Not upheld, recommendations

Summary
Mr C complained that the council unreasonably refused to acknowledge or investigate a failure of their neighbour notification system regarding a planning application for a development in his area. He said that when he and three of his neighbours did not receive notification of the proposed development he complained to the council. Mr C said that the council claimed that there had not been a failing in their system and refused to investigate the matter. Mr C felt that they had not tested what went wrong with the neighbour notification system, despite his evidence that showed the system was failing. Mr C provided copies of his communications with the council.

The council’s view was that they had complied with their neighbour notification system. They provided evidence to demonstrate that this was the case. They said they do not have a statutory obligation to investigate failures in the system beyond what is set out in law and there is no statutory requirement for them to find out whether there was a substantial body of evidence that notification had not been carried out.

In looking at Mr C’s complaint, it was not our role to determine whether there was a systemic failure by the council to carry out neighbour notification, but to determine whether Mr C's complaint about alleged systemic failure was handled correctly. We found that in terms of general complaint handling, it was reasonable for the council not to launch an investigation into alleged systemic failure on the basis of one complaint that one neighbour did not receive notification. (It was alleged but not proven that this also occurred to another three neighbours and we noted that the other three neighbours did not complain to the council.) However, while the council's decision not to investigate further was reasonable, their response about when a reported neighbour notification failure would warrant further action was vague and unclear. Although we did not uphold Mr C's complaint, we made the following recommendations.

Recommendations
We recommended that the council:
• provide clarification, to Mr C and this office, of what they mean by a ‘substantial body of evidence’ and provide details of the steps they would take to investigate any substantial failings; and
• feed back this clarification and our views on this case to the planning staff who deal with complaints about neighbour notification.

Summary
Mrs C said that for eleven years she had been prescribed MST (morphine sulphate based medication) but had received a letter from her medical practice saying that the drug would no longer be prescribed. Mrs C complained that she had asked for the decision to be reconsidered but was told it was final. Mrs C said that because of the decision to stop her prescription she suffered very badly from withdrawal symptoms.

As part of our investigation, we discovered that the medical practice had received anonymous information alleging that Mrs C was selling her MST tablets. Because of this the practice requested a toxicology report on a urine sample. This did not show the presence of opiates and so the medical practice considered that it was reasonable to stop prescribing them. As it appeared that Mrs C was not taking the MST prescribed to her, the practice also considered it unlikely that she would have suffered withdrawal symptoms. We did not uphold the complaint but we made a recommendation to the practice.

Recommendation
We recommended that GPs at the practice:
• in future similar cases should seek patient consent before a toxicology screen is requested.

Summary
Mr C complained that the board failed to reimburse his travel expenses in respect of two appointments at a hospital in England in June and October 2010. Our investigation found that the board had in fact arranged and paid for Mr C's travel in June, but that he had chosen to make alternative and unnecessary arrangements for another date. We considered that it was reasonable for the board not to reimburse Mr C's expenses in those circumstances. With regard to the October appointment we found that the board had told Mr C before he travelled that they did not support this treatment and would not refund his expenses. As travelling expenses require the approval of the board we did not uphold this complaint.
 

Summary
The university awarded Mr C a third class honours degree. When he reviewed his marks, he found that in three of the courses he had achieved a common assessment score of 11. He understood that, if he had achieved a mark of 12 in any of the courses, he would have been awarded a 2:2 degree overall. Mr C drew this to the attention of his subject department, and it was discovered Mr C should have been treated as a ‘borderline’ student, and had his course papers reviewed by an external examiner.

Mr C appealed through the university appeals process. The university corrected the procedural irregularity and arranged for Mr C’s work to be reviewed by an external examiner. Mr C also felt that, as a borderline student, he should have the opportunity to be invited for viva (an oral examination). The external examiner, however, confirmed that Mr C’s work demonstrated a third class performance, and said that Mr C was not eligible for viva. Mr C went to the final stage of appeal and requested a hearing, but this was refused on the grounds that his appeal was based on academic merit rather than other mitigating or extenuating circumstances.

Although the Ombudsman cannot consider matters of academic judgment (such as the level of degree awarded) we reviewed whether the university followed its procedures correctly, and whether it had returned Mr C to the position in which he would have been but for the error occurring. We found that the university did so, that the review by the external examiner was appropriate and sufficient, and that Mr C did not meet the criteria set to be invited for viva. We did not uphold his complaint, although we did recommend that the university apologise to him for their initial failure to correctly follow their procedure, as there was no evidence that they apologised during the appeals process.

Recommendation
We recommended that the university:
• provide Mr C with a full apology for initially failing to follow the examination procedure correctly.
 

Summary
Ms C was given treatment for toothache by a dentist. Ms C complained that the filling was too close to the nerve and resulted in ongoing pain. In addition, she complained that she called the dental practice a few weeks later but no follow-up treatment was provided by the dentist and she had to seek further treatment from a different dentist.

Our investigation found that the first dentist had carried out a comprehensive clinical examination and that it was likely the toothache was caused by damage already done to the nerve as a result of a deep cavity. Furthermore, we did not find any evidence to support Ms C's position that she had contacted the dentist after the initial treatment. We did, however, make a recommendation to the first dentist about record-keeping.

Recommendations
We recommended that the practice:
• ensures that more detailed information is noted in the patient's clinical records in relation to presenting symptoms and treatment given.

Summary
Mr C complained that his mother, Mrs A, had received inadequate care and treatment during two accident and emergency admissions and discharges to a hospital that served a rural area. Mr C was also dissatisfied with the facilities in the wards, staff communication and attitude. Mr C also stated that an out-of-hours doctor wrongly diagnosed Mrs A's medical condition.

Our investigations concluded that Mrs A received proper care and treatment from clinical staff at the hospital. We also concluded that the out-of-hours doctor had not wrongly diagnosed Mrs A's condition. We also found that the board had responded reasonably to Mr C’s complaints.

We did not uphold any of the complaints. However, we did make two recommendations, one about about Mr C's participating in a significant events analysis and one about record-keeping. We noted that before Mr C brought this complaint to us the board had apologised to Mr C for the issues he had raised with them on his mother's behalf.

Recommendations
We recommended that the board:
• ensure that the GP reflects on his procedure regarding the assessment of elderly patients and arranges a Significant Events Analysis (SEA) for this issue; and
• ensure that the GP's written records comply with NHS record-keeping guidelines.
 

Summary
Mr C complained that his partner was falsely accused of exposing her breasts to him, in the presence of her teenage daughter, during a closed visit. The matter came to Mr C's attention when his partner received a visit from social work. He also complained that the SPS failed to properly investigate his complaint in this regard as they had not viewed CCTV to substantiate the allegation.

We asked the SPS about this incident. They confirmed that there was no direct camera coverage in the closed visit area at the time in question so no CCTV footage existed. As such, there was no evidence to establish what happened on the day so we did not uphold that complaint, nor his complaint about CCTV footage not being viewed.

However, as a result of the complaint, it came to our attention that the SPS had not told Mr C or his partner that the matter was being referred to social work. In addition, the completed child welfare report was not countersigned by a line manager. As SPS policy dictates that both of these should have occurred, we recommended that SPS highlight the relevant policy (GMA 25A/04) to staff.

Recommendations
We recommend that Scottish Prison Service:
• highlight the relevant policy to staff and remind them of their duty to inform the carer/prisoner when referring matters to social work; and
• remind line managers that they must countersign any completed child welfare reports.
 

Summary
Mr C, who is a prisoner, complained that he was wrongly put in double handcuffs on a particular occasion and that the reasons for this had not been explained to him. Double handcuffs are a more secure version of normal single handcuffs. Despite extensive enquiries, we could not find any evidence of the type of cuffs used. We are an independent body and, therefore, cannot simply take one person's account in preference to that of another without firm, objective evidence. We, therefore, did not uphold the complaint although we made recommendations to try to avoid similar issues arising in future.

Recommendations
We recommend that Scottish Prison Service consider adding a box to the Personal Escort Record about what type of cuffs should be used.

We recommend that Reliance Custodial Services review certain aspects of their complaint handling and take action to prevent a recurrence.

Summary
Mr C complained that funds received by the Sheriff Court, and ultimately due to him, were not placed in an interest bearing account immediately. He said that this meant he was deprived of interest on the money. When we investigated, we found that the Scottish Court Serice passed the funds to the bank well within the ten days required by law. Any delay after that was not on the part of the SCS and so was not something that we could consider. Although we did not uphold Mr C's complaint about SCS we found that they had not handled it well. We therefore recommended that they apologise to Mr C for this, and take steps to ensure that their staff are aware of the complaints procedure.

Recommendations
We recommend that Scottish Court Service:
• apologise to Mr C for the way they handled his complaint; and
• take steps to ensure that all staff are fully aware of the SCS complaints procedure, and that staff provide information about escalation to the next step and the Ombudsman appropriately.

Summary
Ms C, who is a telephonist, suffered an acoustic shock incident at work for which she needed medical treatment. She was unhappy with the care and treatment she received from the Board and the way they handled her complaint. During a consultation with a specialist, Ms C described the pain in her ear, head and neck. She also described how noise and/or examination made her symptoms worse. The specialist told Ms C's GP that Ms C had suffered an acoustic shock and that the description of the pain sounded like muscle tension. He also said that Ms C had tinnitus and that this was difficult to tie in with acoustic shock, although it was also difficult to say what else might have caused the problem. Ms C complained that this diagnosis was not reasonable and that the Board's subsequent investigation of her complaint was inadequate. After taking advice from one of the Ombudsman's professional medical advisers, we found that the specialist's conclusions were reasonable in the circumstances. We also found that the Board's investigation of the matter was appropriate. Ms C had said she felt that certain clinical aspects of the complaint should have been subject to independent review and that this was missing from the Board's investigation. We explained to Ms C that the second stage of the NHS Complaints Procedure (investigation by our office) provides the independent and impartial examination of the clinical information that she wanted.

Recommendations
We recommended that Tayside NHS Board ensures the doctor concerned has established a tinnitus protocol for his patients.