North East Scotland

Overview
The complainant (Mr C) raised concerns that Aberdeenshire Council (the Council) failed to ensure that the developer of the site adjoining his property (the Developer) complied with the conditions of the planning consent.

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

• (a) has unreasonably delayed to ensure that the Developer complies with the conditions of the planning consent (upheld); and
• (b) has failed to use appropriate (enforcement) action to ensure that the Developer complies with the conditions of the planning consent (upheld).

Redress and recommendations
The Ombudsman recommends that the Council:

• (i) provide details of how they are taking matters forward with the Developer (with timeline) now they acknowledge that a breach of condition has occurred;
• (ii) provide a copy of their review of internal communications between Development Management and Environmental Planning Teams;
• (iii) ensure that measures are taken to feedback the learning from this event to all staff (complaint a);
• (iv) ensure that measures are taken to feedback the learning from this event to all staff (complaint b); and
• (v) issue Mr C with a full apology for the failings identified in this complaint.

The Council have accepted the recommendations and will act on them accordingly, having already met recommendation (v).

Overview
The complainant (Mr C) complained about the treatment he received following his referral to the Orthopaedic Department at Ninewells Hospital for an injury to a muscle in his chest. His GP (Doctor 1) referred him to a consultant orthopaedic surgeon (Doctor 2). Doctor 2 assessed him and concluded that no surgical treatment would improve his injury. He then suggested that if Mr C was worried about the look of the injury, Doctor 1 should refer him to plastic surgery services. Doctor 1 referred Mr C to plastic surgery services for cosmetic repair. A consultant plastic surgeon declined the referral prior to seeing Mr C as cosmetic augmentation of the pectoral muscle was not a procedure offered by the plastic surgery services.

Specific complaint and conclusion
The complaint which has been investigated is that Tayside NHS Board (the Board) have failed to provide appropriate clinical treatment following a GP referral for a chest injury (upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• (i) ensure that Mr C is referred for a second consultation with an orthopaedic surgeon;
• (ii) ensure this case and the identified failings are discussed with Doctor 2 at his next appraisal;
• (iii) ensure the Medical Director is made aware of the identified failure to facilitate the request for a second opinion; and
• (iv) issue a full apology to Mr C for the failings identified in this case.

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

Overview
The complainant (Mrs C) raised concerns about the failure by Tayside NHS Board (the Board) to provide a British Sign Language (BSL) interpreter for a patient (Ms A) in Ninewells Hospital (the Hospital).

Specific complaint and conclusion
The complaint which has been investigated is that it was unacceptable for the Board not to provide a BSL interpreter during Ms A’s 12-day in-patient admission to the Hospital in July 2011 (upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• (i) consider amending their Interpretation and Translation Policy to highlight the legal duties staff have and to explain that using families, lipreading and pen and paper is not likely to be an adequate or reasonable response to the needs of a BSL user. This should make clear that BSL is a registered language and not simply signed English;
• (ii) produce further guidance for staff on: what the protocol is once a patient makes staff aware that they need a BSL interpreter; who is responsible for arranging this and how the interpreter's availability is to be coordinated with that of the health professionals involved; and how reassurance and progress on getting an interpreter should be communicated back to the patient;
• (iii) consider providing further training to staff on deaf culture, language and legal rights;
• (iv) consider seeking input from deaf people on the Board's Interpretation and Translation Operational Group to review the effectiveness of the implementation of the Interpretation and Translation Policy; and
• (v) offer to meet with Ms A and a BSL interpreter to answer any questions she has about her treatment and to apologise, explain and feedback how her complaint has helped them to develop their service.

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

Overview
The complainant (Mr C) raised concerns about the care and treatment his wife (Mrs C) received from the GPs at the medical Practice (the Practice) from January to October 2013.  Mrs C subsequently attended Aberdeen Royal Infirmary, where she was diagnosed with bowel cancer.  Since the events within this complaint, Mrs C's condition deteriorated further, and she sadly died during the course of our investigation.

Specific complaint and conclusion
The complaint which has been investigated is that there was an unreasonable delay by the Practice in 2013 in diagnosing Mrs C's cancer (upheld).

Redress and recommendations
The Ombudsman recommends that the Practice:

• apologise to Mr C for their failure to appropriately refer Mrs C for diagnosis of her cancer during the period from January to October 2013, and for the distress this caused her and her family;
• provide evidence that the actions set out in their Significant Event Analysis have been met, giving consideration to the NHS Education for Scotland Enhanced Significant Event Analysis approach;
• identify the training needs for the practice team relating to the issues raised in this complaint, and reflects these in appraisals and assessments; and
• explain what changes the Practice will introduce to ensure that, in future, their procedures for Significant Event Analyses are in line with national guidelines, and that they receive the prompt attention of the whole Practice.

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

Overview
The complainant (Mr C) raised concerns that his late mother (Mrs A) had not received adequate fluids and nutrition during her admission at Vale of Leven Hospital.  Mr C also complained that, following her diagnosis with oesophageal cancer, Mrs A did not receive palliative treatment for nearly three weeks until he raised his concerns with the consultant in charge of Mrs A's care.

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

• staff at Vale of Leven Hospital failed to ensure that Mrs A received an adequate level of fluids and nutrition despite her swallowing difficulties (upheld); and
• staff at Vale of Leven Hospital and Paisley Royal Alexandra Hospital failed to ensure that Mrs A received appropriate and timely clinical treatment in view of the symptoms which she presented with (upheld).

Redress and recommendations

The Ombudsman recommends that the Board:

• review the processes for ensuring that fluid intake and balance is appropriately monitored and recorded on the Vale of Leven Hospital acute medical ward;
• issue a written apology to Mr C, clearly acknowledging the gravity of Mrs A's experience and the specific failings which led to the delay in her treatment; and
• take steps to ensure that the failings his investigation identified have been fully addressed in the revised pathway for onward speciality referral for upper gastrointestinal within Clyde, and explain what awareness raising has been undertaken in relation to this.

The Board 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 by her medical practice (the Practice) since the beginning of 2012.  Mrs C believed that the doctor treating her failed to acknowledge or deal with the symptoms she was displaying and that the doctor failed to recognise a general decline in her health.  As a result she was not referred timeously for specialist assessment.  Mrs C was subsequently diagnosed with bowel cancer and she believes that earlier referral would have avoided the need for the emergency surgery she was required to undergo.

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

• provided inadequate care and treatment (upheld); and
• unreasonably failed to make the appropriate referrals (upheld).

Redress and recommendations
The Ombudsman recommends that the Practice:

• ensure that the doctor responsible for Mrs C's treatment reflects on their practice in relation to these events and discusses any learning points at their next appraisal;
• review with the doctor involved in Mrs C's care the SIGN guideline 126;
• review the General Medical Council guidance on record-keeping and evaluate a sample of their case notes to see that they are fulfilling the required standards;
• apologise in writing for the failures identified in this report.

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

Overview
The complainant (Miss C) raised a number of issues about the service she received from Greater Glasgow and Clyde NHS Board (the Board) during 2004.  Miss C was admitted to Princess Royal Maternity Hospital on 11 June 2004 to undergo a feticide procedure on medical advice.

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

• failed to explain Miss C's rights to request a private burial or cremation (upheld);
• failed to show, or explain, the cremation forms prior to asking Miss C to sign them (upheld);
• asked Miss C to sign the cremation forms when she was sedated and prior to the delivery (upheld); and
• failed to provide an accurate explanation, when responding to Miss C's complaint, for the inconsistencies in the dates on the cremation forms (upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• apologise to Miss C for the failings identified in this complaint;
• ensure that staff attending patients after a fetal loss follow the guidance notes;
• report back to the Ombudsman on how they will ensure that the options for disposal of remains will be published to parents, so that they are aware of the choices that are available to them;
• report back to the Ombudsman on steps they intend to take to ensure that any form to be completed by a patient after a fetal loss is fully explained to the patient, at a time when they are fully able to understand any explanation given;
• report back to the Ombudsman on steps they intend to take to ensure that patients, following a fetal loss, are not being asked to give consent while they lack the capacity to fully understand and recall what they are signing; and
• formally apologise for the inconsistencies provided in relation to the dates on the cremation forms.

The Board 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 given to her late husband (Mr C) by a locum doctor (the Locum GP) at his GP Practice (the Practice) between 17 September 2013 and his death on 24 September 2013.  She said that the Locum GP did not visit Mr C but, nonetheless, overruled the suggested treatment by an out-of-hours doctor who had visited; he made decisions about Mr C's care and treatment which were contrary to her and Mr C's wishes; he made an error in writing a prescription; and he failed to attend their home to sign the death certificate.

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

• (a) the Locum GP at the Practice provided inadequate care and treatment to Mr C (upheld); and
• (b) the Practice's response to Mrs C's complaint was inadequate (upheld).

Redress and recommendations
The Ombudsman recommends that the Locum GP:

• make a full and formal apology to Mrs C for the omissions and failures identified in this investigation;
• ensure that he discusses all the issues that have been identified above at his next formal appraisal; and
• demonstrate that he has learned lessons as a consequence of this complaint by completing appropriate professional training.

Overview
The complainant (Mrs C) said that Glasgow City Council (the Council) had not adequately investigated her complaint, when she complained that the secondary school her daughter (Miss A) attended had failed to meet Miss A's additional support needs.

Specific complaint and conclusion
The complaint which has been investigated is that the Council did not respond adequately to Mrs C's complaints (upheld).

Redress and recommendations

The Ombudsman recommends that the Council:

• issue a written apology to Mrs C and Miss A for the failings identified in this investigation;
• review the Complaints Handling Procedure (Appendix Two: What is not a complaint) to ensure that complaints about a school failing to meet additional support needs are appropriately signposted to the Additional Support for Learning framework, rather than considered under the Complaints Handling Procedure;
• remind all relevant staff of the alternative dispute resolution avenue available for complaints about schools failing to meet additional support needs;
• remind all relevant staff of the Council's Complaints Handling Procedure on 'what to do when you receive a complaint for investigation', which includes the recommendation to clarify the complaint and the scope of the investigation with the complainant at an early stage;
• review processes and templates for stage two investigations, to ensure that staff are appropriately prompted to consider:  what the issues in dispute are; whether there are disputes about facts; and what evidence is required to resolve these; and
• review processes for capturing and reporting information from complaints, including:  the root cause of the complaint; and possible action to reduce the risk of recurrence  (consideration should be given to these issues regardless of whether a complaint is upheld).

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

Overview
The complainant (Mrs C) complained that a delay in carrying out a Magnetic Resonance Imaging (MRI) scan resulted in her being left with permanent nerve damage, muscle wastage and bladder problems.

Specific complaint and conclusion
The complaint which has been investigated is that staff at the Southern General Hospital, Glasgow failed to assess Mrs C's symptoms as requiring an urgent MRI scan (upheld).

Redress and recommendations
The Ombudsman recommends that Greater Glasgow and Clyde NHS Board:

• apologise to Mrs C for the failings identified in this report; and
• ensure that proper and accurate records are kept of telephone referrals made to the Department of Neurosurgery and this report is shared with the relevant staff.

The Ombudsman recommends that Greater Glasgow and Clyde NHS Board and Lanarkshire NHS Board:

• take steps to implement appropriate protocols, policies or guidance in order to regulate MRI scanning and spinal surgery referrals.

Greater Glasgow and Clyde NHS Board and Lanarkshire NHS Board have accepted the recommendations and will act on them accordingly.