Mid Scotland and Fife

Overview
The complainant (Miss C) complained about the care and treatment provided to her cousin (Miss A) by a medical practice (the Practice) before she died from liver cancer on 28 June 2010. The Practice had carried out a large number of liver function tests on Miss A from May 2004 onwards. These showed that her GGT (Gamma-glutamyltransferase – a liver enzyme) levels were high. Miss C complained about the lack of action taken by the Practice in response to the raised GGT levels.

Specific complaint and conclusion
The complaint which has been investigated is that the Practice failed or delayed to act on Miss A's abnormal test results (upheld).

Redress and recommendations
The Ombudsman recommends that the Practice:

• (i) write to Miss C to apologise for the failure to investigate Miss A's abnormal GGT results; and
• (ii) take steps to ensure that in future they investigate cases where the patient has a persistently high GGT level to try to establish the cause.

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

Overview
The complainant (Mr C) complained that South Lanarkshire Council (the Council) had wrongly advised him of the impact of a transfer of tenancy from his wife (Mrs C) to himself on his Right to Buy discount under the Housing (Scotland) Acts 1987 and 2001. In September 2008, Mr and Mrs C contacted the Council to discuss transfer of tenancy options. A request to assign the tenancy was approved by the Council on 30 September 2008 and the tenancy was transferred to Mr C. Mr C applied to purchase his Council house in October 2008 and, while an offer to sell was initially made under the old Right to Buy scheme, following clarification of Mr C's tenancy commencement date, he was advised that his purchase could only proceed under the modernised Right to Buy.

Specific complaint and conclusion
The complaint which has been investigated is that Mr C was wrongly advised by the Council of the impact of a transfer of tenancy from Mrs C to himself on his Right to Buy discount (upheld).

Redress and recommendations
The Ombudsman recommends that the Council:

• (i) keep a written record of the advice given when processing Assignation of Tenancy applications;
• (ii) ensure that the review of the Tenancy Sign Up Procedure is completed as a matter of urgency;
• (iii) consults with Mr and Mrs C in order to offer them an opportunity to enter into a joint tenancy or to re-assign the tenancy to Mrs C. In the event that Mrs C then subsequently applies to purchase the property either alone or jointly with Mr C, the Council shall apply to the Scottish Ministers for consent to the sale on the basis of the preserved Right to Buy discount to which Mrs C was entitled; and
• (iv) in the event that the Scottish Ministers do not consent to any subsequent sale on the basis of the 70 percent preserved Right to Buy discount to which Mrs C was originally entitled, should ensure that Mr and Mrs C receive an ex-gratia payment to reflect the terms of the loss they have incurred financially being the difference between the price under Section 63 of the Housing (Scotland) Act 1987 under circumstances where a 70 percent discount would have applied under the preserved Right to Buy provisions and the price under Section 63 of the Housing (Scotland) Act 1987 under the modernised Right to Buy provisions.

Overview
The complainant, Mr C, raised a number of concerns in relation to the drug testing procedures at HMP Shotts (the Prison) when he was suspected on two separate occasions of having taken controlled drugs.

Specific complaints and conclusions
The complaints which have been investigated are that:

• (a) the chain of custody was abused, procedure forms were not properly completed and Mr C was not given the chance to have his urine samples independently tested (upheld);
• (b) medication Mr C had been issued in the past, or at the time of the tests, was not checked (not upheld); and
• (c) notices had been put up in the halls regarding changes in the testing procedure after Mr C had been tested and he felt he should have had prior knowledge of this (upheld).

Redress and recommendations
The Ombudsman recommends that the Scottish Prison Service (SPS):

• (i) provide further training to staff within the Prison who are involved in the drug testing of prisoners and ensure copies of the MDT Policy and Procedures manual are readily available to all staff;
• (ii) remind the Prison staff to accurately record on the chain of custody form when prisoners test positive for controlled drugs which they have been prescribed; and
• (iii) consider devising and implementing a policy and protocol that deals with instances whereby a prisoner is suspected of taking non-controlled drugs which have not been prescribed to the prisoner.

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

Overview
The complainant (Mrs C) raised a number of concerns about the care and treatment provided to her husband (Mr C) by Forth Valley NHS Board (the Board) at Stirling Royal Infirmary (the Hospital) from 3 April 2006 until his death on 27 July 2006. Mrs C also raised concerns about the way in which the Board handled her complaint.

Specific complaints and conclusions
The complaints which have been investigated are that:

• (a) the Consultant's actions denied Mr C the opportunity to make informed choices about treatment and end of life care and the Board failed to follow the Liverpool Care Pathway (upheld);
• (b) the Board failed to acknowledge the failings of the Consultant or to make changes or improvements to address the failings (upheld); (c) there was an unnecessary and lengthy delay in the Board's handling of the complaint (upheld);
• (d) the notes taken at a meeting with the Board's representatives did not fully and accurately detail the depth of Mrs C's concerns and the outcome she wished to achieve (upheld); and
• (e) Mrs C's request for a meeting with the Consultant was refused unreasonably (not upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• (i) undertake an external peer review in the Hospital, to include: • the procedures relating to the management of biopsies, including communicating biopsy results; the current strategy for the policy of Living and Dying Well, with particular reference to the implementation of the Liverpool Care Pathway and the role of consultants; the education and training of staff, particularly consultants, relating to end of life care;
• (ii) ensure that the failings identified in this report are raised with the Consultant during his next appraisal, to ensure lessons have been learned from this case;
• (iii) provide evidence about how feedback from complaints is used as part of the consultant appraisal process;
• (iv) review their procedures to ensure they investigate complaints fully, in accordance with the NHS Complaints Procedure, with particular reference to timescales; and
• (v) apologise to Mrs C for the failures identified in this report.

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

Overview
The complainant (Mr C)'s father (Mr A) was admitted to Queen Margaret Hospital (the Hospital) after falling and breaking his left hip. Mr C raised a number of concerns relating to the care and treatment that Mr A received during his stay at the Hospital. He complained that Fife NHS Board (the Board) failed to maintain adequate standards of ward cleanliness, resulting in Mr A picking up two hospital-acquired infections. He also complained about the nursing care Mr A received, noting that his father had fallen four times whilst staying at the Hospital, on one occasion fracturing his right hip. Mr A died at the Hospital. Mr C raised further concerns regarding the Board's failure to contact his family in time for them to be with Mr A at the time of his death.

Specific complaints and conclusions
The complaints which have been investigated are that:

• (a) there was a lack of care and compassion by the nursing staff on Ward 14 when Mr A fell four times (upheld);
• (b) there was a lack of cleanliness in Ward 14 (not upheld);
• (c) there was a lack of concern from nursing staff in Ward 20 when Mr A's family highlighted that his blood pressure reading appeared high (not upheld);
• (d) Mr A contracted MRSA twice (not upheld);
• (e) the Board failed to inform Mr A's family of the rapid decline in his clinical condition or to contact them prior to his death (upheld); and
• (f) the Board failed to remove a catheter tube from Mr A's body (upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• (i) review the circumstances surrounding Mr A's falls with a view to identifying, and rectifying, underperformance in the practical implementation of their falls management and dementia care policies and procedures; and
• (ii) review the circumstances leading to Mr C's complaint and consider introducing measures to improve communication with patients' families.

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

Please note that this Report contained a typographical error in paragraph 2. It should read:

5 October 2009.

Overview
The complainant Mr C raised concerns about the process applied by HMP Shotts (the Prison) in testing a container found in his cell for the presence of drugs. Mr C considered that it was unfair of the Prison to adapt an existing Scottish Prison Service (SPS) process, and then not apply that process properly.

Specific complaint and conclusion
The complaint which has been investigated is that the Prison adapted the existing SPS Mandatory Drug Testing procedure to test the container found in Mr C's cell for the presence of drugs but in doing so, the Prison did not apply that process properly (upheld).

Redress and recommendations
The Ombudsman recommends that the SPS:

• (i) put a policy in place for prison staff to follow when testing liquids or substances for the presence of drugs;
• (ii) take steps to make prisoners aware of this process;
• (iii) remind prison staff to record the timings of cell searches and drug testing confirmation results accurately; and
• (iv) issue an apology to Mr C for the failings identified in this report.

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

Overview
The complainant (Mrs C) raised a number of concerns that her adult son (Mr A) had received inadequate treatment when he presented at the Accident and Emergency Department at Hairmyres Hospital (the Hospital) on the evening of 7 February 2010 and that it was inappropriate to discharge him from the Hospital. Mr A subsequently presented at the Hospital in the early hours of 8 February 2010 and died after an unsuccessful attempt to resuscitate him.

Specific complaints and conclusions
The complaints which have been investigated are that:

• (a) the treatment provided to Mr A at the Accident and Emergency Department at the Hospital on 7 February 2010 was inadequate (upheld); and
• (b) the decision to discharge Mr A from the Accident and Emergency Department at the Hospital on 7 February 2010 was inappropriate (upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• (i) consider the Manchester Triage Scale in their review of ways to introduce an assessment method to establish the clinical needs of patients attending Accident and Emergency; and
• (ii) apologise to Mrs C that staff failed to stress the importance to Mr A of a hospital admission although he was keen to go home.

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

Overview
The complainant, a firm of solicitors (Firm C), complained on behalf of their clients about how its complaint had been dealt with at a Social Work Complaints Review Committee (CRC) held by South Lanarkshire Council (the Council).

Specific complaint and conclusion
The complaint which has been investigated is that the CRC who considered the complaint did not properly explain their decision by reference to the merits of the case (upheld).

Redress and recommendation
The Ombudsman recommends that the Council:

• (i) consults with the Chair and other members of the CRC with a view to the CRC producing an adequate and reasoned explanation for their decision based on the merits of Firm C's case.

Overview
The complainant, Mr C, raised a number of concerns about the care and treatment provided to his mother, Mrs A, by Lanarkshire NHS Board (the Board). Mr C was concerned that there had been delays in Mrs A's treatment, incorrect diagnosis of her bowel problems, poor communication and poor complaints handling.

Specific complaints and conclusions
The complaints which have been investigated are that:

• (a) there was an unacceptable delay in performing triple heart bypass surgery on Mrs A (not upheld);
• (b) there was an incorrect diagnosis of Mrs A's bowel problems (not upheld);
• (c) there was inadequate communication between Monklands Hospital (Hospital 3) and Mrs A's General Practitioner and Hospital 3 and other hospitals involved in her care (upheld); and
• (d) the complaint to the Board raised by Mrs A's MSP was not handled properly (not upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• (i) apologise to Mrs A for the failures identified under head of complaint (b);
• (ii) remind their staff to ensure that written and typed notes are made contemporaneously after any clinical admission or out-patient visit; and
• (iii) apologise to Mrs A for the communication failures highlighted at paragraphs 43 to 45.

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

Overview
The complainant (Mr C) raised a number of concerns regarding the care and treatment received by his late wife (Mrs C) at Wishaw General Hospital (the Hospital), in the area of Lanarkshire NHS Board (the Board). Mrs C was admitted to the Hospital on the evening of 14 January 2008 with a perforated ulcer, having been sent home from Accident and Emergency (A&E) earlier that day with an incorrect diagnosis of gallstones. Thereafter, Mrs C remained in the Hospital where she passed away on 25 April 2008.

Specific complaints and conclusions
The complaints which have been investigated are that:

• (a) the recorded primary cause of Mrs C's death was inaccurate (upheld);
• (b) Mrs C's Alzheimer's was managed inappropriately and she was not treated with respect (upheld);
• (c) Mrs C's nutrition and oral care were managed inappropriately (upheld); and
• (d) Mrs C's perforated ulcer should have been diagnosed earlier and her initial discharge from A&E was inappropriate (not upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• (i) review Mrs C's death certificate in light of the discrepancy with the discharge letter and give the family a definitive answer;
• (ii) undertake an external review of nursing care in the wards on which Mrs C was treated following her release from intensive care. The review should consider the following:  treatment of Adults with Incapacity, including the assessment of ability to consent and administration of medication; and the use of bank and agency staff;
• (iii) clarify how their papers/standards 'Caring and Compassionate Practice' and 'Top Tips in caring for People with Dementia' are being monitored and measured, and how the education and training is being rolled out;
• (iv) provide evidence regarding the implementation of the national policy for Senior Charge Nurses ('Leading Better Care');
• (v) ensure that there are systems in place for assisting patients with feeding, as outlined in the NHS Quality Improvement Scotland 'Food Fluid and Nutritional Care in Hospitals' standards;
• (vi) ensure that there are systems in place for the provision of oral hygiene, including policies and procedures; education and training and audits;
• (vii) remind staff of the importance of detailed record-keeping, particularly in relation to doctors' recognition and appreciation of any abnormalities;
• (viii) remind complaint handling staff of the importance of providing an accurate response to complaints and, where possible, a detailed explanation of events; and
• (ix) apologise to Mr C for the failings identified in this report.

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