West of Scotland

Overview
The complainant (Mr C) raised a number of concerns about the cleanliness of his room in the Royal Infirmary of Edinburgh (the Hospital).

Specific complaint and conclusion
The complaint which has been investigated is that Mr C's room in the Hospital was not adequately cleaned during his stay (upheld to the extent that any evidence to back up Lothian NHS Board's (the Board) position had been mislaid and that the Board's response to Mr C was not adequately evidenced).

Redress and recommendations
The Ombudsman recommends that the Board:
(i) remind the relevant cleaning contractor of the importance of good record keeping; and
(ii) ensure that they obtain all of the available evidence when investigating a complaint and verify any statements provided during the course of the investigation.

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

Overview
The complainant (Mrs C) had concerns about the way the Scottish Ambulance Service (the Service) responded to enquiries and complaints she made about their response to a request to take her husband, Mr C, to hospital in September 2004.  Specifically, Mrs C complained about the Service's request that a disclosure of information form be completed in response to a letter from her Member of Parliament (MP), that the Service failed to make arrangements for a meeting with Mrs C that they advised had been made, that the Service unreasonably expected Mrs C to make arrangements for a meeting, that the Corporate Affairs Manager of the Service inaccurately represented the contents of a letter from the Head of Service (Accident and Emergency – South West) (Head of Service 1) and that the Head of Service (Accident and Emergency – West Central) (Head of Service 2) was unreasonably unable to answer Mrs C's questions during a meeting.

Specific complaints and conclusions
The complaints which have been investigated are that:
(a) the Service incorrectly requested a disclosure of information form to be completed in response to a letter from Mrs C's MP (not upheld);
(b) the Service failed to make arrangements for a meeting with Mrs C that they advised had been made (upheld);
(c) the Service unreasonably expected Mrs C to make arrangements for a meeting (no finding);
(d) the Corporate Affairs Manager of the Service inaccurately represented the contents of Head of Service 1's letter of 9 November 2004 (not upheld); and
(e) Head of Service 2 was unreasonably unable to answer Mrs C's questions during a meeting (no finding).

Redress and recommendations
The Ombudsman recommends that the Service reminds all staff of the importance of ensuring the factual accuracy of communications.

The Service have accepted the Ombudsman's recommendation and will act on it accordingly.

Overview
The complainant, Ms C, complained that she was given conflicting information regarding the diagnosis of her condition and the need for her to have an operation.  Ms C made a further complaint about what happened when she attended the Accident and Emergency department (the Department).

Specific complaints and conclusions
The complaints which have been investigated are that:
(a) between December 2004 and June 2005, Ms C was given conflicting information regarding her diagnosis and treatment (upheld); and
(b) Ms C was not treated in a reasonable manner when she attended the Department on 4 June 2005 (not upheld).

Redress and recommendations
The Ombudsman recommends that the Board:
(i) apologise to Ms C for the shortcomings identified in this report;
(ii) consider offering Ms C further clinical investigation, including imaging of the biliary tract, under the care of a consultant not previously involved with her care, that they liaise with the psychiatric team who provide support for Ms C;
(iii) share a copy of this report with Consultant 1; and
(iv) ensure that there are appropriate procedures for safe storage, filing and tracking of clinical notes in the Department, to ensure they are available for retrieval and reference in future.  She asks that the Board notify her of the action taken in this regard.

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

Overview
Mr C was admitted to the Western General Hospital, Edinburgh, after suffering a brain haemorrhage.  On the following day, during the Consultant Neuroradiologist's attempt to clot the blood vessels, the catheter ruptured and glue escaped which caused Mr C to have a stroke.

Specific complaints and conclusions
The complaints which have been investigated are that:
(a) the cause of the rupture was that the syringe containing the glue was pushed too hard, causing too much pressure on the catheter (not upheld);
(b) the risk of the catheter breaking and the risk associated with the use of that particular catheter were not disclosed to Mr C (partially upheld);
(c) Mr C was not informed of alternative treatments available to him (upheld);
(d) Mr C was not allowed a cooling off period to make a decision about treatment (upheld);
(e) Mr C's consent to the procedure was inadequately documented (upheld);
(f) the incident was not properly recorded or investigated (not upheld);
(g) the explanation of what had happened given to Mr C and his wife was inadequate (no finding); and
(h) Lothian NHS Board (the Board) whitewashed the incident (not upheld).

Redress and recommendations
The Ombudsman recommends that the Board:
(i) provide her with details of the outcome of their review of their current consent policy, taking into account 'A Good Practice Guide on Consent for Health Professionals in NHS Scotland' issued by the Scottish Executive  on 16 June 2006, especially for neurosurgical and radiological interventions;
(ii) advise her of the outcome of their review of their Incident/Near Miss Reporting and Investigation procedure;
(iii) take steps to ensure that where explanations are given in situations such as this they are properly recorded; and
(iv) apologise to Mr C for the shortcomings identified in this report.

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

Overview

The complainant (Mrs C) was concerned that she had not been offered appropriate treatment when she was seen by a doctor (Doctor 1) during an out-patient appointment at the Western General Hospital.

Specific complaint and conclusion

The complaint which has been investigated is that Doctor 1 failed to provide Mrs C with appropriate treatment (not upheld).

Redress and recommendation

The Ombudsman has no recommendations to make.

Overview

The complainant (Mr C)’s brother (Mr A) collapsed suddenly on 1 January 2007 while at his mother’s home in Uig, Isle of Lewis.  Mr A was taken to hospital by ambulance.  Mr C raised a number of concerns:  that a GP working for Western Isles NHS Board (the Board) out-of-hours service did not attend, although the Scottish Ambulance Service (the Service) requested he do so; a First Responders Unit (FRU) was not correctly called; and information was released to the press, relating to this incident, inappropriately.  The Service accepted the problem with the FRU but Mr C remained concerned about the actions taken to remedy this.

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a) a GP working for the Board unreasonably did not attend (partially upheld, to the extent that there were clear issues with communication on the night of 1 January 2007);
• (b) a FRU was not correctly called and actions taken to remedy this were insufficient (not upheld); and
• (c) information was released to the press inappropriately (upheld).

Redress and recommendations

The Ombudsman recommends that:

• (i) the Board review the equipment provided to out-of-hours GPs, in the light of the problems identified in this report;
• (ii) the Board and the Service meet to consider how best to respond to the communication failures identified and ensure that lines of responsibility and procedures are clearly in place where appropriate;
• (iii) the Service undertake a short review of emergency calls in FRU areas, to see if they can identify cases where FRUs could have been called but were not and consider if any lessons can be learned from this;
• (iv) the Service apologise to Mr C for the release of inaccurate information; and
• (v) the Board and the Service use this complaint as a case study with press staff, in order to encourage learning from the problems identified.

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

Overview

The complainant (Mr C) complained about the treatment he received from his General Practitioner (GP) when he received a house call on 21 January 2005.  He complained that the GP took too long to arrive to visit him, and failed to examine him.  He also complained that the GP delayed referral to the ambulance service to have him transferred to hospital for admission.

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a) the GP took three hours to respond to a request for a house call (not upheld);
• (b) the GP did not carry out a physical examination of Mr C (not upheld); and
• (c) Mr C understood the ambulance was going to be arranged as an urgent case (not upheld).

Redress and recommendations

The Ombudsman has no recommendations to make.

Overview

The complainant (Mr C) raised concerns that Midlothian Council (the Council) had failed to consult with the relevant community council (the Community Council) about the closure of leisure centres in the area.

Specific complaint and conclusion

The complaint which has been investigated is that the Council did not consult adequately, and as required by the Council's Code of Conduct for the Exchange of Information, with the Community Council in relation to proposals to close two leisure centres (upheld to the extent that the Council were unable to justify their position).

Redress and recommendations

The Ombudsman recommends that the Council properly consider whether it is necessary to consult with community councils when taking decisions which could reasonably be viewed as matters of importance to a particular area.

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

Overview

The complainant (Mrs C) raised concerns about the delays in being assessed when she attended the Reproductive Health Department of the Royal Infirmary of Edinburgh (the Department) on 28 May 2005.

Specific complaints and conclusions

The complaints which have been investigated are that there was a delay by staff in:

• (a) examining Mrs C on arrival at the Department (not upheld); and
• (b) checking for Mrs C's baby's fetal heart rate (not upheld).

Redress and recommendations

The Ombudsman recommends that Lothian NHS Board, as a matter of urgency, develop and implement:

• (i) a written triage protocol for patients who attend the Department; and
• (ii) a document which records the contents of telephone conversations between patients and the Department and is retained in their clinical records.

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

Overview

The complainant (Mrs C) raised a number of concerns regarding the way that Cairn Housing Association (the Association) investigated her complaints about, what she regarded as, anti-social behaviour from her neighbour (Mr N).

Specific complaint and conclusion

The complaint which has been investigated is that the Association failed to take necessary action to ensure Mrs C's safety and comfort (not upheld).

Redress and recommendation

The Ombudsman recommends that the Association consider offering Mrs C alternative means of dispute resolution outwith the formal complaints procedure.

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