Not upheld, recommendations

Summary

Mr C complained about what he considered to be a lack of action by the council with regard to the operation of a local quarry. Planning permission was granted subject to a Section 75 agreement in 2009 for an expansion of the quarry operation. A Section 75 agreement is a legal agreement about financial contributions to meet the services and infrastructure needs of the local community associated with a new development. Mr C complained that the quarry company carried out works required as a condition of the 2009 planning consent before that consent was in place. He considered that the council failed to take action in relation to this work.

The work in question concerned the expansion and improvement of a local road, used by lorries visiting the quarry. The upgraded road surface meant that lorries could travel at higher speeds. This caused particular concern, as the road ran adjacent to a children's playground. As planning permission and Roads Construction Consent were not yet in place, the council could not oversee the improvement works. We found that the quarry company had a responsibility to maintain the road and that it would be inappropriate for the council to take action until such time as the works strayed into the realm of 'upgrading' rather than maintenance.

The council demonstrated that they passed on residents' concerns to the quarry company and when the work did become 'upgrading,' they reached a conscious decision not to take the enforcement action that was available to them. We were satisfied that, in reaching this decision, the council considered all of the relevant information. While we did not find that the council delayed taking action, we considered that the situation may have been different had the council not told the quarry company up-front that their planning application had been granted. We highlighted that it is good practice to adopt the 'minded to grant' style of decision where Section 75 agreements are required.

Mr C also complained that the council failed to take enforcement action following reports that the quarry company breached conditions relating to an earlier planning consent. We did not uphold this complaint, as the council were able to demonstrate that they had considered relevant information when exercising their discretion not to take enforcement action.

Recommendations

We recommended that the council:

• review their procedures in relation to the processing and determination of planning applications requiring Section 75 agreement to adopt the 'minded to grant' style of decision; and
• clarify their interpretation of what constitutes 'operations' at the quarry.

Summary

Mr C complained that a hospital unreasonably cancelled his late partner (Ms A)'s heart bypass surgery scheduled for May 2010. He also complained that the hospital did not take appropriate remedial action following a report commissioned by the Procurator Fiscal's Office.

Our investigation found that Ms A, who had a history of heart and other health issues, had a second heart attack in February 2010. She was assessed and was first admitted for heart bypass surgery in April 2010, in late May 2010. Although the surgery was successful, Ms A developed complications and died five days later.

Our investigation found that the hospital cancelled all elective (non-emergency) surgery in early May 2010 due to the sudden death of a senior colleague of the team who died in the unit on the day Ms A's surgery was scheduled. The hospital decided to cancel elective surgery as members of staff in the unit were affected by their colleague's death.

We took advice from our medical adviser, a cardiothoracic surgeon (a specialist in surgical treatment of organs found inside the chest). Our adviser said that due to the unusual circumstances it was not unreasonable to decide to cancel elective surgery. Our adviser reviewed Ms A's medical notes and was of the opinion that there had been no deterioration in her condition between her discharge and her readmission for surgery. He was of the view, therefore, that the delay had no bearing on the eventual outcome.

Throughout the complaints process the hospital assured Mr C and our office that a 'careful assessment' had been made of the conditions of all the patients who were discharged that day, including Ms A. Our findings did not support those assurances. Our adviser described the discharge entry in Ms A's notes as 'perfunctory and brusque'. We were concerned that the note contained no references to any examination of Ms A, to test results, or to any standard observations such as pulse, temperature, respiration rate etc. Although we did not uphold the complaint about the decision to cancel surgery in early May 2010, we made two recommendations in relation to the failings found in the discharge process and assessment.

On the matter of the report commissioned by the Procurator Fiscal's Office, the adviser said that the hospital's response to Mr C was reasonable. They noted that one issue raised in the report (the level of a blood clotting agent in Ms A's blood three days after surgery) had not been addressed in the response. However, the adviser was satisfied that staff caring for Ms A took appropriate action and that there had been no failure in care and, therefore, no need for any remedial action. The report for the Procurator Fiscal's Office did not find any evidence of service failure and made no recommendations for remedial action. We agreed that no remedial action was required.

Recommendations

We recommended that the hospital:

• review the discharge processes where surgery is cancelled or postponed for non-clinical reasons and ensure that appropriate examinations are made and recorded; and
• reflect on the quality of their responses on the specific issue of the assessment said to have been done before the patient was discharged and issue a written apology for the failings identified.

Summary

Mr and Mrs C complained about comments that they said a council officer had made about Mr C. The council initially dealt with the complaint through the statutory social work complaints procedure and upheld it. However, after taking legal advice the council decided that the complaint had been outwith the remit of that procedure and had it investigated by a council officer instead. Mr and Mrs C were unhappy with the outcome of that investigation.

Our investigation found that the legal advice said that, as Mr and Mrs C's complaint did not relate to the provision of a service, it should not have been considered by the statutory social work review committee. The council were entitled to seek legal advice, and to decide whether to accept all or part of that advice. However, we were critical that they had not obtained it before having the matter considered by the statutory social work review committee. We were also concerned about the length of time that it took before the council officer's investigation was completed, and made a recommendation about this.

Recommendations

We recommended that the council:

• apologise for the delay and poor handling of the complaint.

Summary

Mr C said that when considering a planning application the council failed to take into account a number of policies in the local plan for the area. He said that this was wrong, and that the council should also have asked the applicant to submit the planning application and the application for listed building consent together.

We reviewed the planning report, the relevant policies within the local plan and the legal framework under which decisions are made and recorded. We noted that the planning officer's report to the committee did not document all relevant policies. However, we were satisfied that the issues highlighted in these policies were taken into consideration. We were also satisfied that listed buildings consent need not be applied for at the same time as planning consent.

We did not uphold the complaint but we made a recommendation about the information that should in future be in officers' reports.

Recommendations

We recommended that the council:

• review the way they produce and document reports to the planning sub-committee to ensure that these properly, and fully, reflect the policy considerations required by the local plan.

Summary

Ms C was living in temporary accommodation. She complained that the council unreasonably failed to consider her personal circumstances when they made offers of permanent housing in an area that was not her first choice.

During our investigation we found that, due to a severe lack of suitable properties, the council was unable to offer a permanent house in Ms C's preferred area. We found that they had offered two properties that they considered met her assessed needs, and which were in the nearest town to her area of choice. This meant that the council had discharged their statutory duty to Ms C as a homeless applicant.

We found no evidence that the council had failed to properly handle her application, however, we were concerned about the length of time she had spent in temporary accommodation.

Recommendations

We recommended that the council:

• apologise for the delay in offering Ms C a permanent house.

Summary

Mr C was unhappy about the council's decision to withdraw his children's school transport provision. He complained about the process followed by the council in reaching this decision, and about the the council's handling of his appeal.

During our investigation we found that the council had measured the distance between pupils' homes and their schools in preparation for the introduction of a new policy on school transport. As a result of the new measurements the council decided that Mr C's children were no longer entitled to free school transport as his house was less than a mile from the school. As this was a decision they were entitled to take, and there was no evidence of anything going wrong in the taking of the decision, we did not uphold the complaint.

We also found that as Mr C had disputed the measurements, the council decided to measure again during the appeal process. Mr C thought that the council should exercise their discretion in the circumstances and provide the transport, but the further measurements showed that his home was still outside the tolerances within which they could do this. Mr C still disputes the measurements but the evidence available demonstrated that the decision on the appeal was taken after considering all available information. However, while information on the appeal process had been given to Mr C we felt that it was not clear that the committee taking the decision could seek further clarification during the appeal meeting. We made a recommendation to address this matter.

Recommendations

We recommended that the council:

• explain in the leaflet outlining the process at the education and children's sub-committee that following the closing submissions, clarification of information may be sought by the sub-committee before reaching their decision.

Summary

Mrs C complained that the board had not explained bruising on her son's chest and neck after he came out of the operating theatre following a procedure. She said that her son (who has a blood disorder) had undergone the procedure regularly over the past eight years but had never sustained bruising. She was also concerned that the board's response to her complaint was contradictory.

The board told Mrs C that the likely cause of the bruising was a combination of force used to remove heart monitor stickers and her son's blood disorder. The board explained that the blood disorder was likely to have been a contributory factor to the bruising on the neck area as no stickers had been placed in this area and it appeared Mrs C's son had been lying on the heart monitor lead during the procedure.

We took advice from our medical adviser, a specialist in working with children with blood disorders. He advised that the most likely cause of the bruising on the chest area was the normal amount of force needed to remove the heart monitor stickers, which was made worse by Mrs C's son's blood disorder. He also considered that the bruising on the neck was likely to have occurred as a result of her son's lying position on the wires during the procedure.

We accepted this advice and did not uphold the complaint, but we made a recommendation to ensure that in future parents are aware of the possibility of such bruising.

Recommendations

We recommended that the board:

• ensure that parents and carers of children with low platelet counts are warned, either at general counselling stage or when seeking consent for an operative procedure, about the possibility that mild to reasonable force could cause unnaturally severe bruising.

Summary

Mrs A was admitted to hospital on numerous occasions in the two years before her death. She had a complex medical history and tested positive for a bacterial infection, Methicillin-resistant Staphylococcus aureus (MRSA), on six occasions during that time. Mrs A's daughter (Mrs C) complained that the board failed to investigate the cause of her mother's MRSA and to successfully treat it.

Our investigation found that the cause of Mrs A's MRSA was appropriately investigated and successfully treated on each occasion she tested positive and we did not uphold the complaints. We noted that the board acknowledged there was poor communication with Mrs C and other members of Mrs A's family about MRSA and how it was being treated. The board apologised to Mrs C for this, and addressed the issue with staff on relevant wards in the hospital.

Although we did not uphold the complaints, we were concerned about problems in the record-keeping and made a recommendation to address this.

Recommendations

We recommended that the board:

• share our adviser's comments with staff involved in Mrs A's case, and ensure that records are kept in line with Royal College of Physicians and Nursing and Midwifery Council guidance.

Summary
Mr C took over business premises in September 2009 and was advised that the water bill was paid as part of his business rate. Shortly afterwards, a water meter was fitted and he was told that he would be informed when it came into operation. Mr C heard no more until October 2011 when he received a bill from Business Stream.

Our investigation confirmed that in October 2009 Scottish Water installed a meter but failed to pass on this information to Business Stream. About two years later, as part of a routine audit, Business Stream established that a meter was in place. They read it and issued a bill for the water used. As it was clear from our investigation that the actions complained of were in fact those of Scottish Water and not of Business Stream, we did not uphold the complaint.

We did, however, make recommendations to Business Stream, and asked them to alert Scottish Water to these, given the circumstances in which the complaint arose.

Recommendations
We recommended that Business Stream:
• make Scottish Water aware of our criticism in this matter;
• satisfy themselves that the lines of communication between themselves and Scottish Water are sufficiently robust to prevent a recurrence of the problem; and
• extend Mr C's repayment period by a further 12 months.

Summary
Mr C studied remotely for a masters degree. He was required to write a dissertation over a period of two years. He proposed a topic for his dissertation and began work on it, supported by his allocated supervisor. Mr C said that he came to realise that his chosen topic had certain limitations. He requested a change of topic but was told that this would not be possible and that he would have to complete the original dissertation or withdraw from the programme. He completed the dissertation but failed. Upon being allowed to resubmit his dissertation, he again asked about a change of topic, but was again refused.

Mr C complained that his change of topic was refused based on time constraints, but felt that there was ample time to complete the required work. He believed he would have passed his masters programme had he been allowed to change topic to one more relevant to his experience and interests.

We found that, although the university's guidance does not mention a specific procedure for considering such requests, it makes it clear that the university has the ultimate say on whether a topic is acceptable. We found that Mr C was told that it was possible to change topics and that the decision was his. However, after submitting his proposed timeline, he was advised that he could not do so. He was told this in good time for completing the required work. After he asked if he could change topics for his resubmission, he was told that this was an option, but was strongly advised against changing due to the lack of support that would be available to him. We found that it was Mr C's choice not to change at this stage.

We did not uphold Mr C's complaint as we were satisfied that nothing went wrong in the university's process when making the decision not to allow Mr C to change dissertation topics. We did, however, make a recommendation as, although they reached their decision quickly and did not alter it, we recognised that some of their communication with Mr C was confusing.

Recommendation
We recommended that the university:
• include in their guidance documents information on the consideration process following requests from students to change dissertation projects.