West of Scotland

Overview
The complainant (Mrs C) complained on behalf of her husband, Mr C.  She said that after Mr C fell down the stairs at home and an ambulance was called, staff failed to ensure that he was properly cared for.  She believed that the actions of the paramedics contributed to his resultant paraplegia (complete paralysis of the lower half of the body including both legs, usually caused by damage to the spinal cord).

Specific complaint and conclusions
The complaint which has been investigated is that the Scottish Ambulance Service (the Service) failed to ensure that their staff used a stretcher and neck brace when transferring Mr C to hospital (upheld).

Redress and recommendations
The Ombudsman recommends that the Service:

• (i)  make a formal apology to Mr and Mrs C for their failure to properly immobilise Mr C after the incident on 24 March 2012 and for the inadequacies of their internal investigation; and
• (ii)  externally audit their complaints handling processes to ensure that they are sufficiently robust and fit for purpose.

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

Overview
The complainant (Miss C) raised a number of concerns about her late father's (Mr A) prostate cancer diagnosis.  This included Mr A's concerns at being advised that he did not have prostate cancer resulting in his treatment being stopped.  Miss C was also dissatisfied with the lack of information and support given to Mr A and the family about the diagnosis, prognosis and side effects of the treatment.

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

• (a) did not provide reasonable care and treatment to Mr A from May 2011 onwards (upheld);
• (b) unreasonably withheld information about his condition from Mr A and his family (upheld); and
• (c) did not reasonably handle Miss C's complaint (upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• review their prostate cancer guidance to ensure it is consistent with national guidelines for the management of patients with widespread prostate cancer when a biopsy is not indicated;
• ensure timely involvement by a specialist cancer nurse shortly after diagnosis of prostate cancer;
• ensure Doctor 4 discusses the failings identified in this report at his next appraisal;
• ensure clinical staff clearly record any verbal responses they provide to patient correspondence;
• apologise to Miss C and the family for the failings identified in this report; and
• ensure that complaint responses are consistent, accurate and set out in a structured manner.

Overview
The complainant (Mr C) raised a number of concerns that Business Stream unreasonably delayed in resolving issues concerning the water meter for his business premises, and involved him in unnecessary expense to pursue his complaint.

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

• unreasonably delayed in resolving issues concerning the water meter for Mr C's business premises; (upheld) and
• involved Mr C in unnecessary expense to pursue his complaint (upheld).

Redress and recommendations
The Ombudsman recommends that Business Stream:

• credit Mr C's account with 50 percent of the balance on the account or £200, whichever is the greater, in further recognition of the extent of their poor handling of the matter;
• provide the Ombudsman with evidence that there is a robust system in place or proposed, to ensure that the errors which resulted in delay in resolving this case do not recur; and
• formally apologise to Mr C for their error in passing his account to a debt collection agency.

Business Stream have accepted the recommendations and will act on them accordingly.

Overview
Miss C complained on behalf of her siblings and herself.  She alleged that when her mother (Mrs A) was admitted to hospital, she was not properly assessed.  In particular that FALLS assessments (a risk assessment tool for the prevention of falls in older people) which were carried out failed to take account of Mrs A's medical conditions.  Miss C said that if a proper assessment had been made, Mrs A would not have been left alone on a commode.  Miss C further complained about the way in which the Lothian NHS Board (the Board) subsequently handled her complaint.

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

• (a) the Board failed to conduct an appropriate risk assessment on Mrs A's admission to the Royal Infirmary of Edinburgh (upheld); and
• (b) the Board failed to address Miss C's concerns adequately (upheld).

Redress and recommendations

The Ombudsman recommends that the Board:

• make a formal apology to Miss C and her siblings for their failure in this matter;
• look again at the FALLS assessment to ensure that staff exercise clinical judgement when assessing risk;
• emphasise to staff the importance of keeping accurate and timely records which would be fully adequate for the purposes of later scrutiny; and
• make a formal apology to Miss C and her siblings for the omissions in their correspondence.

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

Overview
The complainant, who is a chartered surveyor (Mr C), raised a number of complaints against Business Stream on behalf of his client, Forestry Commission Scotland (FCS).  He alleged that a secondary water meter had been installed on FCS's private water supply pipe and that water had been charged for twice.  He also complained about the way in which his subsequent complaint was handled.

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

• (a) unreasonably installed a secondary water meter on FCS's water supply (upheld); and
• (b) failed to handle Mr C's complaint appropriately (upheld).

Redress and recommendations
The Ombudsman recommends that Business Stream:

• (i)  make a full and sincere apology to Mr C (and his client) for their failures in this matter;
• (ii)  reimburse FCS's fees (subject to proper invoices being presented) for the work Mr C did for them after 12 July 2012 (until November 16) when it was known that there was a second meter attached to their water pipe;
• (iii)  formally apologise to Mr C for the delay in dealing with his complaint and for the confusion and inconvenience caused; and
• (iv)  conduct an independent audit of the complaints process and how it is being applied.

Business Stream have accepted the recommendations and will act on them accordingly.

Overview

The complainant (Mr C) attended the Ear, Nose and Throat (ENT) Department of the Royal Infirmary of Edinburgh (the Hospital) on numerous occasions following referral by his GP in June 2010. During this period his symptoms, which included bleeding from the throat, worsened. After each examination, he was discharged and re-referred to his GP. On 28 September 2011, he was diagnosed at the ENT Department with throat cancer (a right tonsil mass).

Specific complaint and conclusion

The complaint which has been investigated is that staff at the ENT Department failed to investigate Mr C’s symptoms appropriately and this led to a delayed diagnosis of stage 2 cancer of the right tonsil (upheld).

Redress and recommendations

The Ombudsman recommends that the Board:

(i)  apologise to Mr C for the failings identified;

(ii)  carry out a Serious Clinical Incident Review; and

(iii)  review the procedure for GP referrals to ensure that where there have been repeated referrals this is taken into account by ENT clinicians when assessing and examining the patient.

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

Overview
The complainant (Mrs C), an advocacy worker, raised a number of concerns on behalf of her client (Ms A) about Ms A's detention under the terms of a Short-Term Detention Certificate and her subsequent transfer, under nurse escort by ambulance, from the Royal Infirmary Edinburgh (Hospital 1) to the mental health unit at St John's Hospital (Hospital 2) in November 2011. Specifically, Mrs C complained about the way in which Ms A was transferred and that she did not receive appropriate information in relation to the detention and transfer.

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

• (a) Ms A was forcibly transferred from Hospital 1 to Hospital 2 without any prior knowledge or explanation of reasons (upheld);
• (b) Ms A was inappropriately told she was being detained under the Mental Health Act but has no recollection of being detained (upheld); and
• (c) the manner in which Ms A was wrapped in a blanket and strapped to a trolley, causing severe bruising to her shoulders, was unreasonable (not upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• (i) ensure that where detention and/or transfer is being considered, the matter is fully discussed with the patient and they are informed of the options available to them and the rationale underpinning the decision;
• (ii) ensure that in such cases discussions in relation to the patient's care and treatment and actions taken, including the use of medication, are clearly recorded in the clinical notes;
• (iii) ensure that, where restraint is required during the transfer of a patient, the appropriate incident report is completed in line with Board policy and the event clearly recorded in the clinical notes;
• (iv) feed back the learning from this complaint to all relevant staff in both hospitals;
• (v) ensure that all staff involved in taking decisions on short term and emergency detention are aware of the requirements of the Mental Health legislation and adhere to the appropriate process when carrying out any detention; and
• (vi) ensure that a physical examination is conducted on a patient on their arrival at a hospital, especially if the patient was the subject of a physical restraint en-route to the hospital; and

The Ombudsman recommends that:

• (i) this report be considered at a meeting of the Lothian NHS Board.

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

Overview
The complainant (Mrs C) raised a number of concerns with Lothian NHS Board (the Board) about the care and treatment she received during her pregnancy, in particular, from her community midwife (the Midwife). Mrs C also raised concerns that medical staff, immediately following her son’s birth (Baby A) on 16 May 2011 when she had a haemorrhage, refused to allow her husband (Mr C) to push her bed to the theatre.

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

• (a) the Midwife failed to deal with Mrs C’s request for a caesarean section properly (upheld);
• (b) the Midwife unreasonably refused Mrs C antenatal appointments (not upheld);
• (c) the Midwife misled Mrs C about when she would be induced (not upheld); and
• (d) the Board unreasonably refused to allow Mr C to push Mrs C’s bed to theatre (not upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• (i) ensure that the comments of the Adviser in relation to complaint (a) are shared with community midwives, in particular, that where there is any deviation from a normal uncomplicated pregnancy, the expectant mother should be referred to an obstetrician or other medical specialist as appropriate;
• (ii) ensure that the comments of the Adviser in relation to complaint (c) are shared with community midwives, in particular, that every case of an expectant mother must be considered individually and that relevant issues of a complex history, maternal age and personal anxieties are taken in to account;
• (iii) review the process of record-keeping by community midwives in relation to patients’ notes. In particular, to ensure that any discussions and advice given concerning requests by an expectant mother for any intervention, induction of labour or a C section are clearly and properly documented in her medical records; and
• (iv) apologise to Mrs C for the failings identified in this report.