Not upheld, recommendations

Summary

Mr C complained that a council officer unreasonably barred his entry into a public event that was being held in a council facility. He also complained that the officer's behaviour at the time was inappropriate. He then complained to the council about this incident but was dissatisfied with their investigation and response. He said that they had not explained the complaints process to him, and they had not interviewed the only independent witness to these events.

We considered the investigation carried out by the council and noted that they had given Mr C information about the complaints process and asked for contact details for his witness by email. We noted, however, that one of these emails was returned undelivered as the email address, despite being correct, was not recognised. We were satisfied that they had properly investigated his complaint and asked for the witness's details, which Mr C had not originally provided. We also noted that council staff were entitled to take action where they consider that their staff are likely to be subjected to unacceptable behaviour by a member of the public, and that this complied with the council's unacceptable actions policy and their policy on dignity and respect in the workplace. We found no additional evidence to support Mr C's claim that staff had behaved inappropriately when barring him from the event. For these reasons, we did not uphold his complaint. However, we did recommend that, for the sake of completeness, the council now contact his witness to see whether his recollection of events would affect their decision on Mr C's complaint. We also recommended that they ensure that all incidents of unacceptable behaviour by members of the public are properly recorded in line with their own procedures.

Recommendations

We recommended that the council:

• phone Mr C's witness to discuss his recollection of the incident and consider whether his testimony would alter their decision on Mr C's case; and
• ensure that all incidents of unacceptable behaviour towards staff, in council offices or outwith the workplace, are recorded appropriately and in line with their unacceptable actions policy and their policy on dignity and respect in the workplace.

Summary

Ms C's daughter has special needs and attended a special school where her behaviour meant she had to be restrained on a regular basis. In March 2014 her daughter was injured and severely bruised whilst being restrained. Ms C herself suggested a different type of restraint for use on her daughter. The school agreed to use this method of restraint and trained staff in this technique. However, Ms C then complained about the council using the original type of restraint and also about the council's subsequent investigation into her complaint.

We noted that the restraint technique used was an approved method of restraint suitable for situations such as this. We noted that the school did change the restraint technique to be used on Ms C's daughter to one which Ms C herself had requested, and they carried out training to ensure staff were fully trained on this new technique. We fully accepted, as had the school and council, that her daughter was injured during this restraint but, as trained staff used an approved restraint technique, in line with the school and council's policies, we did not find evidence of administrative failing in this case. We also noted the investigation carried out by the council into Ms C's complaint was reasonable and found no evidence of administrative failure in the way it was carried out. As a result, we did not uphold the complaints.

Recommendations

We recommended that the council:

• ensure that the school takes steps to ensure that separate incident forms are completed by all staff who are involved in future incidents where force is used, as required by their Therapeutic Crisis Intervention (Restraint) Policy.

Summary

Mr C complained that, due to a high staff turnover within the practice, he had been seen by a number of different dentists over the years. He said that each dentist changed his treatment plan and, as a result, his gum disease was never treated. In responding, the practice noted that the staff turnover was outwith their control. They confirmed that a treatment plan should continue from one dentist to the next unless there were clinical grounds for changing it. They did not comment specifically on Mr C's treatment plan as they did not have his records to hand.

We took independent advice from one of our dental advisers. He said the treatment carried out by the various dentists appeared consistent in that the primary aim was to address Mr C's chronic gum disease. He explained that this was a longstanding condition which progressed to the position where loss of the teeth was inevitable, despite the treatment carried out. He concluded that the treatment provided by the practice was reasonable. We accepted this advice and did not uphold the complaint.

We were concerned, however, that the practice had responded to Mr C's complaint about his dental treatment without specifically referring to his dental records. We also noted that their response had not told Mr C that he could complain to us in the event that he remained dissatisfied. In addition, we noted that the practice sent Mr C's original dental records to us and did not use a secure postal method. In light of these observations, we made some recommendations.

Recommendations

We recommended that the practice:

• apologise to Mr C for the identified shortcomings in their handling of his complaint;
• review their handling of Mr C's complaint with a view to making improvements for future complaints handling. In particular, they should ensure that all available information relevant to the complaint is considered as part of their investigation and all complaint issues raised are fully responded to. They should also ensure that the complaint response includes information about the right to refer a complaint to us and our contact details; and
• review their process for handling secure data with a view to avoiding a repeat occurence of the issues raised during the course of this investigation.

Summary

Ms C attended her dental practice complaining of pain from her molar tooth. Ms C elected to have an extraction, which was performed under local anaesthetic. During the extraction, the tooth fractured and part of the root was displaced into the maxillary antrum (the space within the upper jaw bone). This had to be removed by surgery. Ms C said it was not reasonable that the tooth fractured during the extraction because the dentist had an x-ray showing the size of the tooth and its position before undertaking the procedure. Ms C complained that she had to attend hospital eight times because she suffered a severe infection which disfigured one side of her face and caused extreme pain.

We took independent advice from our dental adviser. We found that there was no indication that the fractured root would become dislodged and penetrate the antrum, and that this was a well recognised complication of this kind of extraction. However, there was no evidence in Mrs C's dental records that the possible complications of the extraction had been explained to her before the procedure had been carried out. While we were satisfied by the evidence that, overall, the treatment decisions and management were reasonable, we made a recommendation to the practice given the lack of evidence showing that possible complications were explained.

Recommendations

We recommended that the practice:

• take steps to ensure the possible risks of extraction are adequately explained to patients and recorded in their records.

Summary

Mr C complained that, although the water supply to his business premises was capped by his plumber when he took entry and, therefore, he used no water, he was still billed for water charges. He was further aggrieved that, although he invited someone to come and inspect the situation, Business Stream failed to arrange such a visit.

The complaint was investigated, and all the relevant information and documentation were given careful consideration. We found that although Mr C had been at the relevant address for a number of years, it was only relatively recently that Business Stream established this, and an account was opened and backdated. It had been Mr C's responsibility to advise them. Even although the supply had been capped, there was still a live connection into the premises which could be reinstated at any time. Mr C was, therefore, responsible for all water charges back to the date of his account opening. While he also complained that Business Stream had failed to arrange for the site to be visited, it was confirmed that they had asked Scottish Water to do so. However, on the grounds that it could be seen from records that no permanent disconnection had been made, Scottish Water considered it unnecessary. Only a permanent disconnection would have removed Mr C's liability for water charges. The complaint was not upheld.

However, in light of the delay Business Stream took in explaining the matter to Mr C, we made a recommendation that Business Stream extend the period in which Mr C has to repay the amount due.

Recommendations

We recommended that Business Stream:

• give sympathetic consideration to extend the period in which to repay the amount due.

Summary

Ms C shared a private driveway with two rented properties. When she experienced problems with access because of the way the tenants parked their cars, she found that there was no landlord registration. She wrote to the council about her concerns. She said the council were not doing enough to address the issues she had raised. She then experienced further problems when a blocked drain at the rented property caused an overflow of sewage onto her driveway and she contacted the council about this matter too. After lengthy and detailed correspondence with the council about her dissatisfaction, the council referred her to our office.

Our investigation considered all the correspondence between Ms C and the council, the council's records of contact with her, and the actions they took, as well as the relevant legislation. We found that the council had reasonably responded and addressed the matters she raised. However, we also noted that it was not always clear how the council were dealing with her complaints in terms of their complaints handling procedure, and we recommended that the council address this aspect.

Recommendations

We recommended that the council:

• take steps to ensure complaints are accurately identified from the outset and complaints handling procedures are clearly communicated.

Summary

Mrs C said her son was admitted to Ninewells Hospital with a suspected infectious disease and was kept in hospital for two nights. Mrs C said she was told that her son's treatment would be free, but during the discharge process she was advised she would have to pay for his treatment as they were visitors to the UK. Mrs C complained that it was unreasonable that she was charged for his care and treatment. Her concerns included that her son's treatment was not immediately necessary and the board's actions were contrary to Scottish Government Guidance CEL 09 (2010) (Overseas Visitors' Liability to Pay Charges for NHS Care and Services) as she was not given the opportunity to make an informed decision about whether, or to what extent, to proceed with treatment.

We obtained independent medical advice on the complaint from one of our medical advisers, a consultant in general medicine. The evidence showed that the initial impression provided to Mrs C by the board was that her son's treatment would be free. The board failed to follow the Scottish Government guidance with sufficient accuracy, and there were opportunities that should been taken to discuss the likely charges with Mrs C at the time of her son's admission to hospital.

However, the type of treatment her son received was chargeable. It seemed unlikely that, had Mrs C been presented with the 'undertaking to pay' form at the time of her son's admission to hospital, she would have refused to sign the form, as he was clearly very unwell and in need of medical treatment. We also noted that Mrs C signed the 'undertaking to pay' form at the time of her son's discharge. We therefore considered that, on balance, it was reasonable that Mrs C was charged for her son's care and treatment.

Recommendations

We recommended that the board:

• ensure that hospital staff receive training on when to discuss charging for NHS care and services with overseas visitors requiring treatment; and
• provide Mrs C with a written apology for failing to discuss the likely charges for her son's treatment with her at the time of his admission to hospital.

Summary

Mr C complained that clinical staff at The Royal Hospital for Sick Children (Yorkhill Hospital) had not diagnosed his newly born son's illness. Mr C said he took his son to the hospital three times (he left the second time without being seen due to concerns about cleanliness), but it was only on a family holiday some weeks later in England that his son's pyloric stenosis (tightness of the muscle that connects the stomach to the small bowel, thus causing problems with digesting food and vomiting) was identified.

We considered whether the evidence indicated that clinical staff had acted reasonably. We took independent advice from our medical adviser, who confirmed that pyloric stenosis evolves over time. He said there was no specific guidance that staff should have followed in such a case and, on the basis of the information available at the time, he said it was not unreasonable that staff did not carry out additional investigations for pyloric stenosis. Although we took Mr C's concerns into account, we did not consider that the evidence indicated that the care was unreasonable. We did not uphold this complaint, but we did make one recommendation because a urine test had been misinterpreted by a junior doctor as pointing to an infection.

In terms of Mr C's complaint about the cleanliness of the hospital on his second visit (when he left before being seen), the evidence was limited to the signed cleaning checklists for that day and Mr C's version of events. Although we did not in any way doubt his honesty, and we recognised that the cleaning logs did not absolutely prove the level of cleanliness at any one time, on the basis of the limited paperwork available, we did not uphold this complaint.

Recommendations

We recommended that the board:

• consider reviewing their staff guidance for interpreting urine culture results.

Summary

Mrs C complained on behalf of her daughter (Miss A) who was a student at the college. Miss A has a complex communication disability which affects her written and oral language skills. However, her IQ and potential to learn is the same as other students. The college supported Miss A with a number of adaptations designed to help her complete her studies. However, after progressing to a higher level of study, Miss A's academic performance dropped. Mrs C believed that the level of support provided by the college was no longer adequate and sought additional adaptations for Miss A. Whilst the college considered her request, they declined to introduce all of the supports that Mrs C felt were necessary for her daughter to demonstrate her full potential.

We found that the college had taken Miss A's condition seriously and had introduced a schedule of adaptations at the beginning of her studies, based on independent medical advice. Regular review meetings were held with her, at which she confirmed that she was happy with the support that was in place. Following Mrs C's complaint, there was evidence of the college looking into the provision of further adaptations and some were implemented. However, there was a lack of clear evidence of discussions that were reportedly held with third parties and which influenced the decisions not to provide some of the requested support. Whilst we were generally satisfied that the college had acted reasonably, we felt that they could have been more transparent and could have included Miss A more in discussions about her support package.

Recommendations

We recommended that the college:

• offer Miss A an urgent review of her support needs with specific regard to the rewording of assessments and share with her any input from outside agencies.

Summary

Mr C complained because he said the prison unreasonably refused to progress him to open (lowest security) conditions. Instead, the risk management team (RMT) - the group responsible for considering whether a prisoner is suitable to progress to less secure conditions - decided that Mr C should transfer to the national top end facility before going to open conditions.

Mr C is serving an order for lifelong restriction (OLR) which is a sentence that provides for the lifelong supervision of high risk violent and sexual offenders and allows for a greater degree of intensive supervision to manage the risk that those individuals pose. The guidance which outlines how risk management is dealt with by the Scottish Prison Service confirms that OLR prisoners will normally transfer direct from closed conditions to the open conditions. However, it also confirms that they can go to a national top end facility if they have been placed there on the request of the RMT at the closed prison. In light of this, it was clear the RMT were entitled to take the decision to progress Mr C to national top end before open conditions and because of that, we did not uphold his complaint.

Our investigation did highlight potential issues with the risk management process followed by the prison when dealing with Mr C's application for progression to less secure conditions. In particular, the guidance indicates that an OLR prisoner's progression to less secure conditions should only be approved once their risk management plan has been updated and agreed by the RMT before being approved by the Risk Management Authority (RMA). In Mr C's case, the RMT approved his progression to national top end before the RMA has approved his risk management plan. Therefore, although we did not uphold Mr C's complaint we did make recommendations.

Recommendations

We recommended that Scottish Prison Service:

• apologise to Mr C for the failings our investigation identified; and
• offer to meet with Mr C to discuss what has happened in his case and provide reassurance that his progression is being dealt with appropriately.