South of Scotland

Overview

The complainant (Mrs C) raised a number of concerns about the diagnosis of her husband (Mr C) and his treatment for small bowel obstruction.  Specifically, she raised concerns that Mr C's GP Practice (the Practice) had delayed referring him to hospital and that the treatment provided by Highland NHS Board (the Board) was inadequate.

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a) the Practice failed to timeously diagnose Mr C with small bowel obstruction and to refer him to hospital for treatment (upheld); and
• (b) the Board failed to provide appropriate care and treatment for Mr C (not upheld).

Redress and recommendations

The Ombudsman recommends that the Practice:

• (i) apologise to Mrs C for their failure to review Mr C following her telephone call on 1 August 2006;
• (ii) review their protocol for telephone consultations to ensure that patients are seen by a doctor when necessary in order to exclude more serious diagnoses; and
• (iii) consider the management of severe abdominal pain over the telephone.

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

The Ombudsman has no recommendations in respect of the Board.

Overview

The complainants (Mr and Mrs C) raised a number of concerns about the handling by the Highland Council (the Council) of a planning application to build a new property next to their home.

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a) the Council failed to ensure that the new property was at least 2 metres from the plot boundary, as specified in the Design Brief (upheld);
• (b) the Council failed to ensure that the footprint of the house did not exceed 25 percent of the plot area, as specified in the Design Brief (not upheld); and
• (c) Mr and Mrs C are unhappy with the Council's response to their complaints about the height of the house (not upheld).

Redress and recommendations

The Ombudsman recommends that the Council review the case to establish if there are any lessons that can be learned for future developments of this nature.

The Council have accepted the recommendations and have acted on them accordingly.

Overview

The complainant, Ms C, raised a number of concerns about the delay in obtaining an appointment at Neurosurgery Out-Patient Services at the Southern General Hospital (Hospital 1).  This was arranged by Highland NHS Board (the Board) as part of Ms C's ongoing treatment for back pain.

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a) the Orthopaedic Consultant Service contracted from NHS Greater Glasgow and Clyde failed to refer Ms C to the Neurosurgeon within Hospital 1 in September 2005 (upheld); and
• (b) the complaint response from the Board did not address the complaint that was raised (partially upheld).

Redress and recommendations

The Ombudsman recommends that the Board:

• (i) review the current pilot in progress and let her know the outcome;
• (ii) consider introducing a system to ensure that a referral has been received by the receiving clinic;
• (iii) provide a local contact for a patient to be able to enquire about their referral;
• (iv) apologise to Ms C for the additional wait experienced as a result of the delay in treatment;
• (v) ensure they have a mechanism in place to follow up on any outstanding issues when an offer of a meeting, as part of local resolution in line with the NHS complaints procedure, has been made and declined;
• (vi) ensure, where appropriate, that they consider if there are any problems which may be faced by a complainant offered a meeting to discuss a complaint and the venue for the meeting is not local to the complainant; and
• (vii) apologise to Ms C for not providing a further response to her complaint.

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

Overview

The complainant, Ms C, was concerned that, a few weeks after discharge from the Raigmore Hospital (the Hospital) following treatment for an obstructed gallbladder, her father, Mr A, was diagnosed with advanced pancreatic cancer.  Sadly, Mr A died shortly after this diagnosis.  In her complaint to the Ombudsman, Ms C was concerned that clinical staff at the Hospital had failed to detect this cancer and, in particular, questioned the quality of an ultrasound examination and why this was regarded as conclusive of Mr A’s diagnosis despite contrary symptoms.

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a) Mr A’s ultrasound examination was not carried out with due care (not upheld); and
• (b) in arriving at his diagnosis, Mr A’s consultant did not take into account symptoms which conflicted with the ultrasound and, in particular, a CT scan should not have been cancelled (not upheld).

Redress and recommendations

The Ombudsman has no recommendations to make.

Overview

The complainant (Mr C)’s brother (Mr A) collapsed suddenly on 1 January 2007 while at his mother’s home in Uig, Isle of Lewis.  Mr A was taken to hospital by ambulance.  Mr C raised a number of concerns:  that a GP working for Western Isles NHS Board (the Board) out-of-hours service did not attend, although the Scottish Ambulance Service (the Service) requested he do so; a First Responders Unit (FRU) was not correctly called; and information was released to the press, relating to this incident, inappropriately.  The Service accepted the problem with the FRU but Mr C remained concerned about the actions taken to remedy this.

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a) a GP working for the Board unreasonably did not attend (partially upheld, to the extent that there were clear issues with communication on the night of 1 January 2007);
• (b) a FRU was not correctly called and actions taken to remedy this were insufficient (not upheld); and
• (c) information was released to the press inappropriately (upheld).

Redress and recommendations

The Ombudsman recommends that:

• (i) the Board review the equipment provided to out-of-hours GPs, in the light of the problems identified in this report;
• (ii) the Board and the Service meet to consider how best to respond to the communication failures identified and ensure that lines of responsibility and procedures are clearly in place where appropriate;
• (iii) the Service undertake a short review of emergency calls in FRU areas, to see if they can identify cases where FRUs could have been called but were not and consider if any lessons can be learned from this;
• (iv) the Service apologise to Mr C for the release of inaccurate information; and
• (v) the Board and the Service use this complaint as a case study with press staff, in order to encourage learning from the problems identified.

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

Overview

The complainants (Mr and Mrs C) formerly lived in a detached house in the country adjacent to a Forestry Commission operation centre (the Depot).  Mr C complained about a number of planning proposals submitted by the Forestry Commission and the handling of those applications by Scottish Borders Council (the Council) and what he considered to be breaches of development control.  Together, Mr and Mrs C raised a number of concerns regarding the operation of the Depot and public access and matters concerning the operation of a café and bicycle hire business (the Business).

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a) the Council, as planning authority, failed properly to exercise their powers of development control and enforcement both with regard to the general planning situation at the Depot and with regard to temporary planning consents for the Business (not upheld);
• (b) the Forestry Commission, as developers, allowed activities to commence ahead of obtaining planning consent and made errors in their proposals to the detriment of Mr and Mrs C (partially upheld to the extent that some activities began before planning consents were granted); and
• (c) the Forestry Commission, as owners of the Depot and landlords of the Business, failed to act with diligence in dealing with issues of indecency, noise, wind blown dust and disturbance to Mr and Mrs C at anti-social hours (not upheld).

Redress and recommendations

The Ombudsman has no recommendations to make.

Overview

The complainants (Mr and Mrs C) formerly lived in a detached house in the country adjacent to a Forestry Commission operation centre (the Depot).  Mr C complained about a number of planning proposals submitted by the Forestry Commission and the handling of those applications by Scottish Borders Council (the Council) and what he considered to be breaches of development control.  Together, Mr and Mrs C raised a number of concerns regarding the operation of the Depot and public access and matters concerning the operation of a café and bicycle hire business (the Business).

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a) the Council, as planning authority, failed properly to exercise their powers of development control and enforcement both with regard to the general planning situation at the Depot and with regard to temporary planning consents for the Business (not upheld);
• (b) the Forestry Commission, as developers, allowed activities to commence ahead of obtaining planning consent and made errors in their proposals to the detriment of Mr and Mrs C (partially upheld to the extent that some activities began before planning consents were granted); and
• (c) the Forestry Commission, as owners of the Depot and landlords of the Business, failed to act with diligence in dealing with issues of indecency, noise, wind blown dust and disturbance to Mr and Mrs C at anti-social hours (not upheld).

Redress and recommendations

The Ombudsman has no recommendations to make.

Overview

The complainant (Mr C) raised a number of concerns in respect of the treatment provided to his wife by a consultant surgeon (Consultant 1) prior to her death on 11 April 2005.  Additionally, he has stated that both he and his wife were not given a clear picture of her condition and the options for treatment available to her.

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a) Consultant 1 did not fully consider the surgical options, including seeking opinions of specialists where necessary (not upheld); and
• (b) the communication from Consultant 1 was unacceptable (upheld).

Redress and recommendations

The Ombudsman recommends that Highland NHS Board (the Board):

• (i) apologise to Mr C for the failure to effectively communicate with both him and his wife;
• (ii) consider using the events of this complaint to inform practise in communicating with patients, particularly when a number of different specialists are involved in care. This consideration should include both communication with patients and family and the recording of such communication in the clinical records; and
• (iii) review their procedures to ensure that all responses provided by them, or on their behalf, to complainants are factually accurate.

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

Overview

The complainant (Mrs C) raised concerns that she had an eye operation at Ayr Hospital (the Hospital) which was performed by a consultant surgeon (the Consultant) on the wrong eye (her right eye) and she has been left blind because of this.  Mrs C also complained that correct procedures were not followed by the senior house doctor who obtained her consent for the operation.

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a) Mrs C was subjected to an eye operation, performed by the Consultant, on the wrong eye (her right eye) (not upheld); and
• (b) Mrs C was asked to sign a consent form for the operation which she could not see and the contents of the form were not read out to her (no finding).

Redress and recommendations

The Ombudsman recommends that Ayrshire and Arran NHS Board (the Board):

• (i) ensure that discussions with patients about treatment is recorded, particularly where a change to the planned operation is made. She also recommends that the Board ensure that the recognised complications arising from surgery are discussed with the patient and a record of the discussion made; and
• (ii) ensure that the Consultant makes certain that his procedure in obtaining consent from patients who are visually impaired is properly recorded in the clinical notes whenever it is followed.

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

Overview

The complainants (Mr and Mrs C) were dissatisfied with the handling of their complaints by the Scottish Environment Protection Agency (SEPA) about issues relating to their planning proposals and SEPA’s role as a consultee, when the complainants’ application was determined by the planning authority and taken to appeal.

Specific complaints and conclusions

The complaints which have been investigated concern the actions of a SEPA Panel, which looked into:

• (a) unacceptable time taken and lack of communication in addressing a contamination complaint (partially upheld);
• (b) inconsistency in delivering information to the Planning Authority and the Scottish Executive Inquiry Reporters Unit[1] (not upheld); and
• (c) failure by SEPA to meet the terms and conditions of their Service Charter (not upheld).

Redress and recommendations

The Ombudsman recommends that SEPA:

• (i) take action to issue Mr and Mrs C with a formal apology for the failure to inform them properly, from the outset, of the remit of the Panel’s investigation and its progress, including implementation of their recommendations;
• (ii) review their investigation process to ensure that, in future, all parties will be made fully aware at the outset of the scope of an investigation, its remit and what can be expected at the conclusion of the process; and
• (iii) take steps to review their policy on redress.

SEPA have accepted the recommendations and will act on them accordingly.

[1] now the Department of Planning and Environmental Appeals (DPEA).  On 3 September 2007 Scottish Ministers formally adopted the title Scottish Government to replace the term Scottish Executive.  The latter term is used in this report as it applied at the time of the events to which the report relates.