Upheld, recommendations

Summary

Ms C, who is an advocacy and support worker, complained on behalf of her client (Mrs A). Ms C complained that the board had failed to provide a reasonable standard of nursing care to Mrs A's late husband (Mr A) when he was a patient at Inverclyde Royal Hospital. Ms C further complained that the board failed to provide Mr A's family with a definitive cause of death, and that their significant clinical incident investigation was not completed in a timely manner.

We took independent advice from a nursing adviser and a consultant physician. We found that there were failings in the nursing care provided to Mr A and we upheld this complaint. However, we considered that the board had appropriately identified and apologised for these failings, and had carried out a large number of improvement actions. We did not make any recommendations in relation to this aspect of Ms C's complaint.

We found that, whilst it was reasonable that clinicians were initially uncertain as to Mr A's cause of death, it was unreasonable that they disagreed about it in front of Mrs A and other family members at a meeting. Therefore, we upheld this complaint. We noted that the board had apologised for this matter, and we made a recommendation in relation to this aspect of the complaint.

Finally, we found that the board had unreasonably failed to complete their significant clinical incident investigation report in a timely manner, and we upheld this aspect of the complaint. However, we found that the board had taken appropriate action to address this failing and so we did not make any recommendations in this regard.

Recommendations

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

• When appropriate, a preparatory meeting of the staff involved should be carried out prior to meeting with families about complaints, in order to allow meetings to go more smoothly and to avoid potential disagreements amongst staff in front of families.

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 cardiology care and treatment given to her late husband (Mr A) when he was a patient at Aberdeen Royal Infirmary. Mr A was admitted to hospital and reported having chest pains and shortage of breath. During his admission, Mr A was also seen by the diabetic team and urology advice was taken.

The next month, he attended the cardiology clinic and he was noted to have continuing and increasing breathing difficulties. It was recommended that he be admitted for tests. However, in order to first rule out an infection, he was referred to the Acute Medical Initial Assessment Unit (AMIA). A few months later, Mr A was admitted to the AMIA for the second time as he was reporting chest pains and breathlessness. The cardiology team were contacted and it was decided only to manage his medical conditions, and not for him to have a clinical review at that time. He was later discharged.

Mr A died the following month and Mrs C believed that this was as a result of the pills he had been taking and she said that she felt he had not been treated properly. She also said that communication had been poor and that Mr A's unexpected death came as an enormous shock. She complained to the board and they considered that Mr A had been treated appropriately. Mrs C then brought her complaints to us.

We took independent advice from a consultant cardiologist and we found that Mr A's cardiology care had not been of a reasonable standard. We found that Mr A and Mrs C had not been given the opportunity of cardiac rehabilitation education. We found that a diuretic (a drug that enables the body to get rid of excess fluids) was recommended to Mr A during his treatment, but that he declined this. The adviser was concerned that this was not discussed further with Mr A during subsequent admissions to hospital. We found that after his second admission to the AMIA, it may have been preferable for Mr A to have been reviewed by the cardiology team. We also found that during Mr A's final admission to hospital, his follow-up should have been more timely. For these reasons, we upheld Mrs C's complaints.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C for the failings in Mr A's care and treatment, and for the failings in communication. 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:

• Patients should receive appropriate medical management including where appropriate, diuretic treatment. Contact between the acute medical and cardiology units should be improved.
• Information and education should be available to long-term cardiac patients.
• To avoid breakdowns in communication, staff should listen to patients and/or their carers and consider any concerns they express.

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 to the council following an upgrade to her heating system. She told us that after the work was carried out she noticed that her furniture, carpet and other personal items had been damaged and she submitted an insurance claim to the council. The council denied responsibility for causing damage to her property. She complained that the council unreasonably delayed in the handling of her insurance claim. The council offered to have her carpet re-laid as a goodwill gesture. Mrs C complained that the council delayed in repairing her carpet.

Regarding the insurance claim, our investigation found that the insurers requested a report from the council. However, the council employee that received the request was on sick leave and this was not picked up by another member of staff. We upheld this complaint and fed back to the council that they should consider reviewing their internal procedures to ensure cases are progressed while a member of staff is on leave. Our investigation also found that the council took 19 weeks to repair the carpet and we considered this to be unreasonable. We upheld this complaint and asked the council to provide Mrs C with a written apology.

Recommendations

What we asked the organisation to do in this case:

• Write to Mrs C to apologise for the unreasonable delay.

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 raised concerns that the council had failed to investigate and act on alleged breaches of a planning condition. The planning condition had been imposed by the council to offset the impact of traffic to build and service a new development. The council accepted there were shortcomings in how the planning condition was framed, which later made it difficult for them to enforce it.

We took independent advice from a planning adviser, who agreed that the planning condition was not sufficiently precise. The planning adviser considered the council had taken reasonable steps to investigate and act on alleged breaches of the planning condition, however the shortcomings in the framing of the planning condition limited the action they could take. The planning adviser considered that safeguarding residential amenity should have been a cited reason for imposing the planning condition, as well as road safety.

In light of the failings identified in the drafting of the planning condition, we upheld Mr C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for the failings in its framing of the condition.The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/leaflets-and-guidance.
• The planning team, in conjunction with the roads and infrastructure team, should monitor vehicles' usage of the new development and the road it sits on to assess whether it is a road safety concern. There should be two periods of monitoring (an immediate three-month period and a further three-month period to assess usage over the winter months). If road safety concerns are noted, the council should take appropriate action to resolve this with the company.

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

The council opened a Multi Use Games Area (MUGA), very close to Mr C's home. Mr C complained to the council about noise nuisance and anti-social behaviour occurring at and around the MUGA. Mr C was unhappy with the response of the council and that the facility was being operated without any management plan when this had been a condition of the planning application. Mr C complained to the council about their response. The council accepted that there was a valid complaint about noise nuisance and that they had failed to implement the management plan, but did not accept that this had had an adverse impact on Mr C as he had described to them. The council made recommendations but did not apologise for the failings or take steps to remedy the problems. Mr C was dissatisfied with the response and complained to us about the council's failure to properly manage the MUGA and their response to his concerns.

We investigated and concluded that the council had failed to fulfil the planning conditions with respect to reducing possible noise nuisance through landscaping and use of noise dampening materials and in failing to implement a management plan. We also concluded that the council's complaint investigation was flawed in its scope and the responses lacked the required empathy and commitment to remedial action. We upheld Mr C's complaints.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for the failure to ensure that the MUGA met the planning conditions with an operational management plan. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/leaflets-and-guidance. The council should also acknowledge the adverse impact these failures have had on Mr C.

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

• The MUGA should operate with the revised agreed management plan and with the required standard of fencing and landscaping. If this cannot be achieved by the agreed date, the MUGA should be closed immediately until this is possible.

In relation to complaints handling, we recommended:

• Complaints responses should be empathetic and include appropriate apologies for failures identified, along with adequate explanations and reasons for decisions. Guidance and standards for good investigations are set out in the SPSO Investigations Toolkit available at www.valuingcomplaints.org.uk/learning-and-improvement/best-practice-resources/decision-making-tool.

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 told us he had been complaining to the council for a number of years about the lack of street cleaning at his business address. He told us that the council have insisted that the street is cleaned regularly. However, he has seen the same rubbish lying there for weeks. In the council's final response to Mr C's complaint, they advised that the litter on his street was due to uncontained refuse from adjacent sites. They told him that the street is scheduled to be swept on Saturdays, and they will continue to monitor the area. Mr C said the situation did not improve and he tried to complain to the council again five months later. The council advised that he had already exhausted the complaints process.

Our investigation found that the council had failed to clean the street, as Mr C reported seeing the same rubbish lying there for several weeks. Where the rubbish had come from was irrelevant. It was also evident that the steps taken by the council following their investigation had been ineffective, as the problem persisted. We upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• The council should monitor the area for a period of four weeks

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 housing association's handling of his reports of neighbour nuisance behaviour. Mr C said that the association failed to reasonably investigate his reports of anti-social behaviour. In particular, he said that there were delays in investigating his reports and a failure to corroborate the reports he made. He also complained that the association's communication with him was unreasonable, in particular, that one of their letters lacked appropriate empathy.

The association acknowledged that they delayed in recording Mr C's reports about neighbour nuisance. We considered that they also failed to keep accurate records of the action taken and the decisions made in their investigation of these reports. The association acknowledged that there were issues with their communication with Mr C in relation to his complaints about them and a failure to escalate his concerns to a stage 2 investigation when he remained dissatisfied. We also found that the letter Mr C complained about lacked the same level of empathy that earlier correspondence to him had.

Based on the information received, and in light of the failings acknowledged by the association, we upheld both complaints.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for failing to keep appropriate records of the concerns he raised, the actions they took and the rationale for the decisions they made. Further apologise for the poor level of communication with Mr C. This apology should comply with SPSO guidelines on making an apology, available at www.spso.org.uk/leaflets-and-guidance.

In relation to complaints handling, we recommended:

• Complaints about service should be recorded and escalated to a stage 2 investigation, where appropriate, in line with the Model Complaints Handling Procedure.

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 from the Scottish Ambulance Service. Mrs A collapsed at home and Mr C phoned the ambulance service. Mrs A was taken to hospital and died shortly after arrival. Mr C said the ambulance service did not provide a reasonable standard of care and treatment for his wife and that there was an unreasonable delay in transferring his wife to hospital. He also said the ambulance service did not reasonably investigate and respond to his complaint.

We obtained independent medical advice on the case from a consultant in emergency medicine. The adviser said that after obtaining a first electrocardiogram (ECG) tracing (a test used to check heart rhythm and electrical activity), which was of adequate quality, the crew then spent 21 minutes obtaining a further five ECG tracings, the reason for which was unclear given that the first reading was adequate. The adviser also said the ambulance crew's clinical assessment of Mrs A was unreasonably minimal, especially with regards to regularly measuring her vital signs. For these reasons, we upheld this part of the complaint.

The adviser said that the time spent trying to obtain an ECG and communicate with the intended receiving hospital was unjustifiably prolonged. He said this was especially the case as Mrs A was only a ten minute drive from the hospital that she was eventually taken to, and because she was so critically unwell. The adviser said that when it became clear that obtaining the ECG and transmitting it to the first intended hospital was becoming problematic, the ambulance crew should have urgently taken Mrs A to the second hospital, which was the closer hospital, for medical assistance. From there a decision could have been made about Mrs A's onward transportation to the first intended hospital. We upheld this part of the complaint.

We also considered that the ambulance service did not reasonably investigate and respond to Mr C's complaint and we upheld this part of the complaint. We asked the ambulance service to provide documentary evidence of their remedial action they said that had taken regarding complaints handling.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for the failings identified in care, treatment and complaints handling. This apology should meet the standards set out in the SPSO guidance on making an apology, available at www.spso.org.uk/leaflets-and-guidance.

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

• The Scottish Ambulance Service should learn from this case. This learning should be across the organisation, and include governance and clinical staff (especially those involved in this case). Learning should be shared with appropriate support and training provided.
• Notes of patient encounters should be comprehensive, and completed timeously and accurately. The status of the patient, treatments administered and sequences of events should be clearly recorded. Clinical staff should be trained and competent to record such notes.
• Crews should understand when it is inappropriate to stay on scene with critically ill patients for prolonged periods, particularly when there are difficulties in obtaining ECGs and transmitting them 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 on behalf of her late husband (Mr A) who was being treated for a brain tumour at Dumfries and Galloway Royal Infirmary. Mrs C enquired with the board about the methylated status of Mr A's brain tumour as she had learned that it was useful to know this in deciding whether to accept chemotherapy. (Methylation is a chemical change which alters the MGMT gene, making treatment more effective.) The board told Mrs C that this information was not available at the time she enquired. Mrs C complained that the board failed to perform a test to confirm the methylated status of Mr A's brain tumour. She also complained that the board failed to respond to her queries within a reasonable timescale. The board responded and advised that the test was not available in the board area at the time.

In investigating Mrs C's complaint, the board carried out the test and it was found that the tumour was unmethylated. The board also confirmed that the methylation test is now carried out in all grade 3 and 4 gliomas (malignant tumours of the glial tissue of the nervous system) in the board area. We took independent advice from a consultant neurosurgeon. The adviser noted that knowing the methylation status of the tumour would have some bearing on the likelihood of the chemotherapy being effective. Our investigation found that even though the test was not routinely carried out by the board at the time Mr A was receiving treatment, the test could have been requested from another department. We also found the board failed to deal with Mrs C's complaints within the required timescale and they failed to advise her of their need to extend their response time. We upheld both of Mrs C's complaints and recommended that the board provide Mrs C with a written apology.

Recommendations

What we asked the organisation to do in this case:

• The board should provide Mrs C with a written apology, acknowledging that they failed to perform the test and failed to respond to her queries 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

Mr C complained that after being put on the waiting list for a transurethral resection of the prostate (surgery used to treat urinary problems caused by an enlarged prostate), he was not given an appointment within the 12 week treatment time guarantee timescale, and that he was not updated about this or his place on the waiting list.

We took independent advice from a consultant urologist and found that the delay Mr C had experienced was unreasonable. Whilst the board had provided evidence of a number of actions they had taken to address the extended waiting times for urology services, including employing more urology consultants and opening extra theatre lists, they had not provided evidence that the board had taken steps to arrange for the procedure to be carried out by another NHS health board or by another provider as is stipulated by the Patient Rights (Treatment Time Guarantee) (Scotland) Regulations 2012. We also found that Mr C should have been contacted by the board and advised of the delay in treatment. We upheld Mr C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for the delay in providing him with an appointment for transurethral resection of the prostate. 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:

• When the treatment time guarantee is not going to be met, the board should take reasonable steps to arrange for the provision of the procedure by another NHS health board or another provider, as set out in the Patient Rights (Treatment Time Guarantee) (Scotland) Regulations 2012.
• Patients should be advised when the treatment time guarantee is not going to be met, and given an explanation as to why this is.

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.