North East Scotland

Overview
The complainant (Mr C) had formally complained to Aberdeenshire Council (the Council) about their handling of planning issues relating to the building of two houses on development plots (Plots A and B) adjacent to his property. The Council investigated Mr C's complaint and established that there had been procedural errors on their part in the handling of the planning applications for these plots. In May 2008, the Council put a proposal to Mr C to remedy his complaint. However, Mr C complained that the Council had failed to fulfil their proposal on a remedy. Mr C also raised a number of concerns relating to the Council's handling of a further planning application which was submitted for changes to Plot B. He complained that the Council failed to have proper regard to issues which affected him, of overlooking and privacy.

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

• (a) the Council failed to fulfil their proposal on a remedy for the acknowledged procedural errors associated with the determination of the planning applications on Plots A and B; (upheld) and
• (b) there were shortcomings in the handling of a further planning application for changes to Plot B (upheld)

Redress and recommendations
The Ombudsman recommends that the Council:

• (i) without further delay, make arrangements to pay Mr C the balance of the outstanding legal costs;
• (ii) without delay, take steps to have Mr C's bills independently audited to verify the costs he has claimed he has expended, as a result of the loss of his right to make representations on the planning applications related to Plots A and B and in pursuing his complaint to the Council;
• (iii) take steps to arrange for the planting of mature laurel bushes of at least 3 metres high to add to or replace those which are sited in front of the habitable rooms on the plane of the main gable of the house on Plot A and over a length of 10 metres, the position to be decided by Mr C;
• (iv) take immediate steps to enter into dialogue with the Agents of the owner of Plot B to secure a formal planning consent for the opaque windows or a formal planning agreement and make this conditional on the Council meeting the costs involved; and
• (v) in recognition of their failure to provide a solution through planning permission, which dealt with the problem of overlooking from Plot B, the Council should formally apologise to Mr C for their further shortcomings in the handling of this planning matter.

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

Overview
The complainant (Mr C), a caseworker at a Citizens Advice Bureau, raised a complaint on behalf of Mr A about the care and treatment of his late wife (Mrs A) by Greater Glasgow and Clyde NHS Board (the Board).

Specific complaint and conclusion
The complaint which has been investigated is that the Board failed to identify that Mrs A had a broken femur, following falls at Stobhill Hospital (the Hospital) in December 2008 and despite concerns about her mobility being raised by her family (upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• (i) remind staff of the need to carry out and record medical assessments in line with policy;
• (ii) provide him with the results of the audit referred to in paragraph 10; and
• (iii) consider implementing the Adviser's suggestions in paragraph 18.

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

Overview
The complainant (Mr C) raised a number of concerns regarding the treatment his late father (Mr A) received during his admission to Ninewells Hospital (the Hospital). Mr C feels that Tayside NHS Board (the Board) failed to assess Mr A's creatine kinase (CK) level early enough and that the treatment he received for high potassium levels fell short of what could be reasonably expected. Mr C believes that the Board's failure to treat Mr A appropriately resulted in his premature death.

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

• (a) there was a delay in testing CK level (upheld); and
• (b) the Board failed to treat Mr A's elevated potassium levels appropriately (upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• (i) ensures patients with new and significant muscular weakness, as was found in this case, who are taking statins, should have their CK level checked on admission;
• (ii) the Board issue an apology to the family of Mr A and accept that there was a failure to provide urgent medical treatment;
• (iii) the Board evaluate existing policy in relation to the usage of 12 lead electrocardiograms when determining cardiac risks and provide Mr C and the Ombudsman with the evidence and outcome of this review; and
• (iv) the Board apologise to the complainant and review the way this complaint was handled to see if there are any lessons to be learned for the future handling of complaints.

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

Overview
The complainants (Mr and Mrs C) raised a number of concerns that, during four attendances at Ninewells Hospital (Hospital 1) during July and August 2007, Tayside NHS Board (the Board) had not taken their concerns for the health of their infant daughter (Child C) seriously, that Child C had not been adequately examined and that her condition had not been investigated appropriately. They were also concerned that the Board's handling of their subsequent complaints was not adequate due to the time taken to respond to the complaints. They also felt the quality of the review the Board undertook was poor and the Board's conclusion that there had been a change in Child C's clinical condition, following her final attendance at Hospital 1, was not supported by the written evidence. Following Child C's final attendance, the Board sent a letter to Child C's GP. Mr and Mrs C complained that this letter contained inaccurate and unnecessary comments, and that sending it was inappropriate.

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

• (a) the Board did not appropriately examine, diagnose and treat Child C at four attendances in July and August 2007 (partially upheld to the extent that further investigations of Child C's condition should have been undertaken in August 2007 and she should have been admitted on 16 August 2007);
• (b) the Board did not respond appropriately to Mr and Mrs C's complaint of 24 August 2007 (partially upheld to the extent that the Board's conclusion that there had been a change in Child C's clinical condition, following her final attendance at Hospital 1, was not supported by the available written evidence); and
• (c) the Board's letter of 3 September 2007 to Child C's GP was inappropriate in the circumstances (not upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• (i) apologise to Mr and Mrs C that further investigations of Child C's condition were not undertaken and that she was not admitted on 16 August 2007;
• (ii) review the decision-making in this case with the appropriate Board staff at their next appraisals; and
• (iii) apologise to Mr and Mrs C that the conclusion that Child C's clinical condition had changed between 16 August 2007 and 17 August 2007 was not supported by the available written evidence.

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

Overview
The complainant (Mrs C) raised a number of concerns about the lack of psychology and other adolescent mental health services available to her daughter (Miss A) by Tayside NHS Board (the Board). In particular Mrs C was concerned that a failure to provide Miss A with appropriate services led to an escalation of Miss A's depression and subsequent eating disorder which ultimately contributed to her death by suicide in 2007. Mrs C also complained that her attempts to raise her concerns with the Board received a patchy and slow response that did not recognise the ongoing importance of the concerns she was raising.

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

• (a) provide Miss A with access to appropriate psychology services (upheld);
• (b) provide Miss A with access to appropriate eating disorder services (upheld); and
• (c) handle Mrs C's complaint in a timely and appropriate manner (upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• (i) apologise in writing to Mrs C for all the failures identified in this report;
• (ii) review the current service provision of family therapy to adolescents with eating disorders; and
• (iii) consider the introduction of an Integrated Care Pathway designed around the NHS Quality Improvement Scotland and NICE guidelines on the management of anorexia.

Overview
The complainant (Ms C) raised a number of concerns about her treatment by Tayside NHS Board (the Board), following the delivery of her first child by emergency caesarean. Ms C said that she suffered major blood loss after her discharge from hospital and had to be re-admitted. Ms C explained that the Board tried various procedures to control her bleeding which proved unsuccessful and eventually carried out a hysterectomy. Ms C said she wanted to know why 'a healthy 24 year old woman goes into hospital to have her first baby and comes out unable to have any more children and nearly dies in the process'.

Specific complaint and conclusion
The complaint which has been investigated is that the care and treatment Ms C received from the Board, following the delivery of her first child, was inappropriate (not upheld).

Redress and recommendations
The Ombudsman recommends that the Board ensure that, in future, good contemporaneous notes are made following delivery by caesarean section.

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

Overview
The Ombudsman received a complaint from an advice worker (Mrs C) on behalf of a member of the public (Mrs A). Mrs A's daughter, Child A, had a narrowing of the main artery from her heart which needed surgical repair. Mrs A complained that the surgery had left Child A paralysed. She also complained about what she considered was poor communication from Greater Glasgow and Clyde NHS Board.

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

• (a) alleged clinical failure during surgery to repair a coarctation of the aorta (not upheld); and
• (b) poor communication from the Board both before and after surgery (not upheld).

Redress and recommendation
The Ombudsman has no recommendation to make.

Overview
The father (Mr C) of a student (Mr A) complained that the supervision of Mr A's teacher training placement at a primary school was inadequately monitored. He considered that the University of Strathclyde (the University) failed to respond appropriately to Mr A's reports of bullying by the class teacher in whose class his placement took place. Mr C also complained about the University's handling of appeals and complaints about these matters.

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

• (a) did not ensure that a placement was suitably supervised (not upheld);
• (b) failed in their duty of care to Mr A with respect to a report of bullying or harassment (not upheld);
• (c) did not respond adequately to a complaint about these matters (upheld); and
• (d) did not conduct Mr A's appeals to the Board of Examiners, Faculty or Senate appropriately (partially upheld to the extent that the presence of the Course Director and the Vice Dean (Academic) at the Senate Appeals Committee was inappropriate and that the minutes of the Senate Appeals Committee lacked clarity).

Redress and recommendations
The Ombudsman recommends that the University:

• (i) ensure that information provided to schools about 'cause for concern' students should require schools to contact the University immediately, given the tight timescale for remedying potential problems on placement, in particular final placements;
• (ii) should work with schools to ensure that, barring exceptional circumstances, all class teachers who are to mentor student teachers are in possession of the relevant documents before placement begins;
• (iii) try to resolve the relationship between placement practice and the Dignity and Respect Policy, given the circumstances of this complaint;
• (iv) acknowledge directly to Mr A their fault in not advising him that he might have wished to discuss his situation with one of the University's Dignity and Respect Advisers, and apologise to him for this failing.
• (v) apologise to Mr A and Mr C for the shortcomings in their complaint investigation highlighted in this report and take steps to ensure that these elements of their process are properly followed in future;
• (vi) apologise to Mr A and Mr C for the shortcomings in their handling of the Senate Appeal highlighted in this report;
• (vii) consider how to deal holistically with cases such as this, where bullying and harassment complaints, academic complaints and academic appeals are made at the same time, taking account of short timescales where students need to progress, graduate and/or complete professional registration;
• (viii) revise relevant policies and procedures to be clear about whether adverse circumstances relating to health should be applied where there is no registered disability and no request from the student to take such circumstances into account. Policies should also be clear on the standard of proof normally required when Board of Examiners consider adverse circumstances;
• (ix) revise relevant policies and procedures to be clear about who should be invited to attend Senate Appeals Committee meetings and in what capacity, with an emphasis on avoiding conflict of interest in line with paragraph 3.16 of the Academic Appeals Procedure; and
• (x) ensure that there is clarity on recording the outcome in terms of whether an appeal is upheld, not upheld or if there is no finding (if no finding is appropriate in the context of an academic appeal).

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

Overview
The complainant (Miss C), supporting her mother (Mrs A), raised a number of significant concerns about the care and treatment her father (Mr A) received at Ninewells Hospital, Dundee in the days leading up to his death, from cancer, in June 2008. Miss C was particularly concerned that Tayside NHS Board (the Board) had delivered sub-standard care to her father in a number of important respects such as assistance with feeding, hygiene, cleanliness, management of symptoms and pain as well as failing to accord him dignity and respect. Miss C also complained that hospital staff failed to communicate adequately with Mr A's family about his palliative care or to properly manage Mr A's transfer to a hospice. Miss C was also unhappy with the handling of her complaint.

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

• (a) failed to treat Mr A with all appropriate medical, nursing and personal care and dignity (upheld);
• (b) failed to communicate adequately with Mr A or his family (upheld); and
• (c) failed to deal with Mrs A's complaint in a timely or appropriate manner (upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• (i) apologise to Mrs A and Miss C for the failings identified in this report;
• (ii) review their administrative policy for the documentation of the administration of controlled drugs; documentation of patient symptom control; and support to foundation level doctors in the management of terminal patients;
• (iii) review their policy for the insertion of chest drains to include the reporting of chest x-rays following drain insertion and the management and investigation of pain following drain insertion; and
• (iv) review their approach to the documentation of complications of procedures such as chest drains including; i) decisions relating to best management of the complications; and ii) information given to the injured party or their relatives.

The Ombudsman also asks that the Board keep him appraised of progress towards achieving the goals of the Action Plan.

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

Please note this report refers to an Annex 4 (at paragraph 16).  The report does not contain an Annex 4 and we apologise for including the reference.

Overview
The complainant (Mrs C) complained that Greater Glasgow and Clyde NHS Board (the Board) did not correctly diagnose her misplaced vertebra when she attended the Western Infirmary with back pain and 'neurological symptoms'. She was further concerned that the Board did not offer treatment once her condition was diagnosed. Mrs C was also disappointed by the Board's handling of her complaint.

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

• (a) the Board failed to correctly diagnose the severity of Mrs C's spinal problems (not upheld);
• (b) the Board failed to treat Mrs C's spinal symptoms (not upheld); and
• (c) the Board's complaint handling was poor (not upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• (i) consider reviewing Mrs C's case with a view to identifying any aspects of the communication between consultants and her GP that could be improved; and
• (ii) consider how NHS Scotland's publication: Can I help you? Learning from comments complaints and suggestions should be taken into account when making decisions on complaint time limits.

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