North East Scotland

Overview

The complainant, Mr C, raised a number of concerns regarding his care and treatment during his admission to Aberdeen Royal Infirmary (Hospital 1) for cardiopulmonary bypass surgery.  At the time, the High Dependency Unit and the Cardiothoracic Ward where Mr C was treated were housed in temporary accommodation, which Mr C considered to be unsuitable.  Mr C required further treatment at another hospital, where it was discovered that he had contracted MRSA.  Mr C also complained about how his complaint was handled by the Grampian NHS Board (the Board).

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a) the facilities at Hospital 1 were unsuitable and did not meet minimum standards (not upheld);
• (b) Mr C was not tested for MRSA before discharge and there were no facilities for quickly diagnosing MRSA and isolating MRSA positive patients (not upheld);
• (c) there was a lack of cleanliness, no control over the numbers of visitors and handwashing advice was ignored (not upheld); and
• (d) Mr C's complaints were not handled appropriately (upheld).

Redress and recommendation

The Ombudsman recommends that the Board remind staff dealing with complaints of the need to have regard to the NHS complaints procedure timescales.

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

Overview

Mr and Mrs C complained to the Ombudsman's office that Aberdeen City Council (the Council) had failed to respond appropriately to complaints they made against a neighbour regarding their alleged behaviour. The complaints centred on, but were not exclusively about, noise emanating from their neighbour's property. At the time Mr C, Mrs C and their neighbour were tenants of the Council. In their various complaints to the Council about their neighbour's behaviour, Mr and Mrs C alleged that the Council both failed to document the reports of anti-social behaviour made by them and that, in meetings held with Council Housing Department officials, decisions were not recorded or followed up.

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a) telephone calls made by Mr and Mrs C to the Council's Neighbour Complaints Unit were either not recorded or not fully recorded (upheld);
• (b) records of meetings held with the Council's Housing Department officials were either not recorded or not fully recorded (upheld); and
• (c) the Council failed to take appropriate action in response to Mr and Mrs C's complaint of anti-social behaviour (not upheld).

Redress and recommendation

The Ombudsman recommends that the Council write to Mr and Mrs C, apologising for the failings identified in this report.

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

Overview

The complainant (Mrs C) raised a number of concerns regarding her new tenancy, in relation to the internal and external condition of the home and garden. She also said that the central heating system (the System) in place on taking tenancy was not fit for purpose and the new central heating system (the Replacement System) installed by Aberdeenshire Council (the Council) was inadequate. Finally, she complained about the Council's failure to connect a mains water supply to her home.

Specific complaints and conclusions

The complaints which have been investigated are:

• (a) the failure of the Council to repair or modernise the house and garden, prior to and since taking up tenancy, and to make the house wind and watertight (upheld);
• (b) the System in place when Mrs C took up tenancy was not fit for the purpose intended and the Replacement System was inadequate (upheld); and
• (c) the failure of the Council to connect a mains water supply to the home (upheld).

Redress and recommendations

The Ombudsman recommends that the Council:

• (i) meet with Mrs C to identify and agree the repairs still required to the house, taking account of the issues identified in paragraphs 13 and 16, together with any other outstanding repairs, and their decision to upgrade all Cruden homes as reported in paragraph 38;
• (ii) provide him with an action plan detailing timescales to complete the outstanding works;
• (iii) reconsider Mrs C's claim for compensation for damage caused to her property from the flood;
• (iv) take action to insulate and draught proof Mrs C's property adequately;
• (v) re-assess the effectiveness of the Replacement System in relation to Mrs C's property, following action to insulate and draught proof Mrs C's home; and
• (vi) provide a full formal apology for the delay in connecting Mrs C to a mains water supply and for the failings identified in this report.

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

Overview

The complainant (Mrs C) complained that Dundee City Council (Council 1) restricted her autistic grandson (Mr A)'s access to education and life skills development by refusing to fund a residential placement for him at college.

Specific complaint and conclusion

The complaint which has been investigated is that Council 1 failed to provide a service to Mr A to meet his assessed needs (not upheld).

Redress and recommendations

The Ombudsman recommends that Council 1:

• (i) review their practices for informing service users and their families of services that have been recommended and agreed;
• (ii) remind staff of the importance of recording on file service users' agreement with the content of their needs assessments;
• (iii) formally apologise to Mrs C and Mr A for the confusion and protracted correspondence caused by their failure to properly explain the reasons for their decision from the outset; and
• (iv) pay Mrs C the sum of £150.00 in recognition of the time and trouble that she went to to pursue this complaint.

Council 1 have accepted the recommendations and will act upon them accordingly.

Overview

The complainant (Mrs C) raised a number of concerns about the care and treatment provided to her by Accident and Emergency (A and E) staff which resulted in her being misdiagnosed and discharged only to be readmitted hours later suffering from bacterial meningitis and septicaemia.

Specific complaints and conclusions

The complaints which have been investigated are that following her admission to A and E on the morning of 11 January 2008 Grampian NHS Board failed to:

• (a) properly monitor and record Mrs C's condition (upheld);
• (b) supervise the actions of junior staff (upheld); and
• (c) provide Mrs C with appropriate transport at discharge (not upheld).

Redress and recommendations

The Ombudsman recommends that Grampian NHS Board:

• (i) undertake an audit (or provide evidence of a recent audit) of the quality of clinical documentation in A and E, with particular reference to discharge documentation;
• (ii) review their practice in relation to patient call buzzers being removed and consider how patients can summon assistance from staff when required;
• (iii) use events of this case to remind frontline staff of the importance of early diagnosis of meningitis and use in teaching for new junior doctors and nursing staff; and
• (iv) stress the importance of documenting consultation outcomes and requests for senior review to all grades of staff in the A and E department.

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

Overview

The complainant (Miss C) raised a number of concerns about the care and treatment that her late father (Mr A) had received before his death.

Specific complaint and conclusion

The complaint which has been investigated is that Grampian NHS Board (the Board) did not provide reasonable care and treatment to Mr A in relation to a referral from his GP for hoarseness (upheld).

Redress and recommendations

The Ombudsman recommends that the Board:

• (i) ensure that all clinical staff are aware that persistent hoarseness should be taken to be a symptom of cancer of the larynx unless proved otherwise;
• (ii) ensure that such cases are dealt with urgently;
• (iii) ensure that endoscopies undertaken to exclude cancer have the direct involvement of a senior trained practitioner;
• (iv) ensure that any junior staff involved in such procedures are adequately trained and supervised and that this is recorded;
• (v) review the way in which the laryngoscopy performed on Mr A in 2005 was carried out to establish if there are any lessons that can be learned and whether further guidelines in relation to such procedures are required;
• (vi)consider further investigation where a laryngoscopy shows no evidence of malignancy, but the patient continues to display laryngeal symptoms; and
• (vii) apologise to Miss C for the failings identified in this report.

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

Overview

The complainant (Mrs C) said that a faulty boiler in her kitchen caused soot damage to her property requiring redecoration and the replacement of blinds and curtains. She complained that her claim for the recovery of expenses incurred as a result of this was dismissed by her landlord, Hillcrest Housing Association (the Association) without adequate investigation. Mrs C also expressed her dissatisfaction with the Association's complaints handling. She complained that some of her letters were not responded to and that she did not receive copies of letters that the Association advised had been sent.

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a) the Association failed to adequately investigate damage to Mrs C's property (partially upheld to the extent that more could have been done to investigate the actual source of Mrs C's soot problem); and
• (b) the Association's complaints handling was poor (not upheld).

Redress and recommendations

The Ombudsman recommends that the Association:

• (i) introduce a policy of seeking third party liability determination for all compensation claims where the claimant is claiming amounts that are higher than the insurance policy excess and for all claims that require expert technical opinion; and
• (ii) consider asking their insurers to reinvestigate Mrs C's claim.

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

Overview

The complainant (Mr C) raised a number of concerns about the treatment which his wife (Mrs C) received leading up to and following a planned left nephrectomy (kidney removal) for transplant, which took place on 22 June 2007. The nephrectomy operation was started but was not completed because the clinicians involved deemed Mrs C's donor kidney was unsuitable for transplantation. Mr C had concerns that the clinicians should have been aware prior to the planned nephrectomy that the kidney was not suitable and this would have prevented Mrs C from having to undergo the operation. Mr C also had concerns about the treatment which Mrs C received following the operation and the way Greater Glasgow and Clyde NHS Board (the Board) handled his complaints.

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a) the process used by the Transplant Team to identify Mrs C's suitability for the nephrectomy prior to the operation was inadequate (not upheld);
• (b) the decision to abort the nephrectomy on 22 June 2007 was unreasonable (not upheld);
• (c) Mrs C’s post-operation management was inadequate (upheld);
• and (d) the Board's handling of the complaint was unsatisfactory (upheld).

Redress and recommendations

The Ombudsman recommends that:

• (i) the clinicians reflect on the Adviser's comments about the level of clinical information which has been entered in the clinical records;
• (ii) the Board apologise to Mrs C for the failings identified in her post-operation management;
• (iii) the Board review their discharge arrangements for surgery of this type and take steps to ensure there is appropriate post-surgery discharge planning in each case; and
• (iv) the Board remind staff of their obligations to manage complaints in line with the NHS complaints procedure and take action to ensure that information about the NHS complaints procedure which is held locally in hospitals and clinics is up to date.

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

Overview

The complainant, Mrs C, raised a number of concerns about her husband (Mr C)'s consultations with various GPs from his GP Practice (the Practice) and from the Greater Glasgow and Clyde NHS Board's GP Out of Hours Service (the Service) prior to his admission to hospital where, sadly, he died of heart problems.

Specific complaints and conclusions

The complaints which have been investigated are that;

• (a) Mr C's heart problems were not diagnosed by GP 1 and GP 2 from the Practice at consultations on 20 October, 28 October and 11 November 2005 (not upheld);
• (b) Mr C's heart problems were not diagnosed by GP 3 and GP 4 from the Service at consultations on 30 November and 1 December 2005 (not upheld);
• (c) the Practice did not deal with Mrs C's complaint properly (upheld).

Redress and recommendations

The Ombudsman recommends that the Practice;

• (i) apologise to Mrs C for failing to deal with her complaint properly; and
• (ii) reflect on their complaints policy, review their complaints protocol and discuss how to respond to complaints from non-patients.

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

The Ombudsman has no recommendations in respect of Greater Glasgow and Clyde NHS Board.

Overview

The complainant (Mr C) raised concerns about the fact that his grandmother (Mrs A) was not provided with NHS funded continuing care by Lanarkshire NHS Board (the Board). Mr C also raised concerns that the Scottish Government's policy on NHS funded continuing care was unclear and did not appear to allow for somebody living in the community to be assessed under the policy.

Specific complaint and conclusion

The complaint which has been investigated is that the Board failed to appropriately assess Mrs A for NHS funded continuing care (not upheld).

Redress and recommendations

The Ombudsman has no recommendations to make.