West of Scotland

Overview
The complainant (Mrs C) complained about the care and treatment provided to her sister (Ms A), who had a diagnosis of Borderline Personality Disorder, after she was admitted to the Royal Edinburgh Hospital (Hospital 1) in September 2010. Mrs C was also unhappy with Lothian NHS Board's (the Board) responses to her complaints.

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

• (a) Ms A did not receive appropriate care and treatment from Hospital 1 during the period 13 September 2010 to 7 October 2010 (upheld); and
• (b) the Board have failed to provide satisfactory answers to Mrs C's questions about the matter (upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• (i) undertake an external peer review in Hospital 1, to include: the assessment of patients on admission; care-planning practice; the completion of risk management plans and proformas; and communication with the named person and relatives and their involvement and participation in decision-making. Practices in these areas should be audited against relevant professional body expectations; national standards, policies and codes of practice; and existing local policy intentions;
• (ii) provide him with details of the findings and the action plan created as a result of the above recommendation;
• (iii) ensure that the findings in this report are communicated to the staff involved in Ms A's care and treatment; and
• (iv) apologise to Mrs C and Ms A for the failures identified in this report.

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

Overview
The Complainant (Miss C) complained on behalf of her friend (Mrs A) who underwent surgery for an inguinal hernia at the Western General Hospital in March 2010. Miss C raised concerns about delays to Mrs A's operation, which she felt could have been avoided. She also raised complaints about the service that Mrs A received from Lothian NHS Board (the Board) when she was in hospital.

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

• (a) Mrs A's operation was unnecessarily delayed (upheld);
• (b) Mrs A's special medical requirements were not made known to ward staff prior to her admission to Ward 23 (upheld);
• (c) cleanliness and staff hygiene practices in Ward 23 were poor (not upheld);
• (d) food service on the ward was poor (upheld);
• (e) the Board discharged Mrs A without ensuring that she had access to adequate support outwith the hospital (upheld); and
• (f) the Board's complaint handling was poor (not upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• (i) share this report with the staff involved in Mrs A's care with a view to identifying any lessons that can be learned from her case;
• (ii) review their procedures for reporting CT scan results back to the referring clinician;
• (iii) review their procedures for tracking the progress of patients whose treatment has been referred to a different consultant;
• (iv) take steps to ensure that nursing staff maintain patient records in line with the Nursing and Midwifery Council's Record Keeping and Guidance for Nurses and Midwives;
• (v) take steps to satisfy themselves that the steady decline in the cleanliness monitoring score between September 2009 and March 2010 was not indicative of an endemic deterioration in cleanliness and hygiene standards on Ward 23; and
• (vi) provide training to staff on Ward 23 regarding nutrition, communication and record-keeping.

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

Overview
Mr and Mrs C complained to NHS Lothian Health Board (the Board) on 24 October 2006 about the treatment and management of medical care provided to their late son (Master C) by the Board's Child and Family Mental Health Service (CAMHS) whilst he was a patient during 2000 and 2001. Mr and Mrs C also complained about the subsequent failure of the Board to provide adequate services for the treatment of his mental health in 2001. CAMHS was governed by Lothian Primary Care NHS Trust until 31 March 2004 and was the accountable body during the period of Master C's treatment in 2000-2001. NHS Lothian Health Board (the Board) was the accountable body thereafter who considered and responded to the complaints made by Mr and Mrs C, and subsequently to this office.

Specific complaint and conclusion
The complaint which has been investigated is that the Board failed in the care and treatment of Master C during the period 2000 - 2001 (upheld).

Redress and recommendations
The Ombudsman has considered all the information presented to this office, together with the action taken by the Board. It is clear the service failures identified in this report demonstrate systemic failures by the Board. It is evident that the service failures were as a result of poor policy and practice. The Ombudsman is satisfied that the Board, as a consequence of this complaint, demonstrated by the evidence presented to this office detailing improvements to CAMHS since 2001, have undertaken action to remedy the service failures identified in order to improve current services.

The Ombudsman recommends that the Board:

• (i) provides evidence that their patient discharge process for CAMHS is clear and robust and available to patients, parents and carers; and
• (ii) ensures their complaints policy reflects a clear process which outlines a structured, timely approach to gathering information from key personnel involved in the complaint.

Overview
The complainants (the Solicitors) brought a complaint to my office on behalf of their clients, the aggrieved (Mrs A) and her son (Mr A). Mrs A raised a number of concerns about a school trip that Mr A attended in February 2009. Mrs A's concerns were subsequently investigated by the Council. There was also an investigation undertaken by the police into an alleged incident on the trip involving a number of pupils, including Mr A, and a report was sent to the Procurator Fiscal.

• (a)  manage and investigate the complaint properly and within the time frame specified (upheld);
• (b) respond adequately to the complaint (upheld);
• (c) provide Mrs A with sight of relevant documents (not upheld); and
• (d)  indicate when their recommendations would be enforced (upheld).

• (i)  should, when preparing risk assessments for off- site activities and education trips, include more detail on the supervision arrangements, in particular, during 'free time' and bed times;
• (ii)  introduce a policy which formalises the action taken at paragraph 16 to deal with situations such as this, involving allegations of a serious nature;
• (iii)  ensure that adequate guidance is given to staff on managing complaints which are high risk, complex or of a sensitive nature and are likely to take longer than the stated timescales; and
• (iv)  when making recommendations in response to a complaint, should state the date by which the recommendation will be implemented.

Overview
The complainant (Ms C) complained about The City of Edinburgh Council (the Council)'s decision to refuse her application for a disabled parking bay outside her home.

Specific complaint and conclusion
The complaint which has been investigated is that the Council failed to fulfil their statutory duties with regard to parking provision for disabled residents (upheld).

Redress and recommendations
The Ombudsman recommends that the Council:

• (i) review their policy for considering applications for disabled parking spaces to take into account the individual circumstances of residents within the CPZ; and
• (ii) reconsider Ms C's application for a disabled parking bay on X Street, taking account of her special circumstances.

Overview
The complainant (Mr C), acting on behalf of a sub-committee of local residents, raised a number of concerns about the consequences for his neighbourhood (the Area) of road traffic regulation changes instituted by the City of Edinburgh Council (the Council), following their decision to develop a light railway (the Tram Link) between North and Central Edinburgh and Edinburgh Airport.

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

• (a) the Council increased traffic in the Area by the way that they have managed traffic flow, following their decision to develop the Tram Link (not upheld);
• (b) residents of the Area were excluded from meaningful participation in the process (not upheld);
• (c) the Council have not carried out a proper and comprehensive environmental impact study regarding noise, air pollution, safety and continual vehicle passage through the predominantly residential area as a proposed permanent situation (not upheld); and
• (d) the Council repeatedly made misleading statements, both to residents of the Area and to other involved parties; most notably to the parliamentary hearings regarding the effect on the area (not upheld).

Redress and recommendations
The Ombudsman has no recommendations to make.

Overview
The complainant (Ms C) raised a number of concerns about the way the relevant medical history of her late partner (Mr A) was initially obtained by Borders NHS Board (Board 1) and provided to Lothian NHS Board (Board 2). She also complained that prior to the decision to operate, Board 2 failed to obtain a full medical history from Mr A and that had they done so, the operation may not have proceeded.

Specific complaint and conclusions
The complaint which has been investigated is that Board 1 and Board 2 failed to ensure all the relevant medical history was obtained prior to the decision to operate on Mr A. There are two elements to this:

• (a) Board 1 failed to ensure all relevant medical history was provided to Board 2 (not upheld); and
• (b) Board 2 failed to ensure a full medical history was obtained during the consultation prior to surgery (upheld).

Redress and recommendations
The Ombudsman recommends that Board 1:

• (i) revise their respective policies in relation to existing medical records protocols to ensure that in appropriate cases, all health professionals have direct access to patients' records.

The Ombudsman recommends that Board 2:

• (ii) apologise to Ms C for the failures identified;
• (iii) ensure Consultant 2 reflects on this report so he can review his practice on taking patients' medical history, including when it would be appropriate to request full medical records; and
• (iv) revise their respective policies in relation to existing medical records protocols to ensure that in appropriate cases, all health professionals have direct access to patients' records.

The Board 1 and Board 2 have accepted the recommendations and will act on them accordingly.

Overview
The complainant (Ms C) raised concerns on behalf of her client (Mrs B) that a Scottish Ambulance Service crew failed to recognise the seriousness of her daughter (Ms A's) condition when they responded to Mrs B's emergency telephone call. This resulted in a delay in transferring Ms A from Mrs B's home to the hospital with fatal results. Ms C was also dissatisfied with how the Scottish Ambulance Service (the Service) had dealt with this complaint.

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

• (a) failed to provide appropriate care and treatment to Mrs B's daughter (upheld); and
• (b) delayed in investigating the matter and failed to keep Mrs B updated (upheld).

Redress and recommendations
The Ombudsman recommends that the Service:

• (i) review the protocol for ambulance crews to ensure it gives clear guidance to staff about the relative roles of different crew members in the assessment of patients;
• (ii) assess this protocol to demonstrate and evaluate that it is properly understood by ambulance crew;
• (iii) ensure that measures are undertaken to feedback the learning from this incident to avoid similar situations recurring;
• (iv) review their methods for learning from complaints and introduce comprehensive, dated action plans for follow-up action specific to each complaint;
• (v) introduce a method of ensuring that any wider learning from complaints is fully integrated into the governance structure of the Service; and
• (vi) issue Ms C and Mrs B with a formal written apology for the failures identified in this report.

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

Overview
The complainant (Mrs C) made a complaint about the care and service provided to her husband (Mr C) by the Scottish Ambulance Service (the Service) in transporting Mr C to and from an Endoscopy out-patient appointment at Crosshouse Hospital in Kilmarnock. Mrs C also complained about the care and treatment provided to Mr C by Ayrshire and Arran NHS Board (the Board) while waiting for his out-patient appointment at the Hospital.

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

• (a) the care and service provided to Mr C by the Service were not reasonable (upheld); and
• (b) the care and treatment provided to Mr C by the Board was not reasonable (upheld).

Redress and recommendations

The Ombudsman recommends that the Service:

• (i) remind all crews in the South West Division to contact their Area Service Office and await instructions if cancellations on their patient list would mean that other patients would be transported to hospital several hours before their appointment time; and
• (ii) remind all crews in the South West Division of the importance of passing on relevant information about a patient's needs following an outbound journey, such as whether a stretcher facility is required for a return journey, to their Area Service Office.

The Ombudsman recommends that the Board:

• (iii) ensure that a record is made of the time a patient is admitted for their procedure and also of all advice given to patients on admission by nursing staff. This requirement should be incorporated into the new guidance;
• (iv) remind nursing staff of the importance of treating people as individuals, even in a very busy unit, as set out in the NMC Code; and
• (v) provide him with evidence of audit and evaluation of the first six months' operation of the new guidance and action plan for dealing with vulnerable adults arriving for Endoscopy appointments.

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

Overview
The complainant (Mrs C) is an Independent Advice Support Services Case Worker with the Citizen's Advice Bureau. She raised a number of concerns about the Scottish Ambulance Service (SAS) on behalf of a client (Mrs A). Mrs A said that when she was out walking with her young great grandson in November 2009, she fell and broke her leg. She said a passer-by called for an ambulance (she said three calls were made) but that it took over an hour to arrive. Meanwhile, she was left in the cold. When the ambulance arrived, she was given pain relief and thus was not fully aware. Mrs A was aggrieved because her great grandson was left in the care of a person she did not know. She also complained that an inflatable splint used on her injured leg was faulty. Thereafter, Mrs C complained that the SAS failed to respond properly to the complaint she made on behalf of Mrs A.

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

• (a) there was delay in responding to the 999 call (not upheld);
• (b) the inflatable splint was faulty (upheld);
• (c) the crew inappropriately handed Mrs A's three-year-old great grandson to an unknown person while she was incapacitated (upheld); and
• (d) there was a failure to handle Mrs C's complaints appropriately, in that there was delay and failure to respond to all of the complaints (upheld).

Redress and recommendations
The Ombudsman recommends that the SAS:

• (i) make an addition to their Child Protection Code of Practice, to take into account circumstances where children are left in their care by virtue of the fact that the responsible adult has been taken ill or involved in an accident. In this regard, they may wish to refer to the Scottish Government's Guidance on Looked after Children (Scotland) Regulations 2009;
• (ii) apologise to Mrs A for any distress caused as a result of allowing her great grandson to be left in the care of a stranger;
• (iii) provide to him a copy of the internal auditors' report on the introduction of the pilot complaints procedure and that he is kept advised of any recommendations made;
• (iv) keep him advised of the progress of the introduction of the new complaints procedure and that he receives a copy of the new complaints handling procedure; and
• (v) apologise to Mrs C (and Mrs A) for the way in which the formal complaint was handled.

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