Mid Scotland and Fife

Overview

The complainant, Mrs C, raised concerns that her late father (Mr A) had not received adequate and appropriate care and treatment from Fife NHS Board (the Board), that the Board had not adequately responded to her complaints and that the action plan generated as a result of her complaints was not adequate.

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a) Mr A's medical treatment and care were inadequate and unsatisfactory in:
• (i)  the Urology Department of Queen Margaret Hospital, Dunfermline (upheld);
• (ii)  the Accident and Emergency Department of The Victoria Hospital, Kirkcaldy (not upheld);
• (iii)  Ward 14 of The Victoria Hospital, Kirkcaldy (not upheld); and
• (iv)   Ward 2 of Glenrothes Hospital (upheld);
• (b) the Board did not adequately respond to Mrs C's complaints (partially upheld); and
• (c) the action plan generated as a result of Mrs C's complaints was not adequate (partially upheld).

Redress and recommendations

The Ombudsman recommends that the Board:

• (i) apologise to Mr A's family for the inadequate care and treatment MrA received at the Urology Department of Queen Margaret Hospital, Dunfermline and in Ward 2 of Glenrothes Hospital;
• (ii) review their procedures on the investigation of symptoms of cancer of the prostate;
• (iii) satisfy themselves that Specialist Urology Nurse and the Urologist have the appropriate competencies to carry out the care required by patients presenting with the symptoms of cancer of the prostate;
• (iv) put in place a firm timescale for when patients in all areas of Glenrothes Hospital will have access to a call bell system;
• (v) review their procedures for the communication of information between departments and wards and the procedures ward staff follow when assessing a patient's well-being on the ward;
• (vi) review their procedures and guidance for the recommendation of catheterisation, and emphasise these to staff in Ward 2 of Glenrothes Hospital;
• (vii) undertake a full audit of their record-keeping procedures, guidance and training, and strengthen these as necessary; and
• (viii) introduce guidance to all staff regarding how to respond to requests for statements on complaints, with specific reference to consulting medical or nursing notes when dealing with events which they were not personally party to.

The Board have accepted the recommendations and will act on them accordingly.

Overview

The complainant, Mr C, raised a number of issues concerning Perth and Kinross Council (the Council)'s support for his daughter (Ms C) attending school.

Specific complaints and conclusions

The complaints which have been investigated are that the Council failed to:

• (a) develop and implement an adequate strategy to support his daughter in school (not upheld);
• (b) substantiate their position that his daughter had made significant progress and that a high level of resources and support had been given to her (not upheld);
• (c) independently assess his complaints (not upheld); and
• (d) respond to his queries in a timely manner or provide an explanation for the delay (upheld).

Redress and recommendations

The Ombudsman recommends that the Council advise her when their new complaints handling system is fully implemented

The Council have accepted the recommendation and will act on it accordingly.

Overview

The complainant (Mr C), a tenant of Falkirk Council (the Council) with a lock-up garage on council land, raised a number of concerns regarding permissions given to owners of a house (Mr and Mrs D) to facilitate the building of a rear extension to their home.

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a) the Council failed to consult with users of the lock-up garage site (the Site) with regard to permissions that they had given to facilitate construction work at Mr and Mrs D's house (not upheld);
• (b) the Council failed to expedite action after they had been informed that users of the Site were being obstructed and inconvenienced (partially upheld); and
• (c) officers of the Council gave misleading information to residents through the local councillor (upheld).

Redress and recommendation

The Ombudsman recommends that the Council look at the circumstances of the consent granted in this case with a view to ensuring that future consents anticipate that activities related to the siting of a skip on Council land are regulated and the consequences of non adherence with any conditions are stated.

Overview

The complainant, Mrs C, complained of a lack of local care provision for her son, Mr A, from June 2004 to March 2007.  Mr A is severely autistic, has learning difficulties and also suffers from epilepsy.  Specifically, Mrs C complained that Mr A was seen by his Consultant (Consultant 1) in June 2004 but that there was no direct access to care offered by Forth Valley NHS Board (the Board) following this review and the departure of Consultant 1 in May 2005.  Mrs C also complained that the medication prescribed for her son by Consultant 1 was inappropriate in that, if fully implemented, it would have placed Mr A at risk.

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a) there was a lack of care provision for Mr A from June 2004 to March 2007; (upheld); and
• (b) medication prescribed for Mr A by Consultant 1 in June 2004 was inappropriate in that, if fully implemented, it would have placed Mr A at risk (not upheld).

Redress and recommendation

The Ombudsman recommends that the Board offer Mrs C a full and sincere apology for the shortcomings identified in this report.

The Board have accepted the recommendations and will act on them accordingly.

Overview

The complainant (Miss C) raised concerns that the Scottish Commission for the Regulation of Care (the Care Commission) did not carry out an adequate investigation of a complaint she made about the quality of care her mother had received at a residential care home.  She also complained that a further complaint that she made to the Care Commission in October 2005 was not properly investigated.

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a) the Care Commission did not carry out an adequate investigation of Miss C's complaint of 30 April 2005 (not upheld); and
• (b) the Care Commission did not adequately investigate Miss C's complaint of 14 October 2005 (not upheld).

Redress and recommendations

The Ombudsman has no recommendations to make.

Overview

The complainant (Miss C) raised concerns that her personal circumstances were not considered by the University of St Andrews (the University) when they determined her degree classification and that her subsequent appeal was not dealt with in line with the University's appeals procedure.

Specific complaints and conclusions

The complaints which have been investigated are that the University failed to:

• (a) take Miss C's personal circumstances into account when reaching a decision on her degree classification (not upheld); and
• (b) follow their appeals procedure when considering Miss C's appeal (upheld).

Redress and recommendations

The Ombudsman recommends that the University:

• (i) remind staff involved in minute-taking at examination board meetings to record the rationale for decisions taken at those meetings;
• (ii) apologise to Miss C for: not fully considering her appeal; the delay in processing her appeal; and failing to provide her with an adequate explanation of the basis on which they took their decision not to uphold her complaint; and
• (iii) reconsider Miss C's appeal, under Section A2.6 of the Code, specifically considering the wider point Miss C made about her honours work more generally having been affected by her mother's illness.

The University are currently considering the recommendations.

Overview

The complainant (Mrs C) raised concerns that the Medical Practice (the Practice) inadequately monitored her husband (Mr C)'s blood clotting therapy, which led to him requiring frequent hospital admissions.

Specific complaint and conclusions

The complaint which has been investigated is that, between January 2005 and June 2007, the Practice inadequately monitored and failed to take appropriate action in relation to Mr C's blood clotting therapy (not upheld).

Redress and recommendations

The Ombudsman has no recommendations to make.

Overview

The complainant (Mr C) raised concerns about the treatment which he received at the Ear Nose and Throat Department at Stirling Royal Infirmary (the Hospital) regarding nasal problems which he had suffered for many years.

Specific complaint and conclusions

The complaint which has been investigated is that, during the period 2003 to 2005, Mr C received inadequate treatment from staff at the Hospital regarding his nasal problems (not upheld).

Redress and recommendations

The Ombudsman has no recommendations to make.

Overview

The complainant (Mrs C) raised a number of concerns regarding her housing circumstances, particularly with regard to her request to North Lanarkshire Council (the Council) for re-housing from her previous home, their handling of her request for a mutual exchange, and their refusal to provide appropriate aid and adaptations in her current flat and to take measures with regard to the presence of asbestos.

Specific complaints and conclusions

The complaints which have been investigated are that the Council:

• (a) did not properly respond to Mrs C's request for re-housing because of threats to her son (not upheld);
• (b) unreasonably requested that Mrs C sign an undertaking not to request adaptations in her current flat (partially upheld);
• (c) infringed Mrs C's human rights and her rights as a disabled person by failing to install adaptations following her move (partially upheld); and
• (d) unreasonably failed to repair or remove damaged asbestos panels in Mrs C's bathroom (not upheld).

Redress and recommendation

The Ombudsman recommended that the Council apologise to Mrs C for the inconvenience caused to her by failing to have proper regard to her assessed needs.

The Council have accepted the recommendation and will act on it accordingly.

Overview

The complainants (Mr C and Mr D) raised a number of concerns about the care and treatment of their late mother (Mrs A) at Stirling Royal Infirmary (the Hospital) between 7 March and 21 March 2006.

Specific complaints and conclusions

The complaints which have been investigated are that Forth Valley NHS Board (the Board):

• (a) failed to provide appropriate care and treatment to Mrs A (upheld); and
• (b) failed to adequately investigate Mr C's original complaint (upheld).

Redress and recommendations

The Ombudsman recommends that the Board:

• (i) inform her of the progress of the recommendations in their Internal Review;
• (ii) apologise to Mrs A's family for the failures identified in this report and their Internal Review and the additional distress caused by the failure of their original investigation to identify and address these failures; and
• (iii) build more robust senior and independent review into the local resolution stage of the NHS Complaints Process to ensure complaints are addressed more comprehensively and review of complaints is built in to Clinical Governance to ensure lessons can be learned form complaints.

The Board have accepted the recommendations and will act on them accordingly.