Not upheld, no recommendations

Summary

C complained about the care and treatment they received from the board for their hearing problems, and for their problems of dizziness/loss of balance.

We took independent advice from an ear nose and throat (ENT) specialist. We found that C's hearing problems were investigated appropriately and they were given multiple repeated investigations. We also found that appropriate steps were taken to investigate C's problems of dizziness/loss of balance. Therefore, we did not uphold C's complaints.

Summary

C complained to the practice about the lack of care provided to their late parent (A). C said that A had reported breathing and sleeping problems in a telephone consultation to the GP but the GP had only provided medication and A died from a suspected heart attack a week later. The practice believed that appropriate treatment had been provided.

We took independent advice from a GP. We found that there was no evidence that A had reported breathing problems to the GP and that there were no recorded symptoms which would have indicated that A required a face-to-face GP consultation, a hospital admission, or that A would suffer a sudden event a week after the telephone consultation. Therefore, we did not uphold the complaint.

Summary

C, a support and advocacy worker, complained on behalf of the late A and their family. A had complex care needs and lived at home. C complained that the council failed to deliver an appropriate care plan to meet A's assessed and eligible needs.

We took independent advice from a social worker. We found that the council took reasonable action to assess A's care needs, in line with relevant guidance and policies. We considered that the council took reasonable action to deliver a care plan to meet A's needs. Therefore, we did not uphold the complaint.

Summary

Prior to 2015, C’s grandchild was placed in their care by social work. C was granted a Section 11 Residence Order by a court (also known as a Kinship Care Order, conveying parental rights and responsibilities in respect of the child). The case was then closed to social work in mid-2015.

C complained that the council did not contact them directly to advise of the changes to the kinship care legislation in October 2015. C stated that they found out that the law had changed through word-of-mouth in September 2019. C also complained that when they applied for a kinship care allowance this was only backdated to the date of their application and not to October 2015.

We took independent advice from a social work adviser. We found that the legislation and guidance did not require the council to directly contact all closed cases where a section 11 order was in place to notify them of the changes. The legislation requires local authorities to publish certain information about kinship care assistance and the council provided evidence that they had done this. We also found that there was no indication in the legislation and guidance that C’s particular circumstances entitled them to a backdated allowance to October 2015.

We did not uphold C’s complaints.

Summary

C complained about the association’s response to anti-social behaviour. C said this had been continual since they moved into their property. It was affecting them and in particular, their child. C said that the association had failed to take meaningful action, or follow up properly on their reports. C believed that they had been misled about what the association would do and the evidence they submitted had been disregarded.

We found that the association had followed their procedures and could evidence the action they had taken in response to C’s complaints. This included liaising with Police Scotland, contacting the tenant responsible and canvassing other residents for corroborating evidence. We found that the association had been restricted by limitations imposed on staff by COVID-19, but that they had responded reasonably and appropriately to C’s concerns. Therefore, we did not uphold this aspect of C's complaint.

C also said their complaint had been investigated by members of staff they specifically did not want involved in their complaint. The association had acknowledged this and said this was due to human error on the part of staff who had recorded the complaint. They had failed to note C’s concerns, resulting in the complaint being allocated to the wrong person. We found that the association had taken the appropriate action to address this mistake. We also found that although C had been concerned about this, there was no evidence it had materially affected the investigation of their complaint. Therefore, we did not uphold this aspect of C's complaint.

Summary

C complained about the support provided to their parent (A) by the partnership. In particular, C complained that the decision was made to move their parent to respite accommodation (planned or emergency temporary care usually provided to give primary caregivers a break from caring). C was also concerned that no further care assessment was carried out of A’s care needs to assess in what way a care home, particularly respite, was considered appropriate to A’s needs. C was concerned that A was not supported to return home.

We took independent advice from a social work adviser. We found that the records indicated that A’s views were not sought and that A was not enabled to make an informed choice regarding the move to respite. However, as this was a crisis/emergency situation it was reasonable for the partnership to make the decision to move A to residential respite because A was not safe to remain in their own home without 24-hour support and the partnership took reasonable steps to ensure that A’s welfare was safeguarded by seeking alternative care (residential respite). It was also reasonable as the records indicate that A was experiencing increasing confusion in the months leading up to the crisis situation and it was unlikely that A would have been able to make an informed decision.

We also found that the assessment of A’s care needs (that A required 24-hour care in a residential setting) was reasonable and that in the circumstances there was no obligation for the partnership to provide 24-hour care to A in their own home. We did not uphold C’s complaint that the partnership had failed to provide reasonable support to A.

C also complained that the partnership failed to investigate allegations that A was being abused and/or neglected. We found that the partnership had appropriately followed up on the concerns and their decisions not to carry out adult protection investigations were reasonable in the circumstances because there were less restrictive interventions that were able to meet A’s needs. We did not uphold C’s complaint in this regard.

Summary

C complained on behalf of their late partner (A) about the care and treatment they received at the Royal Infirmary of Edinburgh for heart disease. A’s condition deteriorated and they were transferred to the intensive care unit and then ultimately referred to another health board for a heart transplant. A died five days later.

C said that the board did not treat the left side of A’s heart which resulted in a grave outcome for A. C also said that the board did not notice that A was deteriorating and that A should have been transferred to the other health board earlier.

The board said that when A was admitted they had a blocked right coronary artery and treatment was given for this. They explained that there was no viability in the left side of A’s heart (due to damage caused by a previous heart attack) and therefore, to treat that side would have subjected A to additional risk. The board said that A was very unwell, but reasonably stable until their sudden deterioration. They said that there was no indication that an earlier referral outwith the health board was warranted or would have altered the outcome.

We took independent clinical advice from a consultant cardiologist (a doctor that that deals with diseases and abnormalities of the heart). We found that it was reasonable for the board not to have a treatment plan for the left side of A’s heart as it would have exposed A to increased risk and there would have been no benefit to A (due to irreversible damage caused by a previous heart attack). The board reasonably monitored A’s condition and provided appropriate care and treatment in response to their deteriorating condition. We also found that the board’s decision to refer A to another heath board was reasonable and that there was no indication this should have been done earlier.

As such, we did not uphold this complaint. We did, however, provide feedback to the board regarding their communication with A.

Summary

C was referred to Raigmore Hospital by their midwife with high blood pressure. C was pregnant and there were concerns they had pre-eclampsia (a condition that causes high blood pressure during pregnancy and after labour). C said that on attending the hospital they did not receive reasonable treatment over a four-day period. C also considered the care provided to their newborn child (A) was unreasonable.

We took independent advice from a consultant obstetrician and gynaecologist (a doctor who specialises in pregnancy, childbirth and the female reproductive system) and a consultant neonatologist (a doctor who specialises in the medical care of newborn infants, especially ill or premature newborns). We found that the tests carried out when C attended the ward were reasonable and in line with relevant guidelines. We considered it was reasonable that C was initially discharged prior to their later admission and when C’s condition worsened, appropriate action was taken. As such, we did not uphold this complaint.

In relation to C's concerns about A's health, we considered that the actions taken after concerns were raised about A’s condition were reasonable. While we considered that the communication and documentation was below a reasonable standard, the clinical care provided to A was reasonable. As such, we did not uphold this complaint. However, feedback was provided to the board.

C complained that the board failed to reasonably respond to their complaint. We found that while the response to the complaint was accurate in relation to the medical records, it would have been good practice to provide more detail as to the board's position on certain points. A consultant spoke with C after events and arranged for further details to be provided regarding A’s care, which was good practice, particularly considering the board had identified communication issues. While further detail could have been given, and we provided feedback to the board on this point, on balance, we found the response to be reasonable. As such, we did not uphold the complaint.

Summary

C complained about the treatment their spouse (A) received for their pressure sores from district nurses. When A died, one of the main causes of death was noted to be multiple pressure sores. C said that there was no examination by a GP at any point. They believed the pressure sores had become infected, causing sepsis and leading to A’s death.

The board outlined the steps district nurses had taken when they identified that A’s sacral and heel pressure areas were starting to break down. They told us that over a four-month period, district nursing staff carried out more than 80 visits as well as providing support over the phone. They said the district nursing team involved A’s GP and the tissue viability service, who agreed with the care and advice that was being provided.

We took independent advice from a nursing adviser. We found that A’s clinical records showed risk factors which increased their risk of developing skin damage: weight loss, poor mobility and double incontinence. We noted that the advice to patients with pressure sores is to move and regularly change position and to use a pressure relieving mattress, cushions and boots. District nurses ordered appropriate equipment for A and monitored A’s pressure areas closely. We found that there was evidence in the notes of appropriate advice being given to A and C regarding sitting in a chair for a long period of time and the detrimental effect this could have on the skin, especially the heels and sacrum. The boots provided to A were returned to the equipment store despite documented advice that these should be worn.

We considered that there was clear evidence of partnership working between the carers, district nurses, and the wider multi-disciplinary team. Noting the complications associated with A’s incontinence, we found that the documented evidence demonstrated the appropriate treatment being delivered.

Therefore, we did not uphold this complaint.

Summary

C operated a bed and breakfast business from their home (the premises) and a number of years ago was identified as a gap site (a property where commercial activity is being conducted and should, therefore, be liable for commercial water charges, but that has not yet been registered for commercial water services). Scottish Water installed a water meter on pipework outside the premises so that C’s water consumption could be measured for commercial water charges. As they had not chosen one, a licensed provider was appointed to manage C’s water account.

Following installation of the meter, C began to receive water bills that were disproportionately high for the number of residents and guests in the premises. Investigations by their licensed provider established that there was likely a leak between the meter and the premises. The location of the presumed leak meant that it was C’s responsibility to locate and repair it. C appointed a contractor to undertake this work. The contractor ultimately decided to lay a new supply pipe from the premises to the meter at a cost to C of more than £10,000.00. In doing so, they did not encounter the original supply pipe and no leaks were identified. However, following the work, C’s water consumption fell to a normal level.

C subsequently learned that a lot of the work carried out by the contractor had been unnecessary. Scottish Water had previously replaced their communication pipe with a narrower pipe, which was connected to C’s original larger supply pipe. C contended that the work carried out by Scottish Water had caused the leak. C also considered that, had Scottish Water informed them that they had installed a narrower pipe, the contractor would have been able to slide a similarly sized pipe through the original larger pipe, negating the need to excavate the ground and saving a substantial amount of money.

C complained that they had incurred substantial financial losses as a result of Scottish Water’s work and lack of communication. They considered that Scottish Water should, therefore, make a significant contribution towards the costs they incurred.

We found that Scottish Water communicated reasonably with C regarding the gap site process and the installation of the meter. We did not consider there to be a particular need for Scottish Water to advise C that they had used a narrower pipe when they changed the communication pipe some years previously. We were also satisfied that Scottish Water reasonably investigated C’s concerns regarding the leak. We found that their conclusions and decision not to cover C’s costs were demonstrably based on information gathered during their investigation. A full leak allowance was paid and we found this to be reasonable in the circumstances. We did not uphold C's complaints.