Some upheld, no recommendations

Summary

We investigated a complaint about the audit of a further education college and an associated report. We found that there had been a change in the scope of the audit on the basis of legal advice but that a record of this advice had not been maintained. We also found that after the scope of the audit changed, a person who was previously advised they would be interviewed was not advised that this would no longer go ahead. Consequently, they were unaware of the progress of the audit until they were sent a copy of the report the day before publication. Audit Scotland acknowledged the issues with communication and there being no record of the legal advice during their own consideration of the case. Audit Scotland concluded that the person should have been informed at an earlier stage as this would have allowed them the opportunity to submit evidence for consideration. Audit Scotland also advised that as a result of their review of this case, they were considering their approach in engaging with people who have a clear interest in their work but are no longer employed by the organisation being audited. Our investigation highlighted some issues with complaints handling and found that in relation to one point, information Audit Scotland provided was misleading. We did not identify any other failings in Audit Scotland's approach in this case. We made a number of recommendations to address the issues highlighted.

Recommendations

What we asked the organisation to do in this case:

Apologise for the failings highlighted in this investigation, including providing inaccurate information. The apology should meet the standards set out in the SPSO guidelines on apology available at https://www.spso.org.uk/leaflets-and-guidance.

In relation to complaints handling, we recommended:

Complaints within correspondence should be identified and recorded as quickly as possible. If complaints are so closely linked to other concerns that they are to be dealt with together, the rationale should be explained to the complainant from the outset.

Complaint responses should be accurate and unambiguous.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

Summary

Ms C, an advocacy and support worker, complained on behalf of her client (Mr A) about the care and treatment he received at Ninewells Hospital. Mr A suffered an injury in which his fingertip was severed at the joint and he wanted to have surgery to have it reattached. However, he was referred for terminalisation surgery (where the finger is shortened and the remaining soft tissue is used to cover the amputated finger stump) instead. Following the surgery, Mr A experienced severe pain and his injury did not heal as quickly as he had hoped. Ms C complained that the board failed to provide Mr A with appropriate medical treatment and that nursing staff failed to appropriately assess and manage Mr A's pain before discharging him home.

We took independent medical advice from a plastic and hand surgeon, and from a nurse. The plastic and hand surgeon adviser considered that terminalisation surgery was the appropriate treatment for Mr A's injury. They explained that the outcome of reattachment surgery was likely to be poor and had higher risks than terminalisation surgery. Therefore, we did not uphold this aspect of Ms C's complaint.

The board accepted that Mr A's pain was not assessed and managed by nursing staff prior to his discharge and apologised for this. They explained that action had been taken to ensure learning from this case. The nursing adviser considered the nursing care was unreasonable so we upheld this aspect of Ms C's complaint. We asked the board to provide evidence of the action they have taken.

Summary

Mrs C, who is an advocacy and support worker, complained on behalf of her client (Mrs A). Mrs A was unhappy about delays in getting confirmation of an appointment with a consultant ophthalmologist (a doctor who deals with injuries and conditions in and around the eye). Mrs A was also unhappy with ophthalmology advice and treatment provided to her by the board.

The board acknowledged that Mrs A's clinic appointments were cancelled on a number of occasions and they apologised to Mrs A for the inconvenience this had caused. We found that, at the time, the board did not know that Mrs A's appointments had been cancelled so many times until Mrs C complained on her behalf. We found that the board had unreasonably delayed in confirming an appointment for Mrs A with a consultant ophthalmologist, and we upheld this aspect of Mrs C's complaint. The board provided reassurance that they were taking administrative steps and had recruited staff to stop such delays happening again. Given these steps taken by the board, we made no further recommendations in relation to this.

Mrs A was given different ophthalmology advice at her most recent clinic appointment from advice she had been given before. Mrs A felt she should have been given the new advice previously. We were satisfied with the board's explanation that the latest advice given to Mrs A was not a new type of treatment, but was a variation of the standard advice given for her eye condition. We did not uphold this aspect of Mrs C's complaint.

Summary

Mrs C complained about the care and treatment given to her late father-in-law (Mr A) after he was admitted to a GP led unit for rehabilitation after a fall. She said that he was not properly supported or cared for which caused him to fall again and break his hip, and that there was a delay in transferring him to hospital for an operation. As well as these concerns, Mrs C also complained about communication with the family and that Mr A's wife (Mrs B)'s views were not taken into account when Mr A's discharge was being considered.

We took independent advice from a GP and from a registered nurse. We found that, while Mr A's medical care was reasonable, including his care when he fell, there were gaps in his nursing notes which were unacceptable and represented a failure in the care provided. For this reason, the first of Mrs C's complaints was upheld. The board said that they had taken steps to ensure improvement in record-keeping, and we asked them to provide us with evidence of this. We did not make any further recommendations in connection with this.

Regarding Mrs C's complaint about communication, we found that Mr A lacked capacity and could not make decisions about his own care. We found that there was no power of attorney in place to do this on his behalf. However, we noted that there were detailed discussions with the family about Mr A's discharge and that Mrs B's views on this were taken into account. We did not uphold this aspect of Mrs C's complaint.

Summary

Miss C complained about the care and treatment provided to her late father (Mr A) at the Glasgow Royal Infirmary. Miss C also complained about communication between the hospital staff and Mr A and his family.

Mr A was seen by the ear, nose and throat department due to having an ongoing hoarse voice and was subsequently referred to the respiratory department. Mr A was started on medication to treat tuberculosis (a bacterial infection mainly affecting the lungs). Mr A was later admitted to hospital due to shortness of breath and it was found he did not have tuberculosis, but lymphoma (a type of cancer). Miss C complained that the board did not consider other possible diagnoses and this resulted in a delay in reaching the correct diagnosis of lymphoma. Miss C also had concerns that the consultants involved in her father's care did not fully take into account his inability to eat properly and the effect this may have had on his existing diabetes.

We took independent advice from a consultant respiratory physician. We found that it was reasonable and appropriate to consider tuberculosis as the most likely diagnosis, and that this was in line with national guidance. The advice we received is that the consultants were open to alternative diagnoses, and that they reasonably took into account the effect of his illness on his diabetic control. Therefore, we did not uphold this aspect of Miss C's complaint.

Miss C complained about communication between the hospital staff and Mr A and his family. We noted that the board had acknowledged and apologised that communication was not of a good standard, and they had discussed this with the relevant staff to determine how this matter could be improved. We upheld this complaint, but found that the board had appropriately taken action on this matter and therefore did not make any further recommendations.

Summary

Mr C complained about the length of time it had taken the board to provide him with treatment for varicose veins. Mr C was referred to vascular surgery at Victoria Hospital by his GP. Around four months later he saw a vascular consultant who said that he needed a special scan before treatment could be decided. He was told that there was a long waiting time for scans and that it was likely he would be seen approximately five months later, which Mr C said was contrary to relevant waiting times standards for treatment (18 weeks from initial referral to start of treatment). Ultimately Mr C received treatment seven months after his appointment with the vascular consultant, and 11 months after his initial referral. Mr C told us that the long delay had caused him considerable stress and that he was in pain on a daily basis. He also said that the board failed to deal with his complaint in a reasonable way.

We took independent advice from a nursing adviser with experience in surgical nursing care. We found that, whilst varicose veins is not considered an urgent clinical need, the waiting time from referral to treatment in this case was excessive (11 months) and clearly breached the relevant standards. We upheld this part of Mr C's complaint. However, we found that the board had already apologised and had taken measures taken to address the long waiting times and so we did not make any recommendations.

In relation to Mr C's complaint about complaints handling, we were satisfied that the complaint was dealt with in a reasonable time and that the response clearly reflected the position in relation to waiting times and reasons for the delays. We did not uphold this aspect of Mr C's complaint.

Summary

Mr C made reports to the council of breaches of planning control. Some action was undertaken but Mr C was concerned that correspondence with him, and the action being taken, stopped abruptly. After a gap of a few months, Mr C contacted the council again. He was told that the officer who had been responsible for his case had been absent from work on a long-term basis and that a review of their caseload had not uncovered the case Mr C was involved in as one requiring further action. The council apologised for this and began further action on the matter. Mr C continued to correspond and submitted information requests. He was dissatisfied with the council's actions and raised his complaints with us.

Mr C complained to us that the council did not take reasonable action following his reports of breaches of planning control. We took independent advice from a planning adviser. We concluded that the council's actions regarding the breaches of planning control Mr C reported were reasonable and we did not uphold his complaint about this.

Mr C also complained to us that the council did not respond reasonably to his correspondence or his complaints. We found that there had been delays and confusion around providing responses to Mr C. We upheld this aspect of the complaint. However, as the council had already taken steps to remedy these matters, we did not make any additional recommendations.

Summary

Ms C complained to the council that the head teacher of her son's primary school had failed to follow correct procedures when they contacted social services regarding concerns about her son. She also did not consider that the head teacher had communicated with her appropriately when they informed her of her son's potential exclusion from school during what she considered to be an informal meeting with the class teacher.

The council met with Ms C to discuss her complaint and confirmed in their initial response that the head teacher had acted appropriately in contacting social services following a disclosure made to a member of staff. The council confirmed that, in order to protect and maintain confidentiality, they were unable to discuss the nature of the disclosure with her. With regards to the meeting informing Ms C of the possibility of exclusion should her son's behaviour not improve, they confirmed that the meeting was in keeping with previous interactions she had with the school and was therefore appropriate and in line with their procedures. Ms C was not satisfied and brought her complaint to us. In addition to the complaints about procedures and communication, Ms C also complained to us that the council's response to her complaint was unreasonable.

We concluded that, based on the records taken at the time regarding the disclosures made by Ms C's son, the head teacher had acted appropriately in contacting social services to discuss the concerns. We found that the head teacher acted in line with child protection policy and, given the nature of the disclosures made, was correct in not sharing the details with Ms C. In relation to the separate and unrelated matter of the potential exclusion of her son, it was clear that the school had complied with relevant policies regarding the management of pupil behaviour and that the communication with Ms C was appropriate in the circumstances. We concluded the council had acted appropriately and did not uphold these aspects of the complaint.

With respect to the complaints responses issued by the council, we found that their two stage two complaints responses were issued a several days outside of the required timescales and that they did not communicate the delays with Ms C. We upheld this aspect of the complaint and, while we did not make a recommendation, we requested that the council remind staff who deal with complaints of the importance to comply with timescales and communicate with complainants effectively.

Summary

Mr C, who is a community activist who supports and acts on behalf of people in his local area, complained about the housing association's investigation of a complaint that he had made on behalf of a neighbour (Mr A) regarding a housing officer. The association confirmed that they had arranged a meeting between Mr A and the housing officer, during which the concerns which Mr C had raised were discussed. We considered that this was a reasonable response and we did not think that any further investigation was necessary. We did not uphold this complaint.

Mr C also complained that the association's communication with him was unreasonable. In particular, he considered that the area housing manager should have met with him after he requested a meeting to discuss the complaint mentioned above. He also complained that a letter from his MSP was not properly dealt with. After Mr C raised concerns about the area housing manager's failure to respond to his concerns in full, the area director responded to him. We considered it appropriate for matters to have been passed to the area director, and considered that the director's response to Mr C was reasonable. We noted that after Mr C's MSP contacted the association they arranged a meeting with the MSP and Mr C, but this was cancelled at Mr C's request. We considered the association's actions to have been reasonable and did not uphold this complaint.

Mr C also complained that the association had requested photographic identification with representation mandates. He said that he had never been asked for identification before and that he thought the association were trying to be obstructive. The association said that previous guidance to staff had confirmed that photographic identification was required, but advised Mr C that they had changed their process and apologised for any upset or inconvenience caused. The association provided us with a copy of the staff guidance in place at the time, showing that photographic identification was required. We did not uphold this complaint.

Summary

Mr C, who is a local councillor, complained on behalf of his constituents (Mr and Mrs A) who are tenants of the housing association. Mr C complained that the association failed to fully reinstate the tenants' garden following repairs to a water pipe that was carried out in their back garden. Mr C also complained the association failed to fully investigate their complaint and to contact them to discuss their concerns at the final stage of the complaints procedure.

The association repaired the section of the garden they damaged by reseeding and laying down extra chips. However, the grass died away and the garden became muddy. The association inspected the garden and concluded that it was likely that the broken pipe was acting as a drain away system for the rainwater, and now the pipe was repaired, the garden was more likely to flood. The association confirmed that they would not carry out any further remedial works.

We found that the association carried out the appropriate level of repairs to the garden and that the garden flooding was not a direct result of their repairs. We did not uphold this complaint. The association acknowledged that they should have contacted Mr and Mrs A to further discuss their complaint at stage two of their investigation. We upheld this complaint and provided some feedback for the association to note.