North East Scotland

Overview
The complainants (Mr and Mrs C) raised concerns regarding the processes followed, in assessing Mr C, by Clinical Psychology and the Specialist Sexual Abuse Service (the Service) within Greater Glasgow and Clyde NHS Board (the Board). They were unhappy with the content of the reports that were produced and with the fact Mr C was not asked to provide clarity on aspects of the reports which they felt were inaccurate and misleading.

Specific complaint and conclusion
The complaint which has been investigated is that the process of the assessment within Clinical Psychology was inappropriate in that Mr C was denied the opportunity of providing supporting information and, as a result, the reports produced were inaccurate and Mr C's reputation was damaged (not upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• (i) review their procedures to ensure that there are clear triggers in place for referring child safety concerns for prompt assessment by individuals with the relevant expertise;
• (ii) ensure that all mental health staff receive appropriate training relating to their child protection duties and obligations. This should be routinely covered in clinical supervision and staff should have access to the relevant guidance;
• (iii) highlight to all mental health staff the importance of explicit record-keeping surrounding child protection. This should include not only the reasoning for decisions but the rationale underpinning them and all verbal referrals should be followed up using the appropriate inter-agency form;
• (iv) ensure that, where appropriate, child protection concerns are communicated to the patients concerned prior to making a referral. When not informing patients, clear and specific reasons for not doing so should be recorded;
• (v) ensure that patients are notified of the outcome of mental health assessments as soon as is practicable; and
• (vi) remind mental health and complaint handling staff of the importance of taking steps to clarify any uncertainty at an early stage, particularly where a child safety concern may exist.

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

Overview
The complainant (Ms C) raised a number of concerns about the care and treatment she received from Greater Glasgow and Clyde NHS Board (the Board) following treatment on 7 and 9 September 2008 for a medical termination of pregnancy (MTOP). Ms C also complained that she had received contradictory information regarding bleeding and that her complaint response from the Board contained inaccurate information.

Specific complaints and conclusions
The complaints which have been investigated are that the Board did not provide:

• (a) adequate care and treatment to Ms C after a MTOP (upheld);
• (b) clear written guidance to Ms C about the expected duration of bleeding after the MTOP (upheld); and
• (c) accurate information to Ms C in their complaint responses (upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• (i) apologise to Ms C for the inadequate care and treatment provided to her after the MTOP;
• (ii) devise a protocol for the management of retained products of conception following a MTOP; and
• (iii) apologise to Ms C for failing to provide her with accurate information in their complaint responses.

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

Overview
The complainant, an advocacy worker (Ms C), complained on behalf of the aggrieved (Miss A) in relation to the care and treatment she received at Paisley Maternity Hospital, in the area of Greater Glasgow and Clyde NHS Board (the Board). Ms C conveyed Miss A's dissatisfaction with the management of her pain during the birth of her daughter on 11 December 2007. Through the course of my investigation, I also identified concerns relating to the quality of the written records of Miss A's care.

Specific complaint and conclusion
The complaint which has been investigated is that the management of Miss A's pain was unreasonable (upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• (i) highlight the issues raised in this report to all staff in the maternity unit, particularly anaesthetic staff, emphasising the importance of keeping clear, detailed and consistent records;
• (ii) offer Miss A an early appointment to be seen in an obstetric anaesthetic clinic, in line with the Adviser's comments at paragraph 23; and
• (iii) apologise to Miss A for the failings identified in this report.

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

Overview
The complainant (Mr C) was aggrieved that the Scottish Prisons Complaints Commission (SPCC) failed to deal with his complaint in a reasonable time, failed to communicate adequately with him or with the Scottish Prison Service (SPS), and did not deal with the substance of his complaint against the SPS or pursue it appropriately.

Specific complaints and conclusions
The complaints which have been investigated are that the SPCC failed to:

• (a) respond to Mr C's complaint within an agreed timescale or otherwise within a reasonable time (upheld);
• (b) intimate the complaint promptly to the SPS (upheld);
• (c) provide adequate information as to progress with the complaint (upheld);
• (d) respond substantively to the complaint which concerned the failure on the part of the SPS to consider on its merits an IT facility request (upheld); and
• (e) ensure receipt of their recommendations by the SPS Chief Executive (upheld).

Redress and recommendations
The Ombudsman recommends that the SPCC:

• (i) apologise to Mr C for the time taken to deal with his complaint, for not keeping him updated with progress on his complaint, and for not addressing his complaint;
• (ii) take steps to introduce their internal timescale targets as quickly as possible, include them in their complaints leaflet, and provide regular updates to complainants;
• (iii) formally notify the SPS as soon as they decide to investigate a complaint;
• (iv) re-state the recommendations made to the SPS in June 2008;
• (v) provide Mr C with redress for failing to deal with his complaint by asking the SPS to: a) clarify whether policy on prisoner access to computers is a blanket national policy or at the discretion of local Governors, b) consider Mr C's request for a laptop on its merits; and c) consider the effectiveness of the system for tracking the shared laptop in Mr C's prison;
• (vi) include a response deadline in their recommendation letters to the SPS Chief Executive. If no response is received by that date, the SPCC should contact the SPS seeking an immediate response; and
• (vii) ensure that copies of all emails that relate to complaints are retained, or duplicated in paper form or otherwise saved in another place.

Overview
The complainant (Mr C) raised concern about the handling by Aberdeenshire Council (the Council) of a prior notification by the owners (Mr and Mrs D) of an adjacent field in respect of the development of an agricultural building.

Specific complaint and conclusion
The complaint which has been investigated is that the Council failed properly to handle Mr and Mrs D's agricultural prior notification submission, representations made by Mr C and his agent, and Mr C's formal complaint (upheld).

Redress and recommendations
The Ombudsman recommends that the Council:

• (i) review the circumstances of this complaint with a view to issuing instructions to case officers to enable them to expedite agricultural prior notifications and to deal with representations made by neighbours on proposals where permitted development rights are sought;
• (ii) review the content of their website on communication with those making representations on planning applications generally and the particular circumstances pertaining in respect of agricultural prior notification; and
• (iii) review their handling of this particular complaint with a view to preventing a recurrence of their poor complaint handling.

Overview
The complainant (Mrs C) raised concerns regarding the Orthopaedic treatment she received at the Royal Alexandra Hospital (the Hospital) in the area of Greater Glasgow and Clyde NHS Board (the Board). Mrs C sustained a fall on 16 June 2007 in which she fractured her tibia and fibula and upon admission to the Hospital, she was seen by an orthopaedic consultant who treated the fracture conservatively by placing Mrs C's leg in a cast. Mrs C complained about the fact that she was not treated operatively and about the standard of follow-up care she received in the Fracture Clinic.

Specific complaints and conclusions
The complaints which have been investigated are that:

• (a) the decision to treat Mrs C's fracture conservatively was inappropriate (not upheld); and
• (b) the standard of follow-up treatment was inappropriate (upheld).

Redress and recommendations
The Ombudsman recommends that the Board should:

• (i) apologise to Mrs C for the failings identified in this report;
• (ii) highlight the issues raised in this report to all relevant orthopaedic staff;
• (iii) remind clinical staff of the importance of documenting their discussions with consultants; and
• (iv) encourage consultants to consider taking a more proactive role in complex cases.

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

Overview
The complainant (Ms C) raised a number of concerns about the diagnosis of diabetes and aftercare offered to her by her GP practice (the Practice).

Specific complaints and conclusions
The complaints which have been investigated are that:

• (a) the Practice failed to follow recognised procedures in reaching a diagnosis that Ms C was suffering from diabetes (upheld);
• (b) the Practice did not arrange for appropriate follow-up for Ms C following the diagnosis of diabetes (upheld);
• (c) the Practice's communication with Ms C regarding her diagnosis and test results was inadequate (upheld); and
• (d) the Practice's response to Ms C's complaint was inappropriate (upheld).

Redress and recommendations
The Ombudsman recommends that the Practice:

• (i) put in place a protocol to ensure that diabetes is diagnosed in line with recognised practices;
• (ii) put in place a protocol to ensure that newly diagnosed diabetics receive appropriate follow-up care;
• (iii) take steps to ensure they deal with complaints in line with the NHS complaints procedure; and
• (iv) write to Ms C with an apology for the failures identified in this report, including those relating to complaint handling and the content of the letter sent to Ms C on 14 July 2008.

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

Overview
Mr C complained about the level of care provided to his daughter, Miss C, prior to her death in Ninewells Hospital, Dundee (the Hospital), on 1 April 2008. Miss C suffered from myotonic dystrophy, a condition in which generalised muscle weakness can be accompanied by a variety of other conditions, which in Miss C's case included learning difficulties. Miss C was admitted to the Hospital on 31 March 2008 for surgery on her parotid gland. Pre-operatively, she did not receive a formal assessment by a consultant anaesthetist. Post-operatively she was returned to the ward, where her initial observations included a period of low blood pressure. She was left to sleep overnight. Her vital signs were not recorded and she was not disturbed in the morning during a post-operative ward round. She was subsequently found to be unresponsive at around 10:30 and a cardiac arrest call was made at 10:58; however, it was not possible to resuscitate her. Her death was recorded at 11:17 that morning.

Specific complaints and conclusions
The complaints which have been investigated are that:

• (a) Miss C was not properly assessed at a formal pre-operative clinic prior to her surgery (upheld);
• (b) the care and treatment Miss C received post-operatively was inadequate (upheld); and
• (c) communications with Miss C's family were not appropriate (upheld).

Redress and recommendations
The Ombudsman recommends that Tayside NHS Board (the Board):

• (i) review the current interface arrangements in place between the ENT and Anaesthesia departments, to gain assurance that adequate communication, planning and multi team working arrangements are now in place with regard to pre-operative admissions; and advise him of the outcome of this review;
• (ii) provide a copy of the appropriate action plans which specifically contain details of how the Board will implement and meet the relevant policies, including:  NHS QIS quality indicators for people with learning difficulties (NHS QIS report 'Learning Disabilities' Quality Indicators February 2004); NHS QIS report 'Tackling Indifference', (Healthcare Services for People with Learning Disabilities. National Overview Report. December 2009);
• (iii) provide a copy of their education and training strategy, including the specific requirement relating to patients with learning disabilities;
• (iv) review and evaluate the current arrangements for pre-operative admission for people with learning disabilities and provide him with a report of the findings;
• (v) confirm the specific action taken to clarify the terms 'special nursing' and 'routine monitoring' to avoid ambiguity over what level of nursing support is required when caring for people with learning difficulties;
• (vi) provide assurance that policies and procedures are in place to ensure that the Nursing and Midwifery Council Code of Conduct and in particular the 'Guidance for record keeping' (2009) is implemented so that communication with patients' families is clear and unambiguous; and
• (vii) provide an explicit, unambiguous and meaningful apology to Miss C's family for all the failings identified in this report, detailing the steps they have put into place to ensure that a similar occurrence is not repeated.

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

Overview
This complaint was brought by the Citizens' Advice Bureau (CAB), acting on behalf of the complainant (Mrs C). Mrs C complained about the standard of care her late son (Mr A) received at the Victoria Infirmary, Glasgow in the area of Greater Glasgow and Clyde NHS Board (the Board). Mr A, a young man aged 27, had been admitted on 9 May 2007, following a referral from his GP, with various symptoms including urinary incontinence, a sore throat, a cough, shortness of breath and facial swelling. He had been dizzy for two days and had had diarrhoea and faecal incontinence the night before admission. He was discharged the following day and died suddenly four days later, alone, at home. The post mortem examination revealed heart muscle disease and evidence of heart failure and it is likely that Mr A died of a sudden irregularity of the speed or rhythm of the heart.

Specific complaints and conclusions
The complaints which have been investigated are that:

• (a) the standard of care Mr A received fell beneath the level expected of medical practitioners (upheld); and
• (b) the Board's responses to the complainant, when Mrs C sought an explanation for Mr A's death, were poor (upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• (i) apologise directly to Mrs C for the serious failings identified in this report;
• (ii) reflect on the medical lessons to be learned from this case and consider appropriate action;
• (iii) produce an action plan, to include education and training, to address the equality, diversity and person-centred care failings identified in this report;
• (iv) apologise to Mrs C and the CAB for the shortcomings identified in this report in their correspondence with them;
• (v) reflect on their handling and investigation of complaints involving the sudden, unexpected death of a patient; and
• (vi) reflect on their handling and investigation of complaints where the family has involved an advocacy organisation such as Action Against Medical Accidents.

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

Overview
The complainant (Mrs C) raised concerns regarding the care and treatment received by her daughter (Miss A) when she attended the Royal Alexandra Hospital with back pain. Miss A was initially treated for a chest infection and referred for physiotherapy in respect of her back pain, however, she was subsequently diagnosed with a spinal infection and Mrs C complained that this was not diagnosed earlier. In addition, Mrs C raised her concerns that Miss A's anti-coagulant medication prevented surgical treatment of Miss A's infection.

Specific complaints and conclusions
The complaints which have been investigated are that:

• (a) there was a delay in referring Miss A for a Magnetic Resonance Imaging scan and, consequently, in diagnosing her spinal infection (upheld); and
• (b) the provision of anti-coagulant medication to Miss A prevented the possibility of surgical treatment of her spinal infection and a potentially more positive outcome (not upheld).
   

Redress and recommendations
The Ombudsman recommends that the Board:

• (i) apologise to Miss A for the delay in diagnosing her spinal infection;
• (ii) review their process in respect of identifying 'red flag' features in patients and taking relevant action upon identification of these; and
• (iii) ensure that complaints officers accurately reflect clinicians' feedback in their response to complaints.

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