West of Scotland

Overview
The complainant (Mr C) had carpal tunnel release surgery performed on his left hand in June 2006. Unfortunately, post-operatively, he suffered pain, numbness and swelling in his hand. Mr C raised concerns about the way the operation was performed and also that he was not referred back to the operating surgeon to be re-examined as soon as possible after he complained of adverse symptoms. He has subsequently been told that he has permanent nerve damage.

Specific complaint and conclusion
The complaint which has been investigated is that Lothian NHS Board (the Board) did not provide reasonable care and treatment to Mr C during and following his operation for carpal tunnel syndrome (upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• (i) reinforce with staff the importance of referring patients back for a consultant review as soon as possible if there are complications or adverse symptoms which need attention; and
• (ii) apologise to Mr C for the failings identified in this report.

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

Overview
The complainant (Mr C) complained that his wife (Ms A) had not received appropriate care and treatment when they both attended the Obstetric Triage Department, Simpson's Centre for Reproductive Health (the Centre), prior to the birth of their baby daughter (Baby A), and that Baby A suffered severe medical complications as a result.

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

• (a) the Centre failed to detect problems with Ms A's pregnancy and failed to carry out appropriate tests when she attended the Centre on 15 and 16 June 2008 (upheld);
• (b) the Centre failed to take Mr C and Ms A's concerns and questions into account on 15 and 16 June 2008 (upheld);
• (c) the Centre failed to give Mr C and Ms A correct advice on 15 and 16 June 2008 or to ensure that adequate follow-up support was in place and offered to Mr C and Ms A on 16 June 2008 (upheld); and
• (d) on 23 June 2008 there was a time lapse of more than 30 minutes (the recommended practice) from the decision to perform an emergency lower uterine caesarean section to the start of this procedure (upheld).

Redress and recommendations
The Ombudsman recommends that Lothian NHS Board (the Board):

• (i) inform him of the measures being undertaken to address the issues raised within paragraphs 26, 27 and 28;
• (ii) inform him of the measures being undertaken to address the inadequate level of staff interface and communication with Mr C and Ms A at the Centre;
• (iii) inform him of the measures they take to ensure that the practice (when presented with a patient with reduced foetal movement) is adhered to, with reference to NICE Antenatal Guidelines 2008;
• (iv) inform him of the measures undertaken to ensure that the delay which occurred in this case, from decision to 'knife to skin', does not recur in a similar situation; and
• (v) issue Mr C and Ms A with a formal written apology for the inadequate standard of care and treatment Mr C and Ms A received on 15, 16 and 23 June 2008, prior to the birth of Baby A, as identified in heads of complaint (a), (b), (c) and (d).

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

Overview
The complainants (Mr and Mrs C) complained that Lothian NHS Board (the Board) did not re-test Mr C for Huntington's disease (HD) when new, more accurate, testing was introduced in 1993. Mr C had previously been diagnosed as a likely sufferer of the condition, but received a negative result when re-tested in October 2007. Mr and Mrs C said that their belief that the condition would affect Mr C, and potentially their daughters, caused a great deal of anxiety and led them to make certain life choices. They complained that, had re-testing been provided routinely upon the introduction of more accurate tests in 1993, much of the stress placed on the family would have been avoided and different decisions made about their daughters' future.

Specific complaint and conclusion
The complaint which has been investigated is that the Board did not act reasonably in failing to re-test Mr C for HD following the introduction of more accurate tests (upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• (i) remind clinicians of the importance of open discussions of available new genetic tests with affected patients in order to enable them to make informed choices; and
• (ii) remind clinicians of the importance of recording such discussions, including relevant information given to patients.

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

Overview
The complainant (Mr C) raised concerns regarding the care and treatment received by his late mother (Mrs A) at the Royal Infirmary of Edinburgh (the Hospital). Mrs A underwent surgery on 27 June 2007 for the removal of a pelvic cyst and a hysterectomy and Mr C was unhappy with the level of information provided prior to the surgery; the appropriateness of the decision to operate; the handling of the surgical complications and the timing of Mrs A's discharge. The specific points of complaint are listed below.

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

• (a) the consent process was not properly carried out and there was insufficient communication with regard to operative risks (partially upheld to the extent that the doctor obtaining consent did not have the appropriate level of seniority and experience);
• (b) the surgical decision-making process was inappropriate (upheld);
• (c) the surgical complications were not dealt with appropriately (upheld); and
• (d) Mrs A was discharged prematurely from the Hospital (not upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• (i) review their procedures to ensure that the process of obtaining patient consent is carried out by a clinician with an appropriate level of seniority and experience, ideally the doctor who will be carrying out the surgery;
• (ii) review their procedures to ensure that there is consultant involvement in decisions to proceed to surgery and in decisions regarding the type of surgery to be carried out;
• (iii) reflect on the delay in identifying Mrs A's intra-abdominal bleed and implement an action to prevent similar future failures;
• (iv) ensure that a proper multi-disciplinary approach to patient care is in place and seen to be effective; and
• (v) apologise to Mr C for the failings identified in this report.

Overview
The complainant (Mrs C) raised a number of concerns that her mother (Mrs A) had not been reasonably cared for or treated by medical staff at St John's Hospital (the Hospital) or her GP practice (the Practice) in the months before her death, and that the responses to Mrs C's enquiries and complaints by Lothian NHS Board (the Board) and the Practice had not been appropriate and had been unnecessarily distressing to her.

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

• (a) the Board did not provide reasonable care and treatment to Mrs A between May 2007 and February 2008 (partially upheld to the extent that the investigation, diagnosis, care and treatment of Mrs A from November 2007 to February 2008 was not reasonable);
• (b) the actions taken by the Board in response to Mrs C's complaints about the care and treatment of Mrs A were not reasonable (upheld);
• (c) Mrs A did not receive adequate care and treatment from the Practice between November 2007 and February 2008 (partially upheld to the extent that the Practice did not reasonably address or follow-up the symptoms that Mrs A displayed which can be linked to cancer, that the Practice's prescription of pills rather than other forms of treatment to Mrs A was not reasonable, that the Practice did not reasonably take into account changes in Mrs A's condition and that the level of information recorded in Mrs A's notes was not comprehensive); and
• (d) the Practice's responses to Mrs C's enquiries and complaints were inappropriate and unnecessarily distressing (partially upheld to the extent that, although the Practice appropriately responded to some of Mrs C's enquiries and complaints, some of the Practice's responses, or lack of responses, to Mrs C's enquiries and complaints were inappropriate and unnecessarily distressing).

Redress and recommendations
The Ombudsman recommends that the Board:

• (i) apologise to Mrs A's family that the chest x-ray of 26 November 2007 was mis-reported and that this led to a delay in the diagnosis of Mrs A's cancer;
• (ii) remind medical staff that letters to GPs should be dictated immediately after consultations with patients;
• (iii) encourage the practice of discussing patients with atypical clinical features at multi-disciplinary meetings;
• (iv) take steps to assure themselves of the quality of their chest x-ray reporting service;
• (v) apologise to Mrs C that the investigation of her complaints did not uncover the mis-reporting of the chest x-ray of 26 November 2007; and
• (vi) ensure that investigations of similar complaints in the future consider the possibility that x-rays, scans, test results or similar may have been mis-reported.

The Ombudsman recommends that the Practice:

• (i) apologise to Mrs A's family for those aspects of her care and treatment that were not reasonable;
• (ii) produce a plan for reviewing their adherence to national guidelines. This plan should be minuted and form part of the Practice's clinical governance meetings. The minutes should be inspected by the Board's clinical governance lead to ensure that the Practice have identified areas for improvement and taken action to address these issues;
• (iii) ensure that national guidelines are readily available to all practitioners;
• (iv) undertake a review of clinical record-keeping using the Royal College of General Practitioners (Scotland) template on section 3D (2) of the Revalidation Toolkit. The review should be discussed with the Board's clinical governance lead to ensure that the Practice have identified areas for improvement and taken action to address these areas;
• (v) apologise to Mrs C that their responses to her enquiries and complaints were inappropriate and unnecessarily distressing; and
• (vi) review their complaints handling procedure to ensure that complainants are given direct answers to reasonable direct questions, that individual circumstances, distress and stated preferences are reasonably taken into account when suggesting meetings with correspondents and complainants, that it is made clear to correspondents how to set in motion the Practice's complaints procedure and that avoidable errors are reasonably eliminated, taking into account the individual circumstances of a complaint.

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

Overview
The complainant (Mr C) complained that Edinburgh College of Art (the College) did not handle his son (Mr A)'s academic appeals appropriately and that this disadvantaged him by delaying the start of his professional career.

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

• (a) there were flaws in the way the College handled the initial approach by Mr A (partially upheld to the extent that the College did not supply Mr A with a copy of the Academic Appeals Policy and Procedures (the Appeals Policy) earlier, and did not advise him of the date of the Preliminary Assessment Panel (PAP));
• (b) the College attempted to influence Heriot-Watt University (the University), as the final point of appeal, inappropriately during the appeal (not upheld);
• (c) the College's responses to the University during the appeals process were inadequate (upheld);
• (d) advice given to Mr A following the initial appeal was inadequate and not documented (no finding);
• (e) procedures identified as potentially misleading following the first appeal (ie undocumented verbal feedback to students) were not corrected before the second (not upheld);
• (f) the attitude of College staff towards Mr C was not appropriate, including legal threats (not upheld); and
• (g) the time taken to deal with the appeals was excessive (partially upheld to the extent that the College's failure to comply with the University's request for comment on the grounds for appeal caused some of the delay in the overall processing of the second appeal);

Redress and recommendations
The Ombudsman recommends that the College:

• (i) provide appellants with a copy of the Appeals Policy, or information on where to obtain a copy, when they first acknowledge receipt of an appeal. The College should also advise appellants of the date of the PAP, allowing reasonable time for appellants to seek advice from the Students' Representative Council General Manager and provide further information in support of their appeal;
• (ii) include, in the letter issued to appellants after the PAP, an explanation of why a decision has been reached that there are no prima facie grounds for an appeal to proceed, and an explicit statement of what avenue of appeal remains open;
• (iii) should not supply information to the University relating to an appeal unless that information can be supported by evidence or the information is clearly an opinion or comment given in response to such a request;
• (iv) apologise to Mr A for supplying unsubstantiated information to the University regarding his attendance;
• (v) should in future comply with requests for comment on the grounds for appeal from the University;
• (vi) draw up and implement a clear policy for managing unacceptable behaviour. The Ombudsman encourages the College to refer to the SPSO Unacceptable Actions Policy when drawing up their own policy; and
• (vii) include indicative timescales for holding the PAP and the Academic Appeals Committee in the next version of the Appeals Policy.

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

Overview
The complainant (Mr C) raised a number of concerns about the administration by The City of Edinburgh Council (the Council) of works instructed in consequence of statutory notices served under section 24(1) of the City of Edinburgh District Council Order Confirmation Act 1991. Those notices were served on Mr C and his wife (Mrs C) and other owners in their tenement building in 2001 and 2002. Mr and Mrs C decided to sell their flat in 2003. Mr C sought to establish the possible cost of the works necessitated by the statutory notices before concluding a sale. From information he obtained in 2003, Mr C anticipated that their share of the projected costs would be of the order of £2,800, when their share of the outcome costs was over £17,000. Mr C believed that the Council failed properly to administer the works to Mr and Mrs C's considerable financial disadvantage.

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

• (a) the Council too broadly defined the works required, instructed significantly different work than set out in the notices, included extensive renewal and rebuilding instead of repair and limited replacement, and allowed additional work of betterment/improvement (partially upheld); and
• (b) Council officers sought to mislead Mr C by maintaining that renewals or replacements constituted general repair work (not upheld).
   

Redress and recommendations
The Ombudsman recommends that the Council review the extent that they were responsible for the delays and increase in contract price and commute part of their administration charge.

The Council have accepted the recommendation to commute part of the administration charge and had authorised his staff to take this to a suitable conclusion.

Overview
The complainant (Mr C) complained on behalf of himself and his family that Lothian NHS Board (the Board) failed to provide reasonable care and treatment to his wife (Mrs C) from 28 September 2007 to 15 January 2008. Mrs C was admitted to the Royal Infirmary of Edinburgh (Hospital 1) following a fall in September 2007. Mrs C suffered a fracture of her left ankle and a plaster cast was applied to her left leg. Mrs C subsequently had an above knee amputation of her left leg. Mr C did not consider this treatment was reasonable given Mrs C's other medical conditions. Mr C further complained that Mrs C contracted a Methicillin-resistant staphylococcus aureus (MRSA) infection while in Hospital 1 and about the overall standard of nursing care that Mrs C received. During the course of my investigation, I also included, as part of the investigation, the standard of record-keeping in respect of Mrs C's medical records.

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

• (a) the plaster cast that was applied to Mrs C's left leg was not appropriate treatment given Mrs C's other medical conditions (not upheld);
• (b) Mrs C contracted a MRSA infection whilst a patient in Hospital 1 (not upheld);
• (c) the standard of nursing care which Mrs C received was inadequate (not upheld); and
• (d) the standard of record-keeping in respect of Mrs C's medical notes was inadequate (upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• (i) undertake a review of the policy for reviewing plaster casts and in particular referral to senior medical staff;
• (ii) encourage the doctor concerned to reflect on the case at their next appraisal;
• (iii) apologise to Mrs C and her family for the failing to review Mrs C's plaster cast which has been identified in head of complaint (a) of this report;
• (iv) provide the Ombudsman with copies of the next Scottish Patient Safety Programme audit documentation in relation to all patient records within the orthopaedics department of Hospital 1; and
• (v) remind staff of the importance of fully completing all significant documentation, paying particular attention to the omissions identified in head of complaint (d) of 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 the care and treatment his late mother (Mrs A) received while a patient in Ward 8 (the Ward) of the Royal Victoria Hospital, Edinburgh (the Hospital). Mrs A died, aged 82-years-old, on 7 May 2007 in the Hospital. The complaint is brought by Mr C on behalf of himself, his sister (Mrs D) and other family members. Mr C and his family were also unhappy with the way in which Lothian NHS Board (the Board) dealt with their complaint.

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

• (a) Mr C and his family were given conflicting reasons by nursing staff for Mrs A's move to a two bedded room in the Ward (upheld);
• (b) the language used by nursing staff about Mrs A was inappropriate (upheld);
• (c) the attitude of a staff nurse on the Ward was unacceptable (no finding);
• (d) the attitude of nursing staff towards mobilising Mrs A was reprimanding in manner and unreasonable (not upheld);
• (e) the temperature in the Ward was high and uncomfortable (upheld);
• (f) the conditions in the two bedded room contributed to the speed of Mrs A's decline in the final days of her life (not upheld); and
• (g) the Board failed to handle the complaint from Mr C and his family appropriately (partially upheld).
   

Redress and recommendations
The Ombudsman recommends that Lothian NHS Board (the Board):

• (i) issue Mr C, Mrs D and their family with a formal written apology for the failings identified in heads of complaint (a), (b), (e) and (g) of this report; and
• (ii) audit and update the Action Plan in one year and share the findings with the Ombudsman's office.

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

Overview
The complainant, Mr C, was a PhD student at Queen Margaret University (the University). He raised concerns that his Director of Studies (the Director of Studies) had claimed that his supervisors had doubts as to the quality of his work, following a meeting on 5 May 2005. Mr C complained that his supervisors had not expressed to him any doubts as to the quality of his work. He was also unhappy that the Director of Studies alleged that there had been research misconduct by him. Mr C said that he only became aware of these issues when he had sight of a letter written by the Director of Studies to a third party in April 2008. Mr C also had concerns about the way the University handled the subsequent investigation into his complaint.

Specific complaints and conclusions
The complaints which have been investigated are that: (a) the Director of Studies claimed wrongly that Mr C was aware of his supervisors' doubts as to the quality of his work, following a meeting on 5 May 2005 (upheld); (b) the Director of Studies alleged inappropriately that there had been research misconduct by Mr C (not upheld); and (c) the University failed to take into account the evidence available to them when investigating Mr C's complaint (not upheld).

Redress and recommendations
The Ombudsman recommends that the University:

• (i) apologise to Mr C for the failure to ensure that he was made aware of his supervisory team’s concerns adequately, in line with the Research Degree Regulations in force at the time (RDR) (2002) and the Research Degrees Code of Practice (CoP);
• (ii) reinforce with all staff involved with research degree supervision the importance of dealing with any concerns which might arise during the course of a student's research, in line with the current RDR;
• (iii) ensure that all staff involved with research degree supervision are fully aware of the provisions of the new CoP when it is published; and
• (iv) reinforce with all staff involved in responding to student complaints the importance of providing a full response to complaints; in particular, that the response includes details of any evidence considered during their investigation.

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