Not upheld, no recommendations

Summary

C complained about the care and treatment that their partner (A) received during an emergency admission to hospital for treatment of a back injury following a fall at home. During admission, C reported that A’s abdomen became very swollen which they were advised by staff was due to constipation and a build-up of faeces, and which was appropriately being treated with laxatives. A’s condition deteriorated and they were subsequently diagnosed with a perforated colon which required emergency surgery. This resulted in a stoma (a surgically made pouch on the outside of the body) and a prolonged period of recovery in hospital.

C complained that the board had failed to diagnose and treat A’s abdominal symptoms earlier. They considered that this may have resulted in a better surgical outcome for A, with no stoma being required. C also complained that the board failed to identify or treat a deep laceration on A’s arm, and they complained about the board’s failure to respect A’s dignity by discussing personal matters in the open ward.

The board’s response advised that A’s abdominal symptoms were timeously managed and treated, particularly noting that there had been no evidence during the admission assessments of a problem with A’s bowel. The board apologised that A’s arm injury had gone unnoticed and for personal matters being openly discussed, which they had provided as feedback to the ward charge nurse for learning and improvement.

We took independent advice from an upper gastrointestinal and general surgeon adviser. We found that A’s bowel perforation had been timeously diagnosed and treated, and the procedure that they received was appropriate to their presenting condition at the time. In relation to A’s arm laceration, we were critical of the board’s failure to identify and treat this as part of the assessment process. In relation to there being open discussion of private matters on the ward, we acknowledged the apology and action taken by the board in response to C’s complaint. On balance, we did not uphold C’s complaint.

Summary

C complained about the care and treatment provided to their spouse (A). C said that the board’s actions or inactions caused unnecessary suffering and stress to A and their family through misdiagnosis of A’s condition, poor administration of treatment, and failure to provide care in a proper manner whilst following health and safety guidelines.

We took independent advice from a consultant radiologist, consultant in emergency medicine and a consultant oncologist.

We found that, overall, the board provided reasonable care and treatment to A, there were no avoidable delays in A’s diagnosis, and the care and treatment prior and after their diagnosis was reasonable, with the exception of a case of poor documentation on a particular admission and poor communication in relation to A’s diagnosis. We did not uphold the complaint.

Summary

C complained that the council failed to provide their grandchild (A) with reasonable support following an incident at primary school.

It is accepted by the council that the school should have held a second Child Protection Meeting (CPM). This was a clear oversight from the school, and it is not clear why this happened. This oversight led to C not being given feedback from the educational psychologist who had planned to feed back at the next CPM.

We found that the support offered to A was documented, evidence based and well thought out. An educational psychologist did not have any concerns about A, following their observation of them in class, that would have indicated further support measures were needed.

When C escalated their complaint with the council, we found that the council provided reasonable answers to the questions put to them in a reasonable timeframe. When it became clear that a CPM that had been cancelled had not been rescheduled, the council offered a further meeting which we consider was a reasonable remedy in the circumstances. Therefore, we did not uphold C's complaint.

Summary

C complained about the council's drainage assessment for a planning application. They said it only considered the likely impact of flooding on the planning site, with no Flood Risk Assessment (FRA) being undertaken to determine the potential off-site impact of excess drainage on the surrounding area, or downstream from the development site. C advised of there being a noticeable increase of water draining from the site and flooding on completion of the first of the three planned plots, and they complained about the longer term impact on the surrounding pathways including of a bridge which was C's only route of access to their home.

The council's response to C's complaint advised that there had been no known problem with flooding in the local area and that they had referred to SEPA flood maps to inform their decision on the level of assessment required for the application. As flooding was not a known problem in the area, there was no requirement to undertake an FRA for the planning application in keeping with the policies in place at the time. The council also advised any possible solution involving third party land would be a civil matter and not one which the council would pursue.

We took independent advice from a planning adviser. We found that the council had reasonably considered the impact of excess drainage on the area surrounding the planning site in keeping with the guidance. Therefore, we did not uphold C's complaint.

Summary

C complained about the care and treatment provided to their late partner (A) who was admitted to hospital with hallucinations and delirium. C complained that hospital staff labelled A an alcoholic and that this negatively impacted the treatment that they received. A was treated for a suspected urinary tract infection (UTI) but died in hospital. C was critical of several aspects of the treatment A received, including concerns about their nutritional intake, the medication they were given and the staff's response to the rapid deterioration of A's condition.

In their response, the board apologised that C had been given the impression that staff felt the only cause of A's delirium was alcohol excess. The board explained A's clinical presentation and the reasoning for treating them for suspected UTI and alcohol withdrawal. The board explained A's condition rapidly deteriorated in hospital and resulted in a cardiac arrest. The board's position was that the care provided was reasonable.

We took independent advice from a consultant in respiratory and general medicine. We found that a reasonable working diagnosis of a possible infection was determined and the treatment plan was appropriate. We considered that the care and treatment provided was reasonable. Therefore, we did not uphold C's complaint.

Summary

C complained about the care and treatment provided to their late parent (A) by the board's out of hours (OOH) service. A was experiencing worsening symptoms of disorientation, fatigue and abdominal pain. C telephoned NHS 24 and received a call back from an OOH GP who arranged for an ambulance to attend A's home. Paramedics examined A and called the OOH service who agreed that an OOH GP would carry out a home visit to A. Paramedics left the house and the OOH GP attended shortly afterwards. Upon examination, A was found to have a mild fever and fast heart rate, with all other observations recorded as normal. The OOH GP prescribed antibiotics. A died a few days later.

We took independent advice from a GP. We found that it was an appropriate course of action to request a paramedic assessment upon receiving C's initial call to the OOH service. We also found that given the observations of the paramedics and the OOH GP, it was appropriate to treat and manage A at home and to take into consideration that A's own GP practice would be open some four hours later. Therefore, we did not uphold C's complaint but did provide feedback to the board in relation to the GP's record-keeping.

Summary

C, an advocacy worker, submitted a complaint on behalf of their client (A). A received treatment from the board for muscular dystrophy (a group of inherited genetic conditions that gradually cause muscles to weaken) over a period of four years. While visiting abroad, A received an alternative diagnosis of polymyositis (a group of rare diseases that involve chronic muscle inflammation and weakness, and in some cases, pain). A complained that their condition was not appropriately investigated or diagnosed, leading to a delay in receiving appropriate care.

We took independent clinical advice from a consultant neurologist (specialist in diagnosis and treatment of disorders of the nervous system). We found that the investigations carried out by the board were reasonable and on receiving further information from an overseas clinician, the board took reasonable steps to consider this information.

We considered that the board reasonably investigated A's symptoms. Therefore, we did not uphold C's complaint.

Summary

C engaged with the board’s mental health services and believed that they had received a diagnosis of Borderline Personality Disorder (BPD, a mental disorder characterised by the instability in mood, behaviour, and functioning). They complained to the board that they had been prematurely discharged from mental health services. They also complained about delays, confusion affecting appointments, as well as a failure from the board to reasonably assess their condition.

The board’s position was that C had been discharged originally due to a lack of response to correspondence. When C was thereafter seen by mental health services they acknowledged some confusion with respect to the arrangement for an appointment. With respect to the subsequent appointments C attended, the board explained that there was evidence of possible BPD, but that a diagnosis had not been confirmed. A further appointment was arranged but C did not manage to keep the appointment. The board considered that the psychiatric consultations, over the telephone, were appropriate and did not uphold C’s complaints.

We took independent advice from a specialist in community psychiatry. We found that it was reasonable to discharge C given the evidence available and that they had received no response to their attempts to contact them. Given attempts were made to contact C, we did not uphold the complaint that C was unreasonably discharged.

With respect to the psychiatric assessment and diagnosis of BPD, we found that the assessments carried out were careful and competent, the diagnostic statement was reasonable and that there was no firm diagnosis made, with reasonable advice and plan for follow up. Whilst it was concerning that C had formed the view that the diagnosis was definite, and it was acknowledged that assessments via Teams were preferred over telephone (as occurred in this case), we found that the assessment of C was reasonable. We did not uphold the complaint.

Summary

C complained on behalf of their parent (A) who was in hospital when they passed away. C complained about the hospitals communication with A and their family during their hospital admission.

We took independent advice from a nursing adviser. We found that there was evidence of a good standard of communication in the medical notes.

Summary

C complained on behalf of their late parent (A) who passed away from cancer. C complained that the practice had unreasonably failed to diagnose A’s cancer. A was suspected of having a chest infection and was given multiple courses of antibiotics. A also had a number of blood tests which C said that A was not always sure what the blood tests were for, nor were they told the results.

We took independent advice from a GP adviser. We found that the blood tests which were carried out were done so for clinical reasons and that there was no error in the taking or analysing of the blood test results. Some of the blood tests were requested by hospital departments. The practice explained that they would not normally contact a patient if the test results were normal. A CT scan carried out by the hospital did not show any malignancy and this would have been reassuring for the GP’s treating A. We did not uphold this complaint.