Mid Scotland and Fife

Overview

The complainant (Mr C) claimed that Stirling Council (the Council) did not take account of the views of local residents when dealing with planning applications for a Public Private Partnership (PPP) project to build a new school and new housing on land near to his home.  Mr C was also of the view that that the Council did not deal with the planning applications impartially.

Specific complaints and conclusions

The complaints which have been investigated are that the Council:

• (a) failed to take account of the views expressed by local residents in relation to the development of a new school and housing (partially upheld); and
• (b) failed to apply appropriate 'standards in public life' measures when following the planning process (not upheld).

Redress and recommendation

The Ombudsman recommends that the Council ensure that the presentation of the volume and format of objections to development proposals and planning applications, in particular on a similar scale to those dealt with in this report, is clear in reports to Council Committees, and that such reports take care to draw a clear distinction between individual correspondence, and objections from individuals which may come collated in petition form.

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

Overview
The complainant (Mrs C) was concerned about the way in which a ward closure in Lynebank Hospital (the Hospital) was handled.  Her niece (Ms A) was resident on the ward.

Specific complaints and conclusions
The complaints which have been investigated are that:
(a) the closure of a ward in which Ms A was resident was poorly handled (upheld); and
(b) the response to Mrs C's complaint about this matter was inadequate (upheld).

Redress and recommendations
The Ombudsman recommends that Fife NHS Board:
(i) apologise to Ms A and Mrs C's husband for the limited time available to prepare for and consult about the move between wards;
(ii) draw on the experience of this ward transfer to review the way in which such moves are planned in future; and
(iii) review the way in which such decisions are documented.

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

Overview
The complainant (Mr C) lived adjacent to a hotel (the Hotel), which received planning consent for an extension.  During the construction of this extension, Mr C raised a number of concerns about the access to the site by contractors by way of a private road that was granted by Fife Council (the Council).

Specific complaints and conclusions
The complaints which have been investigated are that the Council:
(a) did not adequately monitor access to a development site (upheld); and
(b) did not communicate adequately with Mr C over this matter (upheld).

Redress and recommendations
The Ombudsman recommends that the Council apologise to Mr C for any added distress and inconvenience caused by insufficient monitoring of a contractors' use of a private access road and for shortcomings in their communications over this matter.

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

Overview
The complainant (Mrs C) raised a number of concerns about the care and treatment of her late mother (Mrs A) during an admission to Monklands Hospital (the Hospital) between 5 April 2005 and 26 June 2005.

Specific complaints and conclusions
The complaints which have been investigated are that:
(a) Lanarkshire NHS Board (the Board) inappropriately refused to admit Mrs A to the Hospital on 4 April 2005 (not upheld);
(b) two doctors were rude to Mrs A when they saw her in Accident and Emergency on 5 April 2005 (not upheld);
(c) the Board failed to supervise Mrs A when going to the toilet and did not do enough to prevent her from falling over (upheld);
(d) the Board failed to ensure that Mrs A was eating and failed to consider nasal tube feeding (not upheld);
(e) the Board failed to supervise Mrs A's drug-taking, failed to correctly record drug-taking and failed to ensure that the right medication was given to the right patient (partially upheld to the extent that the Board failed to supervise Mrs A's drug-taking and failed to ensure that the right medicine was given to the right person);
(f) the Board failed to introduce a care package for Mrs A despite promises to do so and refused to allow Mrs C to take Mrs A home in the last few days  of her life (not upheld);
(g) the Board failed to diagnose and treat an infection that Mrs A contracted while in the Hospital, which led to additional discomfort and pain and which Mrs A's family believe contributed to her death (not upheld);
(h) the Board failed to record sepsis as a cause of death on the death certificate (not upheld);
(i) the Board failed to carry out a post-mortem even though Mrs A had died sooner than expected (not upheld);
(j) the Board did not provide sufficient nursing care to Mrs A and did not help bring Mrs A's temperature down or remove her teeth and only checked up on her occasionally (upheld);
(k) the Board's nursing staff were unable to fit a syringe driver because a nurse was on her break (not upheld);
(l) a physiotherapist said that she could not help Mrs A because she was not co-operating, which was inappropriate (not upheld);
(m) nursing staff did not inform Mrs C or her brother that Mrs A was dying when they re-entered the room Mrs A was in (not upheld);
(n) no attempt at resuscitation was made and the family were not asked if they wanted it  (not upheld);
(o) an empty syringe driver contributed to Mrs A's death (not upheld);
(p) Mrs A had to wait a long time on both occasions when a doctor was called on 26 June 2005 (not upheld); and
(q) the clinical records were inadequate, because they contained no observations for 25 June 2005 and no fluid charts (upheld).

Redress and recommendations
The Ombudsman recommends that the Board:
(i) emphasise to staff the importance of adjusting care plans in line with risk assessments, especially in relation to supervision needs, and ensure that staff fully understand the importance of, and the procedure for, incident reporting;
(ii) ensure that measures are put in place to monitor compliance with the Medicines Code of Practice;
(iii) reflect on this complaint and consider whether guidance or training is needed to ensure that patients' families feel appropriately supported when they decide to take an active role in caring for a relative; and
(iv) put measures in place to ensure that, where appropriate, fluid charts are filled out for patients and observations are recorded.

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

Overview
The complainant (Mr C) raised a number of concerns that his wife (Mrs C) was misdiagnosed during two admissions at Hairmyres Hospital (the Hospital) in 2004, that she was afforded poor clinical and nutritional care at the Hospital during admissions in 2004 and 2005, that record-keeping and communication between staff in relation to Mrs C's care was poor and that Lanarkshire NHS Board (the Board) did not take appropriate action as a result of Mrs C's experiences and Mr C's subsequent complaints.

Specific complaints and conclusions
The complaints which have been investigated are that:
(a) Mrs C was misdiagnosed during two admissions at the Hospital (not upheld);
(b) Mrs C was afforded poor clinical and nursing care at the Hospital (partially upheld to the extent that Mrs C should have been advised on 6 October 2004 that it was unlikely that the promised visit by the surgical team would be able to be made);
(c) Mrs C was not given appropriate nutritional care at the Hospital (not upheld);
(d) the Hospital's record-keeping in relation to Mrs C was poor (not upheld);
(e) communication between the Hospital's staff in relation to Mrs C was poor (partially upheld to the extent that the prioritisation of Mrs C's endoscopy was not adequate following the observations made during her second admission); and
(f) the Board did not take appropriate action as a result of Mrs C's experience and Mr C's subsequent complaints (not upheld).

Redress and recommendations
The Ombudsman recommends that the Board:
(i) apologise to Mr C that Mrs C was not advised timeously that it was unlikely that the visit by the surgical team would be able to be made;
(ii) remind staff of the importance of keeping patients informed in these circumstances;
(iii) apologise to Mr C for the insufficient urgency attached to the request for Mrs C's endoscopy; and
(iv) audit their referral process to satisfy themselves that the urgency of a referral is clear at all times.

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

Overview
The complainant (Ms C) claimed that the conduct of a rectal/intestinal examination at Falkirk and District Royal Infirmary (the Hospital) was inappropriate and also raised concerns about the subsequent handling of her complaint by Forth Valley NHS Board (the Board).

Specific complaints and conclusions
The complaints which have been investigated are that:
(a) the conduct of a rectal/intestinal examination at the Hospital was inappropriate, in particular that lubricant was not used (not upheld); and
(b) the Board failed to deal with Ms C's complaint appropriately (upheld).

Redress and recommendations
The Ombudsman recommends that the Board:
(i) apologise to Ms C in writing for their failure to conduct as thorough an investigation of her complaint as was required in this situation; and
(ii) reflect on how they obtain evidence from all parties involved in a complaint and ensure that key staff always provide statements, and that those statements deal with the specific issues raised by complainants.  The Board should send the Ombudsman the outcome of this reflection and a copy of any consequent amendments to guidance or procedure.

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

Overview

The complainant (Mr C) raised concerns about the treatment he received at Monklands Hospital (the Hospital), which resulted in the removal of his right kidney.  Mr C had been told by staff that it was suspected a lump on his right kidney was cancerous and that removal of the kidney was required.  Following the operation, Mr C was advised by staff that the removed kidney was non-cancerous.  Mr C had concerns that staff took the decision to remove the kidney without taking a biopsy of the lump and the manner in which he was informed of the pathology of the removed kidney.

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a) staff acted unreasonably in removing Mr C's kidney before a definitive diagnosis had been made on the suspected cancerous lump (not upheld); and
• (b) the manner in which Mr C was informed of the result of the pathology report of his removed kidney was insensitive (upheld).

Redress and recommendations

The Ombudsman recommends that Lanarkshire NHS Board (the Board):

• (i) reflect on the Adviser's comments in relation to the way in which the consent was documented and consider whether they need to make any changes to procedure; and
• (ii) make Mr C a further full and meaningful apology.

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

Overview

The complainant (Mr C) raised concerns on behalf of one of his constituents (Mrs A) about issues relating to a mistake made by the Council in allocating a place for her eldest child at a primary school which was outwith the catchment area.

Specific complaint and conclusion

The complaint which has been investigated is that the Council unfairly withdrew Mrs A's son's right to free transport on his transfer to secondary school (upheld).

Redress and recommendations

The Ombudsman recommends that the Council:

• (i) formally apologise to Mrs A for the errors which have occurred in this case; and
• (ii) put in place arrangements to provide Mrs A's son with free transport to and from school, during his secondary education, for such time as he remains at his current school.

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

Overview

The complainant, Mr C, complained that, despite the fact that Forth Valley NHS Board (the Board) felt unable to treat him, they did not refer him elsewhere.  In the circumstances, he felt that he had to pay for his eye operation.  He believed that he should be refunded the costs involved.

Specific complaint and conclusion

The complaint which has been investigated is that, although the Board felt unable to treat Mr C, they did not refer him elsewhere (partially upheld).

Redress and recommendation

The Ombudsman recommends that the Board write to Mr C expressing their sincere regret that an opportunity to consider all the options in relation to his future treatment was lost.

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

Overview

The complainant (Mr C) was a tenant of Fife Council (the Council) who reported damage to his bathroom which occurred in the course of a replacement programme.  He complained that the Council’s response to this was not adequate.

Specific complaint and conclusion

The complaint which has been investigated is that a contractor caused damage to Mr C’s bathroom in the course of carrying out work on behalf of the Council and the Council’s proposed remedy for this damage was not reasonable (not upheld).

Redress and recommendations

The Ombudsman has no recommendations to make.