Not upheld, recommendations

Summary

Mrs C's dentist extracted her bottom left molar. Eleven days later, the dentist extracted Mrs C's upper right molar and prescribed antibiotics because of pain at the site of the previous extraction. Several days after that, Mrs C was treated by another dentist for infected sockets. They gave her an antiseptic mouthwash and a dressing to promote healing. Mrs C was also given advice about giving up smoking and pain relief. Mrs C said that shards of tooth came out of her gum at the extraction sites. A radiograph was taken and showed no retained roots. She returned to the dental practice a month later and another dressing was put in place. At the end of the following month, Mrs C returned to the practice saying that another back tooth was causing discomfort and that she felt unwell. She was prescribed antibiotics and had further extractions a couple of months later. She was then referred to the dental hospital. Mrs C complained that the extraction sites have not healed, she has loose teeth and she takes antidepressants due to the poor cosmetic appearance of her teeth. Mrs C also complained that there were delays by the practice in responding to her complaint.

We found that the clinical care and treatment provided was reasonable, but that there were failings in relation to record-keeping, about which we made a number of recommendations. In relation to complaints handling, the practice delayed in sending a written response, but did take other action. They arranged a meeting between Mrs C and a dental practitioner to discuss her complaint and referred Mrs C to hospital. We were satisfied that, on the whole, the practice dealt with Mrs C's complaint in line with the NHS complaints procedure as they took action to respond to and resolve it within a reasonable time.

Recommendations

We recommended that the practice:

• ensure that a copy of a signed treatment plan for scheduled appointments is retained in patient records;
• ensure that dentists record information about medication provided;
• ensure that dentists record it when they provide a post extraction information sheet to patients following extractions;
• ensure that dentists report on all radiographic findings in patients' records; and
• ensure that there is written evidence of a British periodontal (gum) examination in patients' records for all scheduled appointments.

Summary

Ms C complained that there was a lack of appropriate care and treatment for her late mother (Mrs A) after she fell while in hospital. Mrs A had been admitted to hospital five days previously because she had fractured her wrist and pelvis. Ms C said that the board's decision not to x-ray her mother and to proceed with her planned discharge on the day she fell was unreasonable. Ms C also raised concerns that staff refused her mother's request to use a zimmer frame immediately before she fell, and that she did not receive adequate pain relief. In response to the complaint, the board advised that it had been appropriate to discharge Mrs A, on the basis of the clinical assessment that had been carried out.

After taking independent advice from one of our medical advisers, we did not uphold Ms C's complaint. Our investigation found that there was evidence to show that during her stay Mrs A had progressed from being able to use a zimmer frame around the ward to using one elbow crutch with the assistance of a member of staff. We considered that appropriate examinations had been carried out by three different doctors, who all agreed that Mrs A could be discharged. In addition, Mrs A's mobility was assessed twice after her fall and although it was noted that she had pain, she was able to weight bear and walk several metres. There was also no evidence of serious injury to suggest that an x-ray should be carried out. However, we took the view that Mrs A's family could have been better involved in the decision to discharge her. We also identified that, whilst Mrs A was given appropriate pain relief, there was insufficient evidence to show that her pain levels had been adequately monitored between the time she was admitted to hospital and her subsequent discharge.

Recommendations

We recommended that the board:

• ensure that relevant staff on the ward clearly monitor and assess a patient's pain using the recognised measurement chart.

Summary

Mr C complained about the care that his late mother (Mrs A) received from doctors and nurses at her medical practice. Mrs A's overall health had been deteriorating for some time. She was admitted to hospital with advanced lung disease and died shortly after admission. Mr C was concerned about the condition of his mother's legs and felt in particular that the doctors and nurses had failed to treat ulcers.

Our investigation found that the care provided to Mrs A was good, and that there was clear evidence that an ulcer was identified and treated appropriately until it healed. We noted that Mrs A's legs had changed colour towards the end of her life due to poor circulation, but we received independent medical advice that this did not reflect unreasonable care. Although we did not uphold the complaint, we did make a recommendation in relation to the practice's complaints handling.

Recommendations

We recommended that the practice:

• provide evidence to the Ombudsman that staff receive advice and/or training in relation to responding to complaints from recently bereaved individuals.

Summary

Mr C runs a business that relies solely on customers visiting his workshop. He complained that work carried out by Scottish Water resulted in disruption to, and closure of, the road that provides access to the workshop. Mr C said that, as a result, he did not have any customers for a period of three months. The road works were originally scheduled to take two weeks, but were extended on more than one occasion. Mr C was dissatisfied with the reasons Scottish Water gave for the closure of the road and their rejection of his claim for compensation.

We accepted Scottish Water's position that the road works had to be extended due to the contractors hitting rock when excavating. We were satisfied that exploratory work had been carried out to assess the ground and that the delays to the work were unforeseeable. We were also satisfied that Scottish Water took reasonable steps to minimise the impact on Mr C's business by ensuring access remained possible to his property and by erecting 'business as usual' signs on the main road.

That said, we found that Scottish Water failed to communicate with Mr C about the extensions to the road closure. We also found that they dismissed his claim for compensation without passing on the details to their claims handlers in line with their customer charter.

Recommendations

We recommended that Scottish Water:

• pay Mr C £20.00 in line with their service standards in recognition of their failure to notify him of the delay to completion of the mains installation; and
• in line with their customer charter, pass Mr C's claim for compensation to their claims handlers for consideration in terms of the inconvenience caused.

Summary

Ms C and Mr C were unhappy that the Care Inspectorate had refused to investigate their complaints. They had told Ms C and Mr C that that the complaints were out of time, were not appropriate for the complaints procedure and were not complaints about the Care Inspectorate.

Ms C and Mr C had felt that there were reasons why the complaints should be considered outwith the normal time limit. Our investigation found, however, that the Care Inspectorate had considered the exceptional circumstances Ms C and Mr C put forward, and had explained why, despite these, they had decided that the complaints were out of time, as they were entitled to do. We also found that they had clearly explained why one of the complaints was not suitable for the complaints procedure and why one was suitable for the review procedure (which Ms C and Mr C had in fact used).

Recommendations

We recommended that the Care Inspectorate:

• should, for the avoidance of doubt, ensure that a complainant understands that other items not related to the review of their complaint may be considered at the committee.

Summary

Mr C owns a tenement flat in Edinburgh but has not lived there since June 2008. He told us that at that time he arranged with the Royal Mail to re-direct his mail, contacted the council’s revenues services about the change in liability for council tax and provided a forwarding address. In June 2010 he had registered with the council as a landlord, and day-to-day property matters were in the hands of a local property management company.

In February 2009, after Mr C had left the property, the council sent a notice to him and other owners under Section 24 of the City of Edinburgh District Council Confirmation Order Act 1991, telling them that repairs were needed to the property. Mr C only learned of the existence of the notice in 2012 when, in arranging a new mobile phone contract, he was told that the council had obtained an inhibition order against him because he had not paid the bill for these repairs, which were ultimately arranged by the council. Mr C was unhappy that despite telling the council that he had moved and giving them his forwarding address, he had not received contact about the repairs notice or the subsequent bill for the work.

Our investigation established that the council’s property conservation section wrote three letters to Mr C at the flat, firstly to inform him of the need for the works. They then said that in light of lack of action from owners the council would arrange repairs, and then in November 2009 they said that a contractor had been instructed with a start date, and provided the duration and indicative cost of the contract. None of these letters were returned undelivered. Some five letters were sent to the flat after the works were completed, in pursuit of Mr C’s share of the costs. Mr C received none of these and none were returned to the council. The council then put the matter in the hands of debt recovery agents who pursued action in the courts, culminating in the inhibition order.

We noted that Mr C had had his letters forwarded to his new address for a long period after he left the flat, and that none had been returned to the council undelivered. Our investigation found that the council had done nothing wrong and we did not uphold the complaint. We did, however, make a recommendation about making earlier contact with an absent owner’s property agent.

Recommendations

We recommended that the council:

• explore whether, before the initial service of accounts for works carried out under statutory notice, a check should be made of the public record for landlord registration to establish whether a property is being let out, to establish the contact address chosen by the landlord for the day-to-day management of the property, and to ask that the landlord make contact.

Summary

Mr C complained that the council failed to take adequate action after he reported noise nuisance from his neighbour. The council's anti-social behaviour case management procedure outlines the action the council can take in response to evidence of anti-social behaviour. This includes considering an acceptable behaviour agreement, making a referral to the mediation service, asking their noise team to monitor the situation, calling a case conference, joint working with their conflict resolution service, and issuing warning notices or advisory warnings.

We found that the council had issued warning notices to Mr C's neighbour and had signed him up to an acceptable behaviour agreement. The council also told us that Mr C did not engage with the conflict resolution team and had rejected an offer of mediation. There was evidence that the council's noise team had attended Mr C's property. Although this did not initially resolve the problem, we were satisfied that the council took action in line with their procedures.

Mr C also told us that a member of the council's staff incorrectly told him that that he would be rehoused quickly if he applied for other housing. We found no evidence that the officer had said this. However, the council had told Mr C that they would update him when they had investigated this, and although they did investigate, they failed to update him of this due to an oversight.

Mr C also complained that the council had accused him of failing to attend a meeting, when he had already told them that he would not be attending. However, we found no evidence of this.

Recommendations

We recommended that the council:

• issue a written apology to Mr C for the failure to inform him that the matter he had raised had been investigated and was considered to be concluded.

Summary

A company acting on behalf of Ms A complained about the management of her throat condition in hospital. They said that, during a tonsillectomy (surgery to remove the tonsils), the uvula (the tissue suspended from the soft palate) at the back of her throat had been removed. Ms A said that the quality of her voice had since changed and that she had difficulty swallowing. In response to the complaint, the board said that they had not removed the uvula but that atrophy (wasting away) of the uvula, while unusual, was a recognised complication of this operation.

Our investigation took account of all the available information, including all the complaints papers and Ms A's relevant medical notes. We also obtained independent advice from a consultant ENT (ear, nose and throat) surgeon, who considered the notes about Ms A's operation. The adviser was satisfied that both the operation and the aftercare given to Ms A were satisfactory. He said that in his view the uvula had not been removed but that rather Ms A's tonsillectomy had led to some scarring of her soft palate. He said that it was likely that this caused the soft palate to tighten, and led to Ms A's concern that her uvula had been removed and to the changes in her voice.

Recommendations

We recommended that the board:

• contact Ms A further in relation to addressing any continuing symptoms.

Summary

Mr C ran a bar and was aware that his water consumption was higher than other bars in the area. He said that he contacted Scottish Water and/or Business Stream to complain, but their engineers told him that there was no problem. He then decided to fit water saving taps. When the plumber switched off the water supply to complete the job, this also switched off the water supply to the flats above the bar. Mr C then realised that the water for the flats was being metered through the bar's supply. He contacted Business Stream, who told him to get the supply split as quickly as possible, as he was liable for the bills. They also said that he was unlikely to get a refund. Mr C had to employ two local plumbers to isolate the flats from his meter, and told us that Business Stream suggested that he sue his neighbours or the local council to get back the extra charges he had paid.

Mr C complained that Business Stream failed to recognise earlier that his meter also served the flats. However, our investigation found that Scottish Water is only responsible for the water main in a street and the communication pipe up to and including the stopcock at the boundary of a property. Property owners are responsible for the supply pipe from the stopcock into the property and all of the indoor plumbing. In addition, there was no evidence that Mr C contacted Business Stream or Scottish Water about his water consumption before he found that that the water for the flats was being metered through the bar's supply.

Mr C was also unhappy that Business Stream did not compensate him. He felt that they should have done so as the flats paid water charges with their council tax and he also paid these through his meter. We found that where a metered supply includes domestic properties, these properties should not pay separately for water services. Business Stream instead charges their business customer, in this case Mr C, for the metered usage. Mr C's neighbours should, therefore, have had a private arrangement with him to pay for their consumption. We noted that Business Stream's policy says that they cannot become involved in such disputes. However, we found that they should have provided Mr C with further advice about how he could pursue this with his neighbours and, although we did not uphold the complaint, we made recommendations to address this.

Recommendations

We recommended that Business Stream:

• provide Mr C with further advice on recouping charges from the domestic properties; and
• take steps to ensure that customers in similar situations are provided with adequate advice about recouping charges from domestic properties.

Summary

In 2005 the council granted planning consent for a developer to build 45 houses in a field in Mr C's village. A condition of the consent required the developer to submit a proposal to provide children's play facilities, and for any approved proposal to be implemented by the time the tenth property was occupied. Mr C complained that, although the development was almost completely built, no new play facilities had been provided. Rather, the council had accepted a payment from the developer to help improve an existing play area. Mr C said this decision was contrary to the planning conditions. He also felt that the council failed to consult with the local community about the developer's proposals, and a change in council policy that allowed the use of such contribution payments.

We were satisfied that the wording of the planning condition did not specifically require a new play area to be provided, and allowed for the improvement of existing facilities. We also found that new supplementary planning guidance specifically encouraged the use of contribution payments to improve existing facilities, as this was considered to provide better value than building new ones. Matters had also been complicated by the developer going into administration. In the circumstances, we felt it was reasonable for the council to consider other options, such as contribution payments, to ensure that play facilities were provided. We were satisfied that the local community was consulted on the introduction of the supplementary planning guidance that led to the introduction of contribution payments as a means of improving existing facilities.

We noted, however, that the tenth house had become occupied a few years ago. The developer should have had their proposed new play area in place by that time and we considered that the council could have taken enforcement action to ensure it was built. We recognised that enforcement action is a discretionary matter and the end result may not have been different. However, we were critical of the council for failing to show any evidence of having considered taking enforcement action or of having recorded their decision making.

Recommendations

We recommended that the council:

• ensure they have a process in place to consider whether enforcement action is necessary and to record their consideration of this.