North East Scotland

Overview

The complainant, Ms C, raised a number of concerns about the care and treatment provided to her mother, Mrs A, in the Vale of Leven Hospital (Hospital 1) between 26 August 2004 and 6 September 2004. Mrs A was subsequently admitted to Gartnavel General Hospital (Hospital 2) on 10 September 2004 but, sadly, died on 19 September 2004.

 Specific complaints and conclusions

The complaints which have been investigated are that:

• (a) a renal ultrasound scan was not performed on admission to Hospital 1 and when one was done at Hospital 2 the results were not acted upon (upheld);
• (b) communication with Consultant 2 at Hospital 2 was inadequate (upheld);
• (c) Mrs A was inappropriately noted as having 'no medical issues' when allowed home on weekend pass (upheld);
• (d) Mrs A was discharged from Hospital 1 without appropriate action (upheld); and
• (e) the discharge letter was inadequate (upheld).

Redress and recommendations

The Ombudsman recommends that:

• (i) this case be discussed urgently with Consultant 1 and formally recorded at her next annual appraisal;
• (ii) the clinical team responsible for Mrs A's care in Hospital 1 consider and act on the lessons to be learned as a result of the failings identified in this report;
• (iii) Greater Glasgow and Clyde NHS Board (the Board) remind staff of the need for accurate records to be kept;
• (iv) the Board share with the Ombudsman a copy of the regular audit of communications which is presented to the NHS Board's Clinical Governance Committee; and
• (v) the Board apologise fully and formally to Ms 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) approached Glasgow City Council (the Council) about problems of dampness he was experiencing in his property. He believed that the source of the dampness was his neighbour (Mr N)'s flat. The Council considered that the water ingress constituted a statutory nuisance and served an Abatement Notice under the Environmental Protection Act 1990, which required Mr N to address the source of the problem. Mr N eventually undertook some work which did not stop the dampness. Mr C believed that the Council unreasonably did not use the powers at their disposal to ensure that Mr N took action that would solve the problem.

Specific complaints and conclusions

The complaints which have been investigated are that the Council:

• (a) failed to enforce an Abatement Notice effectively (upheld); and
• (b) failed to keep Mr C adequately informed about progress of the enforcement of the Abatement Notice (no finding).

 Redress and recommendation

The Ombudsman recommends that the Council:

• (i) apologise to Mr and his wife for a lack of clarity and consistency in their approach to addressing the statutory nuisance; and
• (ii) reflect on what can be done to address the gap between their statutory responsibilities and customer expectations in situations like this.

Overview

The complainant (Mrs C) made 43 separate complaints to the Ombudsman's office about the Crofters Commission (the Commission). The Ombudsman decided to investigate 28 of these complaints, which have been grouped together and investigated under seven separate heads of complaint. The complaints investigated include delay and inaction relating to an apportionment application, failure to take action with regard to the conduct of a Grazings Clerk, delay in providing Minutes and Accounts, mishandling and falsely reporting an Annual General Meeting, failing to deal with and resolve acceptably complaints about the financial accounts of a Grazings Committee, failure to give adequate notice of a meeting, wrongly calling this meeting and recording inappropriate and false statements in the Commission minutes; and failure in the handling of a second application for apportionment.

Specific complaints and conclusions

The complaints which have been investigated are that the Commission:

• (a) delayed and did not take action in respect of an application for apportionment (upheld);
• (b) failed to take prompt or effective action in respect of the conduct of the Grazings Clerk (upheld);
• (c) delayed in providing the requested Minutes and Accounts for an Annual General Meeting held on 30 March 2001 (partially upheld);
• (d) seriously mishandled an Annual General Meeting held on 14 December 2001, produced a false report of that meeting and refused to correct the report or apologise (not upheld);
• (e) failed to deal with complaints made about the financial accounts of the Grazings Committee, including failure to provide correct information on dealing with a formal complaint and putting forward an unacceptable solution to resolve the complaint (partially upheld);
• (f) failed to give adequate notice of a meeting that took place on 22 July 2002, wrongly called and conducted the meeting and recorded inappropriate and false statements in the Commission minutes (partially upheld);
• (g) failed in the handling of an application for a small area of apportionment out of the Common Grazings (partially upheld).

Redress and recommendations

The Ombudsman recommends that the Commission:

• (i) put systems in place to ensure that their staff know how to deal with representations received after an apportionment has been granted;
• (ii) put guidance in place to ensure that both the Commission and the crofting community are clear about the role of the Commission in relation to disputes between shareholders, and between a shareholder and a Grazings Committee;
• (iii) give consideration to the merits of introducing a process whereby an individual shareholder can request an investigation of an alleged breach of the Grazings Regulations;
• (iv) give consideration to introducing an appropriate mechanism to assist in the resolution of disputes between a shareholder and a Grazings Committee;
• (v) Chief Executive reports to the Commission that Mrs C could not have expected that a meeting needed to take place before 27 July 2002 and that the Commission provides a response to Mrs C in relation to this matter; and
• (vi) provide Mrs C with a meaningful apology for the shortcomings identified in the Report.

Overview

The complainant (Mr C) raised a number of concerns about the response he received from Greater Glasgow Health Board (the Board) following an investigation by the Mental Welfare Commission for Scotland into the care and treatment which his late son (Mr A) received at Gartnavel Hospital, Glasgow (the Hospital).

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a) the level of medical supervision for the senior house officer who decided on Mr A's mental health state and supervision status during the period 15 March 2001 to 21 March 2001 was inadequate (upheld);
• (b) the Board's response that a care plan was agreed by all staff was incorrect (upheld);
• (c) the charge nurse failed to act on an instruction in Mr A's medical notes that he was not allowed to leave the ward unless accompanied by members of staff (upheld); and
• (d) the Board have not accepted responsibility for failing in its duty of care or offered an appropriate apology (upheld).

Redress and recommendations

The Ombudsman recommends that the Board:

• (i) give consideration to amending the risk assessment tool to include issues such as impulsivity or when the patient's state of mind is unknown; and
• (ii) offer Mr and Mrs C a full apology for the failings in care which have been identified in this report.  The Ombudsman draws the Board's attention to the SPSO guidance note on 'apology' (which sets out what is meant and what is required for a meaningful apology).

Overview

The complainant, Mr C, complained that treatment received by his late wife, Mrs C, was inadequate and that staff failed to diagnose that she was suffering from melanoma.

Specific complaint and conclusion

The complaint which has been investigated is that the treatment Mrs C received from 2004 was inadequate and staff failed to diagnose that Mrs C was suffering from melanoma (partially upheld).

Redress and recommendations

The Ombudsman recommends that the Board:

• (i) review their procedures, in line with the findings of this report, for the carrying out of biopsies on patients diagnosed with cancer and having a similar history to that of Mrs C;
• (ii) consider the findings of this report in relation to removing complaints from the NHS Complaints Procedure and consider subsequently reinstating them if dealing with future complaints resulting from similar circumstances; and
• (iii) write to Mr C with an apology for the distress caused by the failings identified in this report.

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

Overview

The complainant (Ms C) complained about the care and treatment she received while attending Inverclyde Royal Hospital (the Hospital) on 8 June 2006. She also complained that Greater Glasgow and Clyde NHS Board (the Board) failed to satisfactorily respond to her in good time, following the concerns she raised about the care and treatment she received from the Hospital.

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a) Ms C received inadequate care and treatment from the Hospital on 8 June 2006 (partially upheld to the extent that there were failings in obtaining consent and in communicating with her regarding the administering of the local anaesthetic (LA));
• (b) the Board's final response, dated 5 June 2007, did not address Ms C's complaint satisfactorily (upheld); and
• (c) the Complaints Department of the Board failed to respond to Ms C in good time, after she complained to them about the care and treatment she received at the Hospital she attended for recurring breast cancer surgery (upheld).

Redress and recommendations

The Ombudsman recommends that the Board:

• (i) apologise to Ms C for the way in which the decision to administer the LA was communicated to Ms C;
• (ii) remind staff of the correct procedures to be followed when obtaining consent prior to surgery taking place;
• (iii) apologise to Ms C for their unsatisfactory final response to her complaint; and
• (iv) apologise to Ms C for the delay in responding to her complaint.

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

Overview

The complainant (Mr C) alleged that the prescription of Pramipexole medication was inappropriate in his care and treatment for Parkinson's disease. He also complained that there was a failure in the follow-up care provided for him in the early part of 2006.

 Specific complaints and conclusions

The complaints which have been investigated are that:

• (a) Mr C was inappropriately prescribed Pramipexole after his care transferred to the Southern General Hospital (the Hospital) in June 2005 (not upheld); and
• (b) there was a failure of appropriate support and monitoring of Mr C's condition during the early part of 2006 (partially upheld to the extent that it is possible alternative support services could have been considered as part of Mr C's care).

 Redress and recommendations

The Ombudsman recommends that the Board:

•  (i) ensure that clear agreements, in writing if possible, are made between patients, clinicians and where appropriate, family members, about the plan of care and a patient's responsibility regarding the information expected from them during treatment; and
• (ii) remind clinical colleagues of the potential referral opportunities which may be available to augment aspects of patient care and to discuss these with colleagues and patients as appropriate.

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

Overview

The complainant (Mr C) raised a number of concerns on behalf of his wife (Mrs C) about the way the Scottish Executive Environment and Rural Affairs Department, now the Scottish Government  Environment Directorate (the Directorate), handled her application for the Single Farm Payment Scheme - National Reserve 2005 (SFPS - NR 2005) during the period February 2005 to March 2006.

Specific complaint and conclusion

The complaint which has been investigated is that the Directorate failed to handle properly Mrs C's application made under the SFPS - NR 2005 (partially upheld).

Redress and recommendations

The Ombudsman recommends that the Directorate:

• (i) reminds their staff of the importance of apologising for mistakes;
• (ii) apologises to Mrs C for the lost application;
• (iii) reminds staff of the importance of ensuring they provide consistent responses to all correspondence; and
• (iv) ensures its advice on agricultural scheme requirements is explicit in all its literature.

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

Overview

The complainant (Mr C) raised a number of concerns regarding the clinical treatment that his father (Mr A) received whilst under the care of Greater Glasgow and Clyde NHS Board (the Board).  He believed that staff at Glasgow’s Victoria Infirmary failed to give due consideration to Mr A’s previous medical history and that, had they done so, his death in December 2006 could have been avoided.  Mr C also complained that the medication prescribed for another of Mr A’s conditions was unsuitable and that it potentially contributed to his deterioration.

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a) the Board inappropriately treated Mr A with Methotrexate (not upheld);
• (b) the Board failed to take adequate note of Mr A’s past medical history when treating him (upheld);
• (c) the Board failed to proactively seek information relating to Mr A’s past medical history (upheld);
• (d) the Board inappropriately reduced Mr A’s steroid dosages before the full extent of his illness was known (upheld); and
• (e) Mr A’s death certificate did not accurately reflect the cause of death (not upheld).

Redress and recommendations

The Ombudsman recommends that the Board:

• (i) formally apologise to Mr C and his family;
• (ii) remind all staff of the importance of sourcing and reviewing historical clinical records;
• (iii) review their record-keeping practices and introduce procedures to ensure the prompt identification, sourcing and provision of historical clinical records;
• (iv) considers ways to promptly source specific records relating to relevant information raised by patients and their families; and
• (v) ask the clinical team to review the circumstances of this case to see if there are any lessons that can be learned regarding the diagnosis and treatment of organising pneumonia.

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

Overview

The complainant (Mr C) was a student at The Robert Gordon University (the University) taking a course of professional study for a regulated health profession.  The University took disciplinary action against him for supplying fraudulent evidence to mitigate the late submission of a piece of work on the grounds that this was a serious instance of non-academic misconduct.  He was removed from his course.

Specific complaint and conclusion

The complaint which has been investigated is that the punishment for an incident of misconduct was disproportionate and prejudicial to Mr C's future career prospects (not upheld).

Redress and recommendations

The Ombudsman has no recommendations to make.