Not upheld, recommendations

Summary

Miss C, a tenant of the association, complained that they told her to remove a caravan and a satellite dish from her property. She had been granted permission to site a caravan there, but did not actually do so until several years later. We found that the tenancy agreement said that caravans were not to be parked on association land, and the fact that Miss C was granted permission at the time was clearly an exception to this. In addition, one of the conditions of the permission was that the association had the right to ask Miss C to remove the caravan at any time. She disagreed with the association's reasons for asking her to remove it, but the fact that she disagreed did not mean that the association had done anything wrong.

Miss C said that she applied for permission to install a satellite dish but was refused. At the time, the association's policy was to refuse permission, but they later changed this, to allow satellite dishes to be installed under certain conditions if permission was requested in writing. There was, however, no evidence that Miss C asked for permission in writing after the policy change.

We concluded that the association had acted reasonably in both matters and we did not uphold Miss C's complaints. During our investigation, however, we found that the association's policy on satellite dishes was not clear about a tenant's right to bring a complaint to us and we made a recommendation.

Recommendations

We recommended that the association:

• change the wording of the relevant paragraph of their Policy on Satellite Receivers and External Aerials to make clear that a tenant can bring a complaint to us.

Summary

Mr C was treated for appendicitis at Monklands Hospital. As part of his treatment, he was given antibiotics, including gentamicin, intravenously (directly into a vein) for ten days. During and after this treatment, Mr C experienced symptoms of dizziness and difficulty with his balance. He saw an ear, nose and throat consultant, who diagnosed him with permanent damage to his hearing and balance, possibly as a result of gentamicin poisoning. Mr C complained that the decision to administer gentamicin was inappropriate, and that he was not told of the side effects or asked for his consent before the drug was administered.

We investigated Mr C's complaint and took independent advice from a consultant in general medicine. We did not uphold Mr C's complaints, as we found that gentamicin was the appropriate treatment for his symptoms and condition at the time. We also found that there was no requirement to explain the side effects or seek Mr C's consent before administering gentamicin, given that the side effects are extremely rare. However, we found that the board failed to monitor Mr C for signs of gentamicin poisoning, and failed to consider referral to an audiologist, as required by their guidance. Although we did not uphold his complaint, we made recommendations about this.

Recommendations

We recommended that the board:

• apologise to Mr C for the failings our investigation found; and
• remind relevant staff of the gentamicin guidance in relation to monitoring for ototoxicity (ear poisoning) and considering audiology assessment where gentamicin is administered for more than seven days.

Summary

Mr C complained because he said the prison health centre had unreasonably stopped or reduced his medication. In particular, he said that omeprazole (medication for stomach acid) and vitamin B had not been prescribed. He also said his diabetic medication had been reduced without explanation.

The board confirmed that prisoners were responsible for reordering some medication themselves, including omeprazole. They also confirmed that the health centre at Mr C's previous prison had stopped his prescription for vitamin B. The prison doctor confirmed that he prescribed Mr C's diabetic medication to be taken twice a day, rather than three times. He was unsure why he had reduced the medication but confirmed that he had since increased the dosage back to three times a day.

We took independent medical advice, and asked our adviser whether the decision to reduce Mr C's diabetic medication was reasonable. Our adviser noted the doctor's comments and suggested that the reduction had most probably occurred as a result of an error when writing up the prescription. The adviser said it would be unusual to reduce a patient's diabetic medication without close monitoring or evidence of improvement in blood sugar levels. They also said that because Mr C's medication was increased after he reported raised sugar levels, he was unlikely to have suffered any harm. In light of the evidence, and having considered the views of our medical adviser, we did not uphold Mr C's complaint, although we made a recommendation.

Recommendations

We recommended that the board:

• apologise to Mr C for the possible error when writing his prescription for his diabetic medication.

Summary

Mr C reported dampness in his property that he said was caused by the neighbouring council property. Council officers visited the site and tests were carried out on cavity wall insulation. An independent survey commissioned by the council found that the dampness did not come from the council property but said that the lack of a damp proof course at one location might contribute to moisture building up in a cupboard. The council said they would investigate the installation of a damp proof course and carry out the work required to put right the damp course issue. Mr C, however, disputed the survey report saying that it did not accord with what he and his partner were told by the workmen carrying out the tests. When the contractors attended to carry out repairs after the cavity wall tests, Mr C's partner sent them away, so they did not carry out damp proofing work. Mr C said that access to his property was not required to do this. He complained to the council about continuing problems with dampness and that council officers had not responded reasonably to his emails and calls. The council investigated and did not uphold his complaints, so he complained to us.

Our investigation reviewed the survey reports and correspondence between Mr C and the council. We found that the council had clearly established that the dampness in Mr C's property did not originate from the council property. In an effort to help Mr C they had said they would carry out work on one aspect as a goodwill gesture, but they were then refused access to infill the inspection holes opened up when the independent survey was carried out. We found that the council should have been clearer about what they communicated to Mr C but they had confirmed the dampness was not coming from the council property and that they were not responsible for work on the property that Mr C owned. We did not uphold the complaint, but made a recommendation.

Recommendations

We recommended that the council:

• contact Mr C to discuss arrangements for the inspection holes to be re-filled.

Summary

Mr and Mrs C's son was not allocated a place at their first choice of nursery, and they couple complained that the council did not follow their policy in terms of deadlines for applications and allocation meeting dates when places were allocated. The council investigated Mr and Mrs C's complaint, and advised that they had exhausted the appeals process as laid out in the nursery education admission policy and both stages of the council's complaints procedure.

Mr C then brought his complaint to us. We reviewed the correspondence between him and the council, as well as council policies on the allocation of nursery places and complaints handling, and considered the management of waiting lists and the introduction of new policy. We found that the council had operated allocations and nursery place waiting lists in line with policy and, responding to parental feedback, had taken steps to anticipate changes being introduced in their new policy. We found that Mr C's son was not disadvantaged by the council's actions. Although we did not uphold Mr C's complaint, we found that the council's responses to it were sometimes confusing and contradictory, and so we made a recommendation.

Recommendations

We recommended that the council:

• apologise for the lack of clarity in their responses to Mr C's complaints.

Summary

Miss C attended the A&E department at Hairmyres Hospital with abdominal (stomach) pain. After examination in A&E, she was transferred to one of the wards. She complained about her treatment in both A&E and on the ward, in particular that a doctor wrongly decided she was an abuser of alcohol which had an impact on the treatment she was given.

We took independent advice from one of our medical advisers. Our investigation found that the doctor had formed the conclusion about the alcohol use from a 13-year-old entry in Miss C's medical records, which referred to one episode of alcohol abuse at that time. We did not consider it was appropriate to make the assumption he made from that entry and concluded the doctor should have made more of an effort to find out the current facts. As we otherwise found Miss C's care and treatment to be appropriate, we did not uphold the complaint but we made two recommendations.

Recommendations

We recommended that the board:

• add a note to Miss C's medical records to show the context in which they made their remarks about previous alcohol excess and about a treatment plan; and
• ensure that the doctor discusses the complaint with his education supervisor as part of his training record.

Summary

Mr C, who is a solicitor, complained on behalf of his client (Miss A). Miss A was studying at the university to become a teacher. Part of her course involved a practical placement in a school. During the first two days of the placement, the teacher who was mentoring Miss A made notes about her performance to discuss with her. Miss A read these notes and became upset as she found them very negative. She went to the university to explain her concerns to the course leader. As Miss A had not spoken with the teacher, she was advised to return to the school to discuss the notes. The following day Miss A met with the course leader and her tutor at the university. Her tutor planned a placement visit for the following week. Later that day, Miss A met with the head teacher at the school who subsequently decided to withdraw the placement. The university advised that there was no opportunity to switch to a different placement within the academic year and that Miss A would have to wait until the new semester to do this. Miss A was unhappy that she was unable to complete her course as planned and complained to the university. She also raised concerns about the level of support she received from the university when she told them about her problems at the school. The university advised Miss A that it was not possible to arrange an alternative placement within the academic year as these are arranged annually in advance and once students have started at a school, there is no opportunity to change unless there are extraordinary circumstances. They considered the head teacher's decision to withdraw the placement to be reasonable and based on his professional judgement.

During our investigation, we found that the relevant university handbook states that resits for failed or incomplete placements will take place in the following semester. Therefore, although we did not uphold Mr C's complaint about the arrangements for the placement, we did consider that the handbooks could provide clearer information to students on the withdrawal of placements by schools.

We also found that the university had provided Miss A with adequate support during her placement. Although we also did not uphold this aspect of Mr C's complaint, we were critical that the university did not address Miss A's concerns about support when responding to her complaints, so we made a recommendation about this too.

Recommendations

We recommended that the university:

• ensure that complaints under investigation are defined at the start of the process and that each of these receives an appropriate response; and
• ensure that future handbooks clearly explain the position on rearranging placements that have been withdrawn by the school.

Summary

Mr C complained about the way the prison handled an item of mail that had been sent to him from his solicitor. In particular, Mr C considered that the item of mail has been opened before it was given to him. Mr C also said that the prison failed to handle his complaint on the matter appropriately.

Our investigation found that the prison had a system in place which allowed staff to identify and record any damaged letters that arrived at the prison. They also had a process in place for staff to follow when an item of privileged mail - which included mail from a prisoner's solicitor - is opened in error. In Mr C's case, the prison advised that they did not consider his item of mail to be damaged, or opened in error, and because of that, the procedures referred to were not applied. Therefore, we considered the prison's handling of Mr C's mail to be reasonable. We also considered that the prison's overall handling of Mr C's complaint was reasonable and we did not uphold his complaints. However, during our investigation we did identify some issues that we made recommendations to the Scottish Prison Service about.

Recommendations

We recommended that Scottish Prison Service:

• remind staff to respond to each issue raised in a complaint including any complaints handing matters;
• review the SPS staff guidance on prisoner complaints to ensure it is consistent with the prison rules; and
• consider revising the PCF1 (complaints) form to include the information sought by the witness information request form.

Summary

Miss C complained there was an avoidable delay before her hip replacement surgery was carried out. We took independent advice from one of our medical advisers, who explained that total hip replacements are best avoided in younger patients until all other possibilities have been considered. This is because such replacements have a limited time span and in younger patients they wear out and loosen earlier due to physical activities. In such cases the patient might need at least one further surgery, if not two. As Miss C was a younger patient, the delay before surgery was appropriate as it was important to explore all other non-surgical options before operating. We also found that Miss C asked to delay the surgery further, for personal reasons, and so not all of the delay was caused by the surgeon.

Miss C had replacement surgery on both hips. While the right hip surgery was successful, Miss C experienced pain after the surgery on her left hip and needed another operation. She complained that there was a failure to take timely action or arrange appropriate investigations to try to diagnose the cause of her pain. Our adviser said, however, that the investigations carried out on this were reasonable and appropriate. In particular, after unsuccessful surgery there may be complications with a further operation, and the adviser said that it was reasonable to wait and see if a patient's symptoms settled down (which in many cases they do) before taking further action.

Although we did not uphold Miss C's complaint, our adviser noted that the cause of Miss C's pain and her dissatisfaction with the surgery on her left hip was likely a direct consequence of the hip replacement socket being badly positioned. Our adviser said that in this respect her care and treatment fell below an acceptable standard, and we made recommendations about this.

Recommendations

We recommended that the board:

• apologise to Miss C for failing to ensure that her left hip replacement operation was undertaken to a reasonable standard of care; and
• carry out an internal audit of any known or reported complications of the doctor's surgery and a review of all postoperative x-rays of the hip replacements performed by them over a twelve month period; report to us the findings of the audit and in the event that this shows that Miss C's case was not an isolated incident inform us of the action they intend taking to address this; and raise the findings of our investigation with the doctor for reflection.

Summary

Mrs C complained on behalf of her son (Mr A) that the board failed to provide him with an earlier diagnosis of Asperger's syndrome. She said that for many years he had been under the care of mental health services in both England and Scotland. In 2010 he saw a consultant psychiatrist in New Craigs Hospital, and continued to see him until early 2011. During this time, Mr A was not considered to show signs of mental illness, although he spent time in hospital for assessment. He was encouraged to become more active and independent, establish proper sleep hygiene and reduce his medication.

Mr A requested a second opinion and was moved to the care of another consultant psychiatrist. No formal diagnosis was made and, again, Mr A was encouraged to develop independent structures in his life. While he appeared content with this, Mr A also mentioned the possibility of Asperger's. He was referred to a consultant neuropsychologist for review and was diagnosed with Asperger's later that year.

Mrs C complained that it took too long to provide this diagnosis and that meanwhile her son had been treated incorrectly, which was very traumatic for him. She also complained that his medication was withdrawn too quickly and without proper support.

We took independent advice from one of our medical advisers, who is a mental health specialist. Our investigation found that this kind of diagnosis was very difficult to make, particularly where the condition was mild and where the spectrum for the diagnosis overlapped with the general population. We noted that there was no specific treatment for such a diagnosis. We found that Mr A was treated reasonably and appropriately during his treatment, and that referrals were made in a timely way. Although an earlier diagnosis was not made, this did not have an adverse effect on his management and treatment. There was no evidence that Mr A's medication was unreasonably withdrawn or that he was not given appropriate support, and we did not uphold Mrs C's complaint, although we made a related recommendation.

Recommendations

We recommended that the board:

• give consideration to setting up a specific team to ensure multi-disciplinary assessment as per the recommendation of the national Strategy for Autism in Scotland.