital. Mr C complained that there was a delay in the board diagnosing Mr A's non-Hodgkin's lymphoma (a form of blood cancer), and that the board did not follow-up his complaint in a reasonable way.

We took independent advice from a consultant radiologist (a doctor who specialises in x-rays and scans) and from a consultant geriatrician (a doctor who specialises in medicine of the elderly). We found that there was an error in the reporting of a scan that Mr A had undergone for an unrelated condition, which resulted in a delay in the cancer diagnosis. We found that the board had acknowledged this delay and had taken some action to address this failing, however we made a further recommendation on this matter.

We also found that, after a meeting had been held with Mr C regarding his complaint, there appeared to be some uncertainty within the board as to what action they had agreed to take. We found that they should have contacted Mr C to clarify what outcome he was seeking and the failure to do so meant there were perceived delays in complaint handling.

We upheld both of Mr C's complaints.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr A for the unreasonable delay in diagnosing him with non-Hodgkin's lymphoma; and apologise to Mr C for failing to follow up his complaint in a reasonable way. 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:

• As far as possible, scan findings should be accurately reported.

In relation to complaints handling, we recommended:

• Where it is not clear what outcome is expected from a complaint, steps should be taken to find out.

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 complained about the care and treatment she received at Wishaw General Hospital. Her concerns included that the consultant failed to initially list her for a colonoscopy (examination of the bowel with a camera on a flexible tube) as intended, and she was subsequently listed for a gastroscopy (examination of the gullet and stomach with thin, flexible telescope) in error. Ms C said that this error was not identified until the day of the procedure, despite her having called up in advance to query it. She said that the consultant did not contact her at any stage with an explanation of her results or treatment plan. Ms C also said that the consultant discharged her from their care as a result of her having submitted a complaint to the board. Although Ms C was later advised that they would arrange for one of their colleagues to see her instead, she heard nothing further.

We took independent advice from a consultant gastroenterologist (a doctor who specialises in the digestive system). We found that the board failed to list Ms C for a colonoscopy and later listed her for a gastroscopy in error. We also found that this error was not identified until the day of the procedure. We noted that a letter from the consultant to Ms C, requesting a stool sample, failed to explain the reasoning behind the request and inform Ms C of the findings and of a further management plan.

We also found that the consultant unreasonably discharged Ms C from their care and failed to ensure safe transfer of the necessary information on her case to a colleague, in line with the correct guidelines. We considered that the board then failed to take appropriate action when this was raised with them. Therefore, we found that the care and treatment Ms C received was unreasonable and upheld her complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms C for sending a letter requesting a stool sample that contained inadequate information; unreasonably discharging her from their care; and failing to ensure safe transfer of the necessary information on her case to a colleague.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 should be accurately listed for endoscopic procedures and the steps for this process documented. Phone contact by patients about listed procedures should be documented, tracked, and where appropriate, acted on.
• Essential patient information on care and treatment should be provided to the patient. Patients should be discharged from care in line with the correct guidelines. Patients should have the safe transfer of the necessary information on their case to another consultant.

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, who works for an advocacy and support agency, complained about the care and treatment that her client (Mrs B)'s adult son (Mr A) received from the board's mental health services. Mrs B and Mr A had been told that Mr A had an assumed borderline personality disorder and that, as part of his treatment, he would attend a specified cognitive behaviour therapy programme. However, the decision was taken that Mr A should attend another course which caused Mr A and his family great distress and they felt that the staff had not diagnosed his condition appropriately. Subsequently, Mr A was reassessed by a consultant psychiatrist as having an Emotionally Unstable Personality Disorder (EUPD) and was placed on the original specified cognitive behaviour therapy programme. The family felt that there was an undue delay in the diagnosis of EUPD.

We took independent advice from two mental health advisers and found that Mr A had been seen by a number of clinicians in mental health over an extended period of three years. We found that, although Mr A had displayed some traits of EUPD, no formal structured assessments had been completed which would have led to an earlier diagnosis of EUPD. We found that this was contrary to national and local guidance. The assessments which were carried out during the period lacked detail and consistency. They concentrated on current symptoms, rather than someone taking on collective responsibility and arriving at a diagnosis of EUPD by carrying out a structured assessment using recognised tools. We also found that there was a failure by the board in arranging for Mr A to receive a second medical opinion which had been requested by one of the consultant psychiatrists. We upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr B and his family for the unreasonable delay in reaching a diagnosis of EUPD and for not arranging a second medical opinion. The apology should comply with the SPSO guidelines on making an apology, available at www.spso.org.uk/leaflets-and-guidance.

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

• Staff should familiarise them themselves with relevant guidance for personality disorders.
• Staff should ensure that requests for a second medical opinion are actioned.

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, who works for an advocacy and support agency, complained on behalf of his client (Ms A) about the care and treatment she received at Royal Alexandria Hospital. Specifically, the complaint was about a procedure in which Ms A was given a femoral line (a tube placed by needle into a large vein near the groin) for pain relief. Mr C complained that Ms A was not given any warning or explanation before the procedure. Mr C also complained that it was not carried out properly, as Ms A found it extremely painful.

We took independent advice from a consultant in acute medicine. We found that Ms A should have been given alternative pain relief while medical staff prepared to insert the femoral line. We noted that Ms A's consent for the procedure was not properly obtained and/or documented. Finally, we found that the board had a checklist for carrying out this type of procedure but as it was not used, it was unclear if the procedure was carried out appropriately. Therefore, we considered that the board failed to provide Ms A with reasonable care and treatment and upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms A for not giving her appropriate pain relief, for failing to obtain and/or document her consent appropriately, and for failing to document the procedure reasonably. 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:

• Adequate pain relief should be given to all patients.
• Information given verbally to a patient about a procedure should be documented (including the rationale for the procedure, any alternatives, the risks involved and what the procedure will entail), along with the outcome of the consent discussion.
• Femoral lines should be inserted using the appropriate technique, equipment and anaesthetic, which can be ensured by using the central line checklist.

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.