West of Scotland

Overview
The complainant (Mrs C) complained that her dentist (the Dentist) failed to fit her correctly for dentures, leading to additional unexpected expense and further dental work.

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

• (a) failed to fit Mrs C with correctly sized dentures (not upheld); and
• (b) failed to detail treatment charges prior to treatment (upheld).

Redress and recommendations
The Ombudsman recommends that the Dentist:

• (i) introduces a policy of discussing the full treatment plan and costs with her patients prior to the commencement of treatment and that a note of this discussion is recorded in the clinical records.

The Dentist has accepted the recommendation and will act on it accordingly.

Overview
A Member of Parliament (Mr D) raised a complaint on behalf of a constituent (Ms C). It was first raised within Lothian NHS Board (the Board) on 25 July 2007. The complaint focused on the lack of consent on 2 March 2007 for additional clinical procedures to be undertaken during a pre-arranged surgical procedure. In her view, Ms C had not been given adequate time to fully consider the options and the attendant risks before consenting fully to the potential, additional surgery. It subsequently took 17 months to resolve her complaint at the local resolution stage of the NHS complaints procedure before the matter was referred to the Ombudsman's office on 27 July 2009.

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

• (a) the Board's actions in relation to obtaining consent from Ms C for the removal of her left fallopian tube during a laparoscopic adhesiolysis and left salpingostomy were unsatisfactory (upheld); and
• (b) the Board delayed in responding to Ms C's complaints (upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• (i) apologise to Ms C for the decisions taken to carry out additional surgery without her clear understanding of the potential outcomes;
• (ii) ensure elective surgical consent forms are clearly set out and appropriately understood and signed by the patient or their representative;
• (iii) apologise to Ms C and her representative for the delays experienced in the handling of their complaint; and
• (iv) ensure the revised internal complaints procedure provides all the necessary components set out in the NHS complaints procedure to guarantee a consistent approach to complaint handling within the Board.

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

Overview
The complainant (Ms C) raised a complaint against the Scottish Ambulance Service (the Service) about the length of time it took for a paramedic response unit (the PRU) and accident and emergency vehicle to attend an emergency call-out when her brother, Mr A, collapsed with chest pains at her home. Mr A later died in hospital.

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

• (a) the PRU took an unreasonable length of time to attend (not upheld); and
• (b) the accident and emergency vehicle took an unreasonable length of time to attend (upheld).

Redress and recommendations
The Ombudsman recommends that the Service:

• (i) undertake the actions outlined at paragraph 19 of this report and provide him with evidence that these have taken place;
• (ii) review their current system for the allocation of back-up accident and emergency vehicles to PRUs, to ensure that the risk of unnecessary delay is minimised;
• (iii) consider introducing a system to record all calls from paramedics' mobile phones to the Emergency Medical Dispatch Centre; and
• (iv) apologise to Ms C for the failings identified in this report.

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

Overview
The complainant (Mrs C), a Senior Project Worker for an advocacy service, complained about the care and treatment of a member of the public (Mrs A) during an admission to St John's Hospital (the Hospital).

Specific complaints and conclusions
The complaints which have been investigated are that Lothian NHS Board (the Board):

• (a) failed to prevent a male patient from entering Mrs A's room on a number of occasions (not upheld);
• (b) failed to explain what action they had taken to prevent a recurrence, when responding to the complaint (upheld);
• (c) inappropriately continued to barrier nurse Mrs A, despite a negative stool specimen being provided on 26 May 2009 (not upheld); and
• (d) stated, in response to Mrs A's complaint, that she was moved to Ward 17 for further assessment, whereas Mrs A had understood that she was simply being moved there because it was a safer environment (not upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• (i) ensure that, in future complaint responses, they provide complainants with information regarding the action they intend to take to prevent recurrence of any problems identified; and
• (ii) consider Adviser 1 and Adviser 2's comments at paragraph 18 and revise their action plan in order to ensure that it is comprehensive.

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

Overview
Mrs C raised a complaint against Lothian NHS Board (the Board) regarding the care which her son, Mr A, had received when he was admitted by ambulance to the Accident and Emergency Department (the Department) at the Royal Infirmary of Edinburgh (the Hospital) complaining of chest pain. Mr A was discharged with a diagnosis of indigestion. Some weeks later, Mr A collapsed and died. A post mortem examination found that he had been suffering from acute heart disease.

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

• (a) the ECG performed by the ambulance crew was not available to or checked by the Department doctor (upheld); and
• (b) apart from an ECG, no other investigations were undertaken on Mr A when he arrived at the Hospital and local protocols and Scottish Intercollegiate Guidelines Network guidelines for patients presenting with chest pain were not adequately followed (not upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• (i) review their current communication methods between ambulance staff and clinical staff (both verbally and documentary) in respect of patients who are admitted to the Department;
• (ii) remind clinical staff of the importance of ensuring that all ECGs are available for review by clinical staff for patients presenting with chest pain; that their findings are documented in the patient's clinical records; and the Board's audit procedures in relation to ECG sign off are followed;
  (iii) remind staff of the importance of seeking details of any family history of heart problems from patients presenting with chest pain and documenting this in the clinical records; and
• (iv) apologise to Mrs C for the failings identified in this report.

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

Overview
The complainants (Mr C and Ms C) wanted to alter and extend their home which is a listed mid-terraced building in a conservation area. They sought advice from Midlothian Council (the Council) about the acceptability of their intentions before committing expenditure on making applications for planning and listed building consent. Those applications were refused and appeals to the Directorate of Planning and Environmental Appeals failed. Mr C and Ms C considered that the Council's response to their pre-planning application enquiries had been inadequate.

Specific complaint and conclusion
The complaint which has been investigated is that the Council's response to Mr C and Ms C's pre-planning application enquiries was inadequate (not upheld).

Redress and recommendations
The Ombudsman has no recommendations to make.

Overview
The complainant (Mr C) was unhappy with the care provided to his late wife (Mrs C) by Lothian NHS Board (the Board). Mrs C was admitted to the Royal Infirmary of Edinburgh (Hospital 1) on 18 August 2008, but was transferred to Liberton Hospital (Hospital 2) on 19 August 2008. She was given a course of antibiotics, but these were subsequently discontinued. Mrs C's condition deteriorated and she died in Hospital 2 on 26 August 2008.

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

• (a) provide appropriate treatment to Mrs C (upheld);
• (b) provide the correct course of antibiotics to Mrs C (upheld); and
• (c) communicate effectively with Mr C (upheld).

Redress and recommendations

The Ombudsman recommends that the Board:

• (i) ensure that their transfer protocol includes a requirement to consult with appropriate available relatives prior to transfer, when a patient is unable to give consent;
• (ii) provide guidance on documentation to all relevant staff at induction;
• (iii) adhere to their Incident Management Policy when a significant adverse event review is initiated, by ensuring that consideration is given to the inclusion of members with appropriate objectivity to the event;
• (iv) remind staff in Hospital 2 of the importance of assessing the competency of patients to make decisions to refuse treatment or medication where appropriate;
• (v) undertake an external peer review of the nursing care in Ward 1 in Hospital 2;
• (vi) provide him with details of the findings and action plan created as a result of the above recommendation and provide updates where relevant;
• (vii) ensure that the findings in this report are communicated to the staff involved in Mrs C's care and treatment; and
• (viii) issue an apology to Mr C for the failings identified in this report.

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

Overview
The complainants (Mr and Ms C) operate a movable food unit (the Unit) in an area (the Area) where The City of Edinburgh Council (the Council) issue street traders' licences. When Mr and Ms C applied to renew their annual street trader's licence, they were told that the street trading policy for the Area had changed and that only temporary licences could be issued. Mr and Ms C complained that the Council had changed the street trading policy without consulting them. They also complained that they had been charged non-domestic rates as well as street trader's licences, contrary to street trading legislation, and that the handling of the temporary licence applications was inadequate. Mr and Ms C were also unhappy about the Council's delay in dealing with their complaint.

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

• (a) the Council changed their policy regarding street traders' licensing in the area where Mr and Ms C operate without consulting them (upheld);
• (b) Mr and Ms C were inappropriately charged for both non-domestic rates and street trader's licences (upheld);
• (c) the handling of the temporary licence applications was inadequate (upheld); and
• (d) the Council delayed unreasonably in dealing with the complaint (upheld).

Redress and recommendations
The Ombudsman recommends that the Council:

• (i) ensure that full written consultation is undertaken with those directly affected by any proposed change to street trading policy in future;
• (ii) remind staff involved in drafting reports to Council committees of the importance of ensuring that accurate information is presented;
• (iii) reimburse Mr and Ms C for the cost of the two temporary licence applications and take steps to ensure that information provided to applicants is clear and accurate;
• (iv) ensure that when officers are making a recommendation to the Licensing Sub-Committee to refuse a temporary licence application, the reasons for recommending refusal are clear and consistent;
• (v) ensure that, when a decision is made to refuse a temporary licence application under paragraph 5(3)(d) of Schedule 1 of the 1982 Act, the Council provides an adequate explanation for the 'good reason' which justified the refusal to the applicants;
• (vi) remind staff within the licensing department of the Council's stated timescales for responding to complaints and the importance of keeping the complainant updated if there is to be a delay in responding to a complaint; and
• (vii) apologise to Mr and Ms C for the failings identified in this report.

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

Overview
Ms C complained that in 2007 the respite care that was offered by The City of Edinburgh Council (the Council) for her teenage daughter (Miss A), who has complex special needs, did not meet her daughter's assessed needs.

Specific complaint and conclusion
The complaint which has been investigated is that, in 2007, the respite care offered by the Council did not reasonably meet the assessed needs of Miss A (not upheld).

Redress and recommendation
The Ombudsman has no recommendations to make.

Overview
In early 2008, Ms A was diagnosed with osteomyelitis of the maxilla, following investigation at a private hospital. This is a condition where the main bone of the upper jaw (maxilla) has become inflamed and damaged by infection. Ms A had suffered from symptoms since at least 2004 and previously attended at both Borders NHS Board (Board 1) and Lothian NHS Board (Board 2) hospitals. She complained that, despite this, she had not been correctly diagnosed by the NHS and that, as a result, she had had to pay for private treatment. Ms A's complaint was brought to the Ombudsman's office by her MSP (Mr C).

Specific complaint and conclusion
The complaint which has been investigated is that Ms A was not investigated properly and that the diagnosis could have been made sooner by the NHS (upheld).

Redress and recommendations
The Ombudsman recommends that Board 1:

• (i) review their procedures for monitoring and auditing the referral process in light of the problems identified;
• (ii) remind clinicians involved of the need to consider carefully the information provided as part of the referral process;
• (iii) consider the best practice advice made by the Adviser to the Ombudsman; and
• (iv) provide him with reassurance that there has been an improvement in the time taken to review CT scans and discuss them with patients.  He also asks that Board 1notify him when the recommendations have been implemented.

The Ombudsman recommends that Board 2:

• (i) review their procedures for monitoring and auditing the referral process in light of the problems identified;
• (ii) remind clinicians involved of the need to consider carefully the information provided as part of the referral process;
• (iii) consider the best practice advice made by the Adviser to the Ombudsman;
• (iv) undertake a short, focussed audit of record-keeping in the Ear Nose and Throat clinic and the Dental Institute and put in place an action plan to deal with any problems identified; and
• (v) reimburse Ms A for the costs of the private treatment required to identify her condition.

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