West of Scotland

Overview
On 2 February 2010, I received a complaint from the complainant (Ms C) against Lothian NHS Board (the Board). The complaint concerned the care and treatment her grandfather (Mr A) received in the Maple Villa Care Home, Livingston (the Care Home) prior to his death. Mr A suffered from Alzheimer's disease and the Care Home is a specialist dementia unit catering for patients with particularly challenging aspects of that condition. Mr A resided there from 2004 until July 2009. On 24 July 2009 he was admitted to St John's Hospital, Livingston, where he died three days later. Ms C said that on his admission he was severely dehydrated, had a urinary tract infection and bedsores.

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

• (a) provide Mr A with proper nutrition (upheld);
• (b) provide Mr A with general personal care (upheld);
• (c) take action to prevent bedsores (not upheld);
• (d) provide any form of stimulus to Mr A as a patient suffering from Alzheimer's disease (upheld); and,
• (e) communicate adequately with the family (upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• (i) make a written apology to Ms C for their failures with regard to Mr A and for the misinformation given;
• (ii) emphasise to staff in the Care Home the necessity of following adopted procedures and the proper completion of standardised forms;
• (iii) monitor procedures in the Care Home for a period of four months;
• (iv) provide evidence to the Ombudsman of the range of structured recreational or diversional activity now available to residents in the Care Home and emphasise to staff the importance of such;
• (v) emphasise to their staff the benefit to all parties of clear communication; and
• (vi) ensure that, on each new admission, the Care Home take steps to discuss and record the level and means of communication required with families; and provide evidence to the Ombudsman that this is happening.

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

Overview
The complainant (Mr C) raised a number of concerns relating to East Renfrewshire Council (the Council)'s decision to install a multi use games area (MUGA) in the grounds of a primary school (the School) adjacent to his flat and their subsequent decision that the gates remain open at all times providing unrestricted community use, with consequent detriment to his amenity.

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

• (a) the Council failed to consult residents before installing the MUGA at the School in March 2007 (not upheld);
• (b) the Council ignored a more suitable site (not upheld);
• (c) the Council ignored Mr C's reasonable requests that the gates of the MUGA be locked after supervised activities had ended in the early evening (not upheld);
• (d) the Council's decision in May 2008 to leave the gates open permanently was taken without consulting with or hearing from residents most directly affected (upheld);
• (e) the Council ignored Mr C's requests after May 2008, that respite be provided by closing the gates all day on Sundays (not upheld); and
• (f) the Council delayed in informing Mr C of his entitlement to make a formal complaint and, if dissatisfied with the way it was dealt with, to take his complaint to the SPSO (upheld).

Redress and recommendations
The Ombudsman recommends that the Council:

• (i) given the change to community use of the site, now consult with adjacent residents on the change and the current 'open gate' access to the MUGA and, following this, reconsider the 'open gate' policy, taking into account the views expressed. If the 'open gate' policy continues, the matter should also be raised with the Planning Department to consider whether there has been a material change of use and, if so, whether it constitutes a bad neighbour development; and
• (ii) advise both the SPSO and Mr C of the outcome.

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

Overview
The complainant (Mr C), the owner of a tenement flat, raised concerns about the handling of statutory notices issued by The City of Edinburgh Council (the Council) under the City of Edinburgh District Council Order Confirmation Act 1991 and about financial advice and assistance he received.

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

• (a) the Council failed to give Mr C correct and sufficient advice regarding obtaining finance for his share of the costs of works instructed under statutory notices (not upheld); and
• (b) the actions of the Council and their agents (the Agents), with regard to the apportionment of costs, were inconsistent (upheld).

Redress and recommendations
The Ombudsman recommends that the Council:

• (i) revisit, and take steps to seek to prevent, the situation where the Agents sent out invoices in April 2008 on the basis of an erroneous list of owners;
• (ii) reimburse Mr C for any additional costs he incurred in consequence of the Agents' initial erroneous invoice; and
• (iii) consider formally whether it is appropriate for them to seek recovery of the costs of works on the basis of title and, if they are mindful to do so, inform Mr C accordingly in order that he can seek appropriate legal advice on his own options.

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

Overview
The complainant (Ms C) raised concerns about the treatment she had received when she attended the Accident and Emergency (A&E) unit at the Royal Infirmary of Edinburgh in the area of Lothian NHS Board (the Board) following an injury to her leg.

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

• (a) the diagnosis provided by the Board was not reasonable (upheld); and
• (b) the care provided in Hospital 1 was inadequate (upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• (i) should give consideration to implementing the Ottawa knee decision rules when assessing A&E patients if these are not already in place;
• (ii) should apologise for the shortcomings in the care provided which are highlighted in this report; and
• (iii) devise/review their pain management guidelines and ensure that all A&E clinical staff are aware of the guidelines.

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

Overview
The complainant (Miss C) attended the Royal Infirmary of Edinburgh, in the area of Lothian NHS Board (the Board), on two separate occasions in early 2009 with a history of abdominal pain and irregular menstrual bleeding. She complained about the management of her pain during these attendances.

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

• (a) Miss C's pain was managed inappropriately (upheld); and
• (b) the standard of record-keeping was inadequate (upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• (i) review their systems for ensuring that patients' pain is properly assessed in Accident and Emergency and on the gynaecology ward and that patients' needs are met with timely pain management, and provide copies of audits regarding pain assessment and management. The review should consider triage arrangements for patients directly referred by their GP and also initiatives for meeting patients' needs if medical staff are not readily available to prescribe pain relief;
• (ii) ensure that, when handling complaints, all complainants' concerns are addressed and that responses refer to relevant standards and guidelines where appropriate;
• (iii) apologise to Miss C for their failure to manage her pain appropriately and for not fully addressing this issue when responding to her complaint. The apology should also acknowledge the inappropriate reference to Miss C using her mobile telephone; and
• (iv) provide evidence that appropriate strategies are in place to ensure that all nursing records meet the standards outlined by the Nursing and Midwifery Council.

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

Overview
The complaint centres on a property and campsite (the Property) situated in a country park (the Park) which is leased from Midlothian Council (the Council) by a young people's organisation (the Organisation). The Property, which lies approximately 800 metres from the Park main entrance, is accessed by a driveway through the Park. The Property is used mostly at weekends and has a small car park adjacent to it. Following a risk assessment conducted on 22 July 2008, the Council informed the Organisation that, due to complaints having been received, they would be enforcing an earlier amendment to the lease. This meant the Organisation would no longer be allowed vehicular use of the driveway. The Organisation's lease was amended again at a later date to allow them vehicular access on Friday evenings when children were being dropped off by parents/carers, but not on Sunday afternoons when they were being collected. The complaint was brought by a spokesperson for the Organisation, referred to as Mrs C. She complained about the Council's handling of the Organisation's complaints, representations and proposed solutions following the restrictions to their vehicular access.

Specific complaint and conclusion
The complaint which has been investigated is that following an amendment to the Organisation's lease in November 2007, the Council's administrative handling of their proposed solutions, representations and subsequent complaints was poor (not upheld).

Redress and recommendations
The Ombudsman recommends that the Council:

• (i) give the Organisation appropriate consideration in any future decisions concerning the Park and balance their particular needs with the needs of other park users;
• (ii) record complaints received about any incidents in the Park involving vehicles and pedestrians; and
• (iii) provide guidance to the Organisation on how they can improve their control of the use of the driveway.

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

Overview
The complainant (Mr C) has raised concerns about the time it has taken to receive an operation following a referral by his GP. He has also complained of Lothian NHS Board (the Board)'s failure to provide a clear explanation for the delay.

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

• (a) there was an unacceptable delay between referral for surgery and being offered an appointment (upheld); and
• (b) the Board failed to provide a clear and consistent explanation for the delayed appointment (upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• (i) write to Mr C to apologise for their failure to provide him with surgery within their own targets of 12 weeks from referral;
• (ii) write to Mr C to apologise for their failure to provide him with an explanation for the delay in offering him an accurate date for surgery within their target period and also their failure to adhere to their 'guaranteed' date for surgery of 18 September 2009; and
• (iii) review the way they carry out and monitor referrals for surgery.

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

Overview
The complainant (Ms C) attended her dentist (the Dentist) with toothache. She believed the pain was coming from a particular tooth, but the Dentist removed the neighbouring tooth. She said the pain continued until a dentist at another dental practice removed the one which she considered should have been removed. She felt this was proof that the Dentist had taken out the wrong tooth.

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

• (a) the examination of Ms C's mouth was inadequate (upheld); and
• (b) the record-keeping was inadequate (upheld).

Redress and recommendations
The Ombudsman recommends that the Dentist:

• (i) apologises to Ms C for the shortcomings identified;
• (ii) ensures adequate investigation of patients with toothache; and
• (iii) improves his record-keeping to the standard described in this report.

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

Overview
The complainant (Ms C) was concerned about the care and treatment provided to her father (Mr A) when he had attended at St John's Hospital (Hospital 1) following a fall at home. Mr A had been taken to Hospital 1 by ambulance on 1 November 2008 but had been discharged a short time later. Mr A was found some distance from his home in the early hours of 2 November 2008. On that occasion he was taken by ambulance to a hospital in another board area (Hospital 2). Despite requests, Hospital 2 was not provided with Mr A's notes from Hospital 1. Mr A died in Hospital 2 on 5 November 2008.

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

• (a) the decision to discharge Mr A was inappropriate (upheld); and
• (b) the complaints handling and information provided was inadequate (upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• (i) undertake an audit of the action plan and provide him with details of the outcome;
• (ii) satisfy themselves that the transfer of records between hospitals and Board areas is being carried out quickly and efficiently;
• (iii) review their complaints procedure and related guidance to staff, in order to ensure that complainants are provided with a full response supported by staff statements and records;
• (iv) ensure, when investigating complaints, that documentation is kept of interviews and key actions;
• (v) apologise to Ms C and Ms D for the failings identified in this report.

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

Overview
The complainant (Mr C) raised a number of concerns about delay in him accessing appropriate care from NHS Lothian's Primary Care Mental Health Services. He also complained that there was a delay in reporting child protection issues and in responding to his complaint.

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

• (a) there was a delay in Mr C receiving appropriate care following his initial assessment (not upheld);
• (b) child protection issues were not reported for a two week period, contrary to guidance, and that Mr C was not offered appropriate support (upheld); and
• (c) there was a delay in responding to Mr C's complaint (not upheld).

Redress and recommendation
The Ombudsman recommends that the Board:

• (i) write to Mr C acknowledging that the Community Mental Health Nurse Therapist should have acted sooner on the issue of child protection and apologising to him for the delay in doing so.

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