West of Scotland

Overview
The complainant (Mr C)'s wife (Mrs C) was admitted to the Western General Hospital (the Hospital). Mrs C is paraplegic and uses a wheelchair. Whilst in the Hospital, she developed pressure ulcers which ultimately required her to go into permanent residence in hospital. Mr C complained about the failure of Lothian NHS Board (the Board) to prevent her pressure ulcers. He also raised concerns about their staff's communication with Mrs C and questioned the appropriateness of the initial decision to discharge her from the Hospital.

Specific complaint and conclusion
The complaint which has been investigated is that care and treatment at the Hospital regarding the pressure ulcers and discharge home, including communication, were unreasonable (upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• (i) provide training to their staff on the proper implementation of their pressure ulcer policies, including the completion of all relevant documentation in the clinical records;
• (ii) apologise to Mr and Mrs C for the issues highlighted in this report; and
• (iii) provide this office with evidence of the action taken to implement the action plan with particular reference to ensuring a multi-disciplinary assessment of patients' suitability for discharge.

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

Overview
The complainant (Mrs C) questioned the care and treatment given to her late husband (Mr C) on 3 October 2011. Mr C died early the next day.

Specific complaints and conclusions
The complaints which have been investigated are that staff at the Accident and Emergency (A&E) Department of Borders General Hospital (the Hospital):

• (a) failed to thoroughly assess and treat Mr C during his first attendance on 3 October 2011 (upheld); and
• (b) unreasonably discharged Mr C home on 3 October 2011 (upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• (i) apologise sincerely to Mrs C for their failures concerning the care and treatment given to Mr C; and
• (ii) apologise to Mrs C for unreasonably discharging Mr C on the evening of 3 October 2011.

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

Overview
The complainant (Mr C) complained to the Scottish Government Learning Directorate (the Directorate) about the manner in which the Registrar for Independent Schools (the Registrar) conducted an investigation into Mr C's request that a notice be served on Mr C's son (Master C)'s school (the School) under section 99 of the Education (Scotland) Act 1980. Mr C made the request following his dissatisfaction about the manner in which the School had conducted an investigation about an allegation of sexual assault.

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

• (a) the Registrar unreasonably failed to undertake a thorough investigation of Mr C's complaint by not consulting with the Social Work Department or consulting with Mr C about the report the Registrar had prepared for the Scottish Ministers (upheld); and
• (b) the Registrar's report was based on factually incorrect information (upheld).

Redress and recommendations
The Ombudsman recommends that the Directorate:

• (i) ensure that written procedures are in place for investigating and reporting to Ministers on a request for a section 99 notice to be served;
• (ii) ensure that any recommendations which are made by the Registrar in relation to a request for a section 99 notice to be served are notified to all relevant parties;
• (iii) draw the findings of this investigation to the attention of the Registrar; and
• (iv) apologise to Mr C and Master C in relation to the failings identified within this report.

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

Overview
The complainant (Mr C) had difficulties with his dentures and sought help from his general dental practitioner at his dental practice (the Practice). He was referred to Edinburgh Dental Institute (the Institute)'s Department of Restorative Dentistry (Restorative Dentistry); however, he was advised he would be unable to receive treatment from there, and was referred back to the Practice. Mr C was not satisfied by NHS Lothian - University Hospitals Division (the Board)'s response to his complaint about this.

Specific complaint and conclusion
The complaint which has been investigated is that in late 2011, the Board unreasonably refused to give Mr C an appointment at the Institute's Restorative Dentistry, or to inform him of alternative options to conventional dentures (upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• (i) issue a full apology to Mr C for the failings identified in this report;
• (ii) urgently arrange for Mr C to be examined by the Department of Restorative Dentistry;
• (iii) draw this report to the attention of the Consultant within the Department of Restorative Dentistry; and
• (iv) in light of the findings of this case the Board take steps to ensure that the services referred to as being provided to patients under the Institute's Guidelines for the Referral of Patients to the Department of Restorative Dentistry are being provided.

Overview
The complainant (Mrs C) raised concerns about the City of Edinburgh Council (the Council)'s handling of a planning application for the erection of a two-storey extension at her neighbour's property.

Specific complaint and conclusion
The complaint which has been investigated is that the Council failed to follow due process prior to planning permission being granted for the erection of a two-storey extension at Mrs C's neighbour's property (upheld).

Redress and recommendations
The Ombudsman recommends that the Council:

• (i) refer the application to committee to consider whether it would be appropriate to make a revocation order, in terms of the use and development of the land;
• (ii) review the email system currently in place in the planning team to ensure that overloading of inboxes does not result in lost emails on planning applications;
• (iii) feed back my decision on this case to the planning team; and
• (iv) apologise to Mrs C for failing to investigate her complaint properly and for failing to ensure that a local Councillor's request was processed correctly.

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

Overview
The complainant (Mrs C) raised a number of concerns on behalf of her mother (Mrs A) about the care and treatment her late father (Mr A) received while a patient in the Golden Jubilee National Hospital, Clydebank (the Hospital). Mr A had been referred to the Hospital following a diagnosis of lung cancer and died there, several days after surgery.

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

• (a) there were unreasonable shortcomings in Mr A's care and treatment in the Hospital (upheld); and
• (b) there has been an unreasonable lack of clarity by the Hospital in explaining why Mr A died (upheld).

Redress and recommendations
The Ombudsman recommends that the Hospital:

• (i) apologise to Mrs A and her family for the failings identified in complaint (a);
• (ii) consider a review of the wording of the consent form a patient signs prior to surgery, so as to include the main operative risks;
• (iii) reflect on the comments of Adviser 1, in relation to the advice given on treatment options and the carrying out of a preoperative physiological assessment;
• (iv) reflect on the comments of Adviser 1, in relation to Mr A's postoperative nutritional management;
• (v) revise their nursing action plan, so as to address the failings identified in this report;
• (vi) apologise to Mrs A and her family for the failings identified in complaint (b); and
• (vii) consider obtaining a copy of the post mortem report, where a patient dies and a post mortem is instructed by the Procurator Fiscal, so as to inform the clinicians who cared for the patient and to be able to discuss the findings with the patient's family, if required.

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

Overview
In October 2008, the complainant (Mrs C) decided to assume responsibility for looking after her niece and nephew. Her complaint concerned the refusal by Midlothian Council (the Council) of her request for financial assistance in the form of kinship care allowance. Mrs C's complaint about that decision was considered but dismissed by the Council's Complaints Review Panel.

Specific complaint and conclusion
The complaint which has been investigated is that the Council's Complaints Review Panel was not provided with adequate information on the children's situation to reach a decision (not upheld).

Redress and recommendation
The Ombudsman recommends that the Council:

• (i) in the light of the circumstances of this case consider whether, when they are acting on behalf of an another social work authority, they provide a clear written statement of the limitations of their role and direct a carer to sources of further information.

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

Overview
The complainant (Mrs C) raised a number of concerns about the inadequate care and treatment her late mother (Mrs A) received from her GP Practice (the Practice).

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

• (a) failed to refer Mrs A to Liberton Day Hospital (the Hospital) following their 17 August 2010 consultation (not upheld);
• (b) failed to monitor the fluid on Mrs A?s lungs (upheld); and
• (c) failed to treat cellulitis adequately by only prescribing antibiotics, not arranging for attention by a district nurse and failing to follow up Mrs A?s condition, given her history of cellulitis (upheld).

Redress and recommendations
The Ombudsman recommends that the Practice:

• (i) ensure that patients are appropriately monitored and the outcomes recorded during the course and administration of diuretics;
• (ii) conduct a Significant Event Analysis on this case; and
• (iii) provide Mrs C with a full apology for the failures identified within this report.

The Practice 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 late mother (Mrs A) by the Medical Centre she attended for several years (the Practice), leading up to her death from cancer in June 2010. Mrs C is supported in her complaint by Mrs A's husband (Mr A) and her sister (Mrs D).

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

• (a) did not listen to the concerns raised (not upheld);
• (b) failed to carry out adequate tests and investigations (upheld); and
• (c) did not take adequate steps to help with the diagnosis of Mrs A's cancer (upheld).

Redress and recommendations
The Ombudsman recommends that the Practice:

• (i) undertake a significant event review of Mrs A's care and treatment from March 2010 onwards and consider lessons that can be learned for future practice;
• (ii) ensure that Practice records comply with NHS record-keeping guidelines; and
• (iii) apologise for the failures identified in this report.

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

Overview
The complainant, (Mr C), complained that The City of Edinburgh Council (the Council) had failed to respond reasonably to his enquiries about a statutory notice that had been served on his property. He complained to the Council's Customer Care Team (within the Corporate Contact Centre) that his enquiries were not being responded to. Thereafter he complained that the Customer Care Team had failed to respond to his complaints.

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

• (a) did not reasonably respond to Mr C's enquiries about a statutory notice served on his property (upheld); and
• (b) failed to respond to Mr C's complaints about the Edinburgh City Development Department and the Customer Care Team (upheld).

Redress and recommendations
The Ombudsman recommends that the Council:

• (i) provide a full apology from the Edinburgh City Development Department to Mr C for failing to appropriately respond to his enquiries about an outstanding statutory notice affecting his property;
• (ii) following consideration of the findings of the external enquiry, report back to the Ombudsman about the measures being put in place in the Edinburgh City Development Department in relation to customer care and in particular in relation to enquiry handling, to ensure a similar situation does not occur;
• (iii) provide a full apology to Mr C for the failures identified regarding the handling of his complaints by the Customer Care Team; and
• (iv) review the Corporate complaints policy, and provide evidence to the Ombudsman that procedures are being adhered to effectively when handling complaints from customers.

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