North East Scotland

Overview

The complainants (Mr and Mrs C) are tenants of Fife Housing Association Ltd (the Association).  They raised a number of concerns regarding the Association's actions in respect to an extension built by their neighbour (Mrs N) in 2004.

Specific complaints and conclusions

The complaints which have been investigated are that the Association:

• (a) failed at the outset to discuss with Mr and Mrs C the implications of the application for planning consent made by Mrs N (not upheld);
• (b) failed to take appropriate action when Mr and Mrs C reported to them that the extension encroached into Mr and Mrs C's tenancy (partially upheld);
• (c) changed their view, to Mr and Mrs C's detriment, to allow access to Mrs N's builder to carry out underpinning work which could and should have been done from Mrs N's own property (not upheld);
• (d) failed to ensure that undertakings they gave to Mr and Mrs C to permit access to Mrs N's builder were adhered to (not upheld ); and
• (e) failed to take up with Fife Council as building authority, Mr and Mrs C's continuing concerns about the safety of an extension wall (not upheld).

Redress and recommendations

The Ombudsman has no recommendations to make.

Overview

The complainant (Mrs C) raised a number of concerns that she had not consented to the operation as performed and had not consented to a spinal anaesthetic.  Mrs C also complained that there was a lack of follow-up.

Specific complaints and conclusions

The complaints which have been investigated are that Tayside NHS Board (the Board):

• (a) failed to obtain informed consent for spinal anaesthesia (upheld);
• (b) performed an operation which was different to the planned haemorrhoidectomy without appropriate explanation of the new procedure (upheld); and
• (c) failed to provide the necessary follow-up care and treatment (upheld).

Redress and recommendations

The Ombudsman recommends that the Board:

• (i) apologise to Mrs C for the failure to ensure she adequately understood and consented to the anaesthetic options; and
• (ii) use the events of this case and in particular Mrs C's experience, as part of induction and training programmes about the consent process.

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

Overview

The complainant (Mrs C) felt that the death of her husband (Mr  C) could have been avoided had staff of Greater Glasgow and Clyde NHS Board (the Board) been more proactive in diagnosing his condition.  She complained that Mr C's assigned consultant (Consultant 1) should have been more directly involved in his care.

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a) Mr C was not seen by Consultant 1, the consultant that he was referred to at Glasgow Royal Infirmary (not upheld);
• (b) the diagnostic process was unnecessarily delayed (upheld); and
• (c) ward staff did not deal with Mr C respectfully (no finding).

Redress and recommendations

The Ombudsman recommends that the Board:

• (i) consider asking the clinical team to review the circumstances of this case to see if there are any lessons to be learned regarding communication with patients and relatives;
• (ii) apologise to Mrs C and her family for the additional distress and suffering caused by the delays to Mr C's diagnosis; and
• (iii) revise their procedures to include written notice to the referring consultant of all failed scan results.

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

Overview

The complainant (Mr C) raised a number of concerns about a lack of physiotherapy assessment, provision and follow-up as well as the quality of the in-patient care provided and the overall discharge planning by Tayside NHS Board (the Board) following his late mother (Mrs A)'s admission to Ninewells Hospital, Dundee on 17 February 2006.  Mr C was also dissatisfied with the Board's responses to his concerns which he considered to be deliberately confusing and contradictory.  Mr C considered that these many failures had hastened his mother's death.

Specific complaint and conclusion

The complaint which has been investigated is that the Board failed to properly assess and provide appropriate care and treatment to Mrs A (upheld).

Redress and recommendations

The Ombudsman recommends that the Board:

• (i) reflect on the failures identified by the advisers in the management of Mrs A as part of the on-going reviews already being undertaken by the Board;
• (ii) monitor compliance with the revised template for the discharge letter as part of the existing review of record-keeping; and
• (iii) review the Guidelines for (physiotherapy) Referrals and consider specifically how it impacts on those discharged to a nursing home (particularly in light of the advisers' comments that this appears to be discriminating against such patients).

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

Overview

The complainant (Mrs C) said that the death of her husband (Mr C) could have been avoided if staff of Tayside NHS Board (the Board) had done more to establish the extent of his condition.  Mrs C felt that the diagnostic process was unnecessarily delayed and that, had Mr C's liver cancer been diagnosed sooner, it may have been treatable.

Specific complaint and conclusion

The complaint which has been investigated is that the Board took unnecessarily long to diagnose and treat Mr C's condition (not upheld).

Redress and recommendation

The Ombudsman recommends that the Board consider ways to minimise any delays to cases being discussed by the upper gastrointestinal multi-disciplinary team.

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

Overview

The complainant, Ms C, raised a number of concerns that her late mother (Mrs A) had received inadequate medical post-operative care in her own home from her practice GP ( GP 1) and the District Nursing Service (the DNS), before Mrs A was re-admitted to a Dundee hospital (the Hospital) and subsequently died.

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a) GP 1 failed to re-refer Mrs A back to the Hospital when this was requested by a district nurse (no finding);
• (b) during the period when Mrs A was receiving post-operative care within her home, the district nurses failed to enter relevant details in case notes about Mrs A's condition (upheld); and
• (c) during the period when Mrs A was receiving post-operative care within her home, the district nurses failed to relay family concerns to the practice GPs (upheld).

Redress and recommendations

The Ombudsman recommends that:

• (i) GP 1 reflects on Adviser 1 and Adviser 2's comments (see paragraphs 17 to 21) and considers discussing these at her next appraisal;
• (ii) the fundamental standards of documentation are considered by the practice and the Board and revisited across the DNS as an outcome of complaints (b) and (c); and
• (iii) although the services within the complaint (the Board, the practice and the DNS) have demonstrated a willingness to deal with complaints and identify solutions, from the information reviewed, there is no evidence to suggest that any of the work/actions identified have fully addressed the fundamental areas of holistic assessment and communication between teams, or been referenced to any professional standards or guidelines in relation to the assessment process, documentation, communication, wound care, care planning and patient held records. Accordingly the Ombudsman recommends that these areas are explored and that she is advised of the outcome.

The Board and the Practice have accepted the recommendations, some have already been implemented and others will be acted on accordingly.

Overview

The complainant (Mr C) raised a number of concerns about the way the University of Glasgow (the University) dealt with his appeal, regarding their decision to award him an honours degree in a class lower than he felt he should have received.

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a) the University failed to fully consider his appeal against the degree they awarded him (not upheld); and
• (b) it took the University too long to consider Mr C's appeal (upheld).

Redress and recommendations

The Ombudsman recommends that the University:

• (i) apologise to Mr C for the delay in reaching a decision regarding his appeal; and
• (ii) advise her on the steps they have taken to ensure that delays in conducting and concluding appeals do not recur.

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

Overview

The complainant (Mr C) raised a number of concerns against New Shaws Housing Association (the Association), regarding the property (the Property) they let to him from August 2004 onwards.

Specific complaints and conclusions

The complaints which have been investigated are that the Association:

• (a) failed to warn Mr C of the presence of asbestos in his flat (no finding);
• (b) failed to provide Mr C with a well maintained flat in good order (not upheld);
• (c) failed to take action against anti-social neighbours (not upheld); and
• (d) let the Property to Mr C when they were aware there was a history of anti-social behaviour and neighbourhood nuisance (not upheld).

Redress and recommendations

The Ombudsman recommends that the Association consider ways of recording the information and leaflets provided to tenants by their Housing Offices at the point of completing missives and report back to the Ombudsman.

GHA on behalf of the Association has accepted the recommendation and have confirmed the Association will action in it accordingly.

Overview

The complainant (Ms C) raised a number of concerns about the care and treatment given to her late father (Mr A) at the Western Infirmary, Glasgow (the Hospital) from the day he was admitted on 10 August 2005, up to his death in the Hospital on 13 August 2005.  Ms C also complained that the Hospital's communication with her during this period was poor and that her subsequent complaint to Greater Glasgow and Clyde NHS Board (the Board) was dealt with inadequately.

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a) the late Mr A received inadequate care and poor treatment when he was a patient in the Hospital between 10 August 2005 and 13 August 2005 (not upheld);
• (b) the Hospital's communication with Ms C was poor from 10 August 2005 to 13 August 2005 when Mr A was alive (upheld);
• (c) no medical records were available for 12 August 2005 (upheld);
• (d) the Board's reply to Ms C's complaint was unsatisfactory; she did not receive it in good time and they delayed in providing Ms C with a copy of Mr A's medical records or giving reasons why these were not sent (upheld); and
• (e) nurses failed to attend a meeting between Ms C and Hospital staff on 27March 2006 (upheld).

Redress and recommendations

The Ombudsman recommends that the Board

• (i) advise her on the steps they have taken to avoid breakdowns in communication recurring;
• (ii) advise her on the steps they have taken to avoid medical notes being unavailable;
• (iii) emphasise to staff the need to adhere to the terms of the NHS guidance for dealing with complaints and ensure that their records are updated when a patient dies; and
• (iv) apologise to Ms C and explain the reason why the clinical nurse manager did not attend the meeting on 27 March 2006.

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

Overview

The complainant (Mr C) considered that his partner (Ms A) did not receive professional care and treatment from hospital staff, and that former Argyll and Clyde NHS Board Area (the Board) failed to deal with his complaint appropriately.

Specific complaints and conclusions

The complaints which have been investigated are:

• (a) inadequate treatment by staff at Inverclyde Royal Hospital (the Hospital) prior to and after Ms A's day surgery on 25 May 2005 (upheld); and
• (b) the Board's failure to adequately address Mr C's complaint in their response to him (partially upheld).

Redress and recommendations

The Ombudsman recommends that the Board:

• (i) with reference to the SPSO Guidance Note on Apology, apologise to Ms A and Mr C for the distress and pain caused by the poor preparation for the procedure carried out on 25 May 2005, as well as the uncertainty over the stent before that time which led to Ms A having to be x-rayed unnecessarily; and
• (ii) ask staff at the Hosptial's Day Surgery Unit to review their practice for Endoscopy procedure preparation, and benchmark that practice against other similar units within the Board area. This would form part of the work already in progress to review pre-assessment practice for day surgery throughout the Board area.

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