Some upheld, recommendations

Summary

Mr C complained about the council's handling of a planning application for the development of a local sports ground. Mr C said the council's report to the development management sub-committee contained significant errors and omissions and that, as a result, the committee did not make its decision on the basis of all the material considerations as required by law. Mr C listed eight separate areas where he considered there to be failings by the council. This included that there was an unreasonable failure by the council to adequately assess the information provided by the applicant about the height of the stadium, the size (footprint) of the development and attendance figures, and to ensure that this was correct. Mr C also said the council unreasonably failed to have regard to, and report properly on, the independent report obtained by consultants on the methodology used in the transport submission to the planning application.

We obtained independent advice on Mr C's complaint from a planning adviser. Our adviser did not find failings by the council in six of the eight areas identified by Mr C in his complaint. On the first of the remaining two areas, our adviser considered that the council did not unreasonably fail to adequately assess the information provided by the applicant about the height of the stadium, the size (footprint) of the development and attendance figures, and ensure that this was correct, so we did not uphold this complaint. However, our adviser was concerned about the planning report's lack of clarity in relation to the height dimensions detailed in Mr C's complaint so we made a recommendation to address this.

On the second matter, we accepted the council's view that they were not required to include every detail of the consultants' report in their planning report. However, we were concerned that, having commissioned an external assessment by consultants on the transport methodology used in this case (in response to concerns raised about the way in which the transport impacts of the proposed development had been handled by the council) the council did not adequately report the consultants' views in their planning report to committee, so we upheld Mr C's complaint about this.

Recommendations

We recommended that the council:

• ensure that staff are aware of the need to provide appropriate descriptions/definitions of the dimensions being used in planning reports to committee;
• feed back our decision to the staff involved in this case; and
• provide Mr C with a written apology for the failings identified.

Summary

Mr C complained about the council's handling of his social work complaint. The council convened a social work complaints review committee (CRC) to hear Mr C's complaint, but did so on the basis of written submissions from both Mr C and the social work department, rather than allowing Mr C to attend in person. Mr C complained to us about the appropriateness of the decision to hold the hearing in private and also about the overall delay in responding to his complaint. In addition, he complained that the council had failed to provide appropriate reasons to support the eventual decision not to uphold his complaint.

We considered that the council had taken reasonable steps in order to ensure that a fair and balanced review of Mr C's complaint was carried out. They had undertaken an assessment of the risks involved in him attending the CRC meeting in person, and Mr C and the social work department were given equal opportunity to submit written representations. We were satisfied that this fulfilled the council's statutory obligations, and that their decision to hold the hearing in private did not contravene the relevant directions. We did not uphold this aspect of the complaint.

However, we were concerned with the level of information provided to Mr C by the council in support of the decision. We considered it reasonable to expect a fuller explanation of the reasons underpinning the decision to have been provided, particularly as Mr C was not given the opportunity to attend the hearing. Further, while we noted that this case raised particular challenges for the council, we considered that the overall time it took them to respond to Mr C's complaint was unreasonable. We upheld these two aspects of the complaint.

Recommendations

We recommended that the council:

• apologise to Mr C for failing to provide full and appropriate reasons for the decision not to uphold his complaint;
• provide Mr C with a more detailed explanation of how the CRC arrived at their decision not to uphold his complaint;
• apologise to Mr C for the unreasonable delay in responding to his complaint; and
• review their handling of Mr C's complaint with a view to identifying learning points and ensuring future compliance with their statutory obligations.

Summary

Ms C complained to the council that trees at the rear of her property were blocking sunlight into her back garden. Ms C was not happy with the council's response, and so she complained to us that the council failed to prune or remove the trees, and about the council's handling of her complaint.

We found that the council's tree and woodland management policy, while acknowledging that trees could create inconvenience for residents, stated that, as a general rule, pruning or removal works would not be carried out due to restriction of sunlight, unless it was judged to be excessive. In the professional opinion of council officers who assessed the trees the restriction was not excessive, taking into account the health of the trees and their position. Ms C disagreed with this assessment. However, we explained to Ms C that her disagreement was not evidence of a failing on the part of the council, and that it was not for us to determine whether there was excessive sunlight restriction. We did not uphold this complaint.

We had some concerns about the time taken by the council to respond to Ms C's complaint, about the records kept by the council about site visits to the trees, and about the level of detail and explanation in the council's final response to Ms C. We also found that the council's written responses to Ms C did not explicitly deal with the key issue of restriction of sunlight. Therefore, on balance, we upheld this aspect of Ms C's complaint.

Recommendations

We recommended that the council:

• remind staff that written replies to complaints must explicitly respond to the key issue(s) raised.

Summary

Mrs C complained about the council's decision not to allow her child to delay starting primary school. Mrs C was concerned that her original application for this had not been considered and that the council were unaware of this error until she raised it with them. Mrs C did not consider that the council had provided her with accurate information about delaying entry to primary one, or that they had shown that a proper assessment of her child's needs had been carried out. Mrs C also complained that the council had not followed their complaints handling procedure.

Following our investigation, we upheld Mrs C's complaint that the council had not dealt with her application properly and noted that they had already provided her with an apology for this. We found that there was no system in place to confirm that all applications submitted via schools had been logged at the council's central pupil placement department. We upheld Mrs C's complaint about the information she was provided with as we found that this was confusing and lacked clarity. The complaint about the handling of her concerns was also upheld. We found that the council had already acknowledged this failing and apologised to Mrs C.

After considering her concerns about the assessment of her child's needs, we found that there was evidence that this had taken place and, although this could have been better communicated to Mrs C by the council, we did not uphold this part of her complaint.

Recommendations

We recommended that the council:

• consider the introduction of a system to confirm with schools that all submitted applications have been logged by the pupil placement department;
• confirm that the difference between deferment and a retained year will be clearly explained in the next revision of their guidance;
• consider the benefits of separating the deferment and retained year application process to avoid confusion in future;
• ensure that accurate information about routes for resolution is provided at an early stage;
• ensure that the reasoning and final decisions reached on such applications are formally recorded; and
• raise awareness amongst staff in the education department of the definition of a complaint and when their complaints handling procedure should be used.

Summary

Mrs C complained on behalf of her father (Mr A). When Mr A moved out of his property, the council had sent him a bill for rechargeable repairs. Mrs C appealed the bill. The council told her that the charges were accurate and that she had completed their complaints procedure.

When Mrs C brought her complaint to us, we asked the council for a copy of their final complaint response. The council told us that the complaint had not been logged or responded to in line with the complaints procedure. In the circumstances, we referred Mrs C back to the council for them to provide a full and final position, and closed the complaint.

Mrs C then returned to our office. We found that the council had still not responded to her complaint and so we upheld her complaint that it had not been reasonably handled. We made recommendations to address this.

However, regarding the charge for repairs, we found that Mr A had told the council he wanted the repairs completed and agreed to them being recharged to him. Therefore, we did not uphold this complaint.

Recommendations

We recommended that the council:

• reflect on why Mrs C's complaint was not responded to appropriately and how to prevent this in future;
• remind the staff involved in this case of the complaints procedure; and
• apologise to Mrs C for the failings identified.

Summary

Mr C, a solicitor, complained on behalf of his client (Mr A) that the council had failed to adequately consider Mr A's request for a disabled person's parking bay. We found that the council had adequately considered Mr A's application and had considered both his own and his wife's medical circumstances. The decision to refuse the application because a disabled person's parking bay had already been installed at the rear of Mr A's property was a decision that the council were entitled to take. In view of this, we did not uphold the complaint.

That said, Mr C also complained about how Mr A had been notified of the decision on his application. The council's process for applications for a disabled person's parking bay clearly states that the council should advise the applicant in writing that either the request has been forwarded to the roads service for consideration or that the applicant does not meet the criteria. The council had referred Mr A's application to their roads service for consideration, but they had failed to notify Mr A of this in writing in line with their process. The council had then phoned Mr A to tell him that they had refused his application, but there was subsequently some confusion for both Mr A and the council about whether a decision had in fact been made. In view of this, we upheld this complaint.

Recommendations

We recommended that the council:

• take steps to ensure that applicants for a disabled person's bay are notified in writing that either the request has been forwarded to the roads service for consideration or that they do not meet the criteria;
• consider whether the procedure should be amended to state that applicants should be notified of the final decision in writing; and
• issue a written apology to Mr A.

Summary

Mrs C was scheduled to undergo a flexible sigmoidoscopy (a procedure whereby the rectum is examined by a camera). She had experienced pain during a similar procedure in the past and said that she requested sedation. Mrs C complained that, when the surgeon arrived, he advised that she would not require sedation and started the procedure. Mrs C experienced pain during the procedure and asked for sedation, however, the surgeon carried on. Mrs C was subsequently diagnosed with a perforated bowel. She complained that her requests for sedation before and during the procedure were ignored. Mrs C also complained that the board failed to answer points raised in her formal complaint regarding the procedure.

We took independent medical advice from a consultant general and colorectal surgeon. We found that Mrs C's records indicated she consented to the procedure commencing without sedation, so we did not uphold this aspect of her complaint. However, her care plan noted that she may require sedation during such a procedure so we were critical of the board, as the surgeon proceeded with the procedure despite Mrs C's discomfort and requests for sedation. This went against pre-operative advice given to patients that they can ask for the procedure to be halted at any time and request sedation. We concluded that the surgeon proceeded based on what he considered was best for Mrs C, rather than taking her own views into account.

Whilst we were satisfied that the board responded to the questions that Mrs C raised in her complaint, we considered that the response failed to demonstrate that her core concerns had been taken on board and appropriate action taken to avoid similar problems for other patients.

Recommendations

We recommended that the board:

• bring the failings our investigation has found to the attention of the surgeon for reflection as part of his next annual appraisal;
• remind relevant surgical staff of the contents of the patient leaflet, including that the patient may request sedation at any point; and
• issue Mrs C with an apology, acknowledging that it was not acceptable for the surgeon to override her request for sedation.

Summary

Miss C complained about the medical and nursing care that her late mother (Mrs A) received at the Royal Infirmary of Edinburgh after she was admitted with upper abdominal pain. Miss C felt there had been a delay in a scan being performed which contributed to Mrs A's premature death from cancer; that there was a lack of communication from the staff about the severity of Mrs A's illness; that a decision had been made not to resuscitate Mrs A without this being discussed with the family; and that nursing staff should have monitored her mother's condition more closely.

We took independent advice from our medical adviser who found that there had been an unreasonable delay in the scan being done, although an earlier scan was unlikely to have altered Mrs A's prognosis. Had the scan been done two days earlier, Mrs A and the family could have been informed of the diagnosis in a more timely manner before her death several days later. The board said that the delay was due to the ward being closed because of an infection. However, we concluded that infection control measures could have been put in place, so we upheld the complaint. We also found that there was a lack of records to provide evidence that the medical team clearly communicated, to either Mrs A or the family, about the strong suspicion of cancer. Furthermore, we considered it was unreasonable that the family were not given the opportunity to be involved in the medical decision about resuscitation. In terms of the nursing care, we found evidence that reasonable checks were carried out. Furthermore, the medical staff noted that nursing staff had raised concerns with them about Mrs A's deteriorating condition. We did not uphold the complaint but recommended the board share with nursing staff the importance of recording when such action is taken.

Recommendations

We recommended that the board:

• apologise for the delay in performing the scan;
• share the findings about the delay in the scan with relevant staff to prevent this recurring;
• share with relevant nursing staff the need to make accurate records in line with guidance issued by the Nursing and Midwifery Council;
• ensure that doctor 1 reflects on the failings in relation to communicating with patients about suspected diagnosis at his next appraisal; and
• draw the findings about the lack of discussion about the decision not to resuscitate Mrs A to the attention of doctor 2.

Summary

Mr C complained about the care and treatment he received from a prison health centre in relation to his eye condition. He was concerned that he received various different medications, none of which helped and some of which appeared to worsen his condition. He, therefore, felt that he had been inaccurately diagnosed, and he complained that he was not referred to an eye specialist sooner.

We took independent advice from one of our medical advisers, who observed that Mr C had been seen on a number of occasions by healthcare staff and examined repeatedly. Our adviser noted that examinations did not reveal any serious underlying problems and that this mirrored the subsequent findings of the eye specialist. As such, she did not consider there to have been an earlier indication for a referral to a specialist. We fully accepted this advice and did not uphold this aspect of the complaint.

Mr C also raised concerns about the way his complaint was handled. We noted that he submitted multiple complaint forms on the issue, and the prison health centre continued to try to resolve these informally. The guidance only allows a three-day window for informal resolution, following which the complaint should be formally acknowledged and investigated. This did not happen for several weeks and, seemingly, only upon Mr C's prompting. We identified other failings to follow due process, such as an initial failure to inform Mr C of his right to approach this office. In the circumstances, we upheld this part of the complaint.

Recommendations

We recommended that the board:

• review their handling of this case with a view to making improvements and ensuring compliance with their statutory responsibilities, as set out in the ‘Can I help you?’ guidance; and
• apologise to Mr C for the identified failings in their handling of his complaint.

Summary

Ms C, an advocacy worker, complained about Mr A's care and treatment at Caithness General Hospital, where he underwent keyhole surgery to remove his gallbladder. She noted that Mr A was led to believe the surgery would be routine, but complications were encountered, requiring corrective surgery at Raigmore Hospital and an extended hospital stay. She complained that the risks of the surgery were not adequately explained and that reasonable steps were not taken to avoid the complications encountered, such as infection. She also complained that the surgery resulted in Mr A developing a foot drop (a condition which impairs the ability to lift the front part of the foot).

We took independent advice from one of our medical advisers who noted that consent forms were completed both prior to Mr A's admission and on the day of the surgery. However, our adviser observed that the forms did not document the potential risks of the surgery. Our adviser stated that it was good practice to list common complications, or those which are rare but severe. In the absence of this, we could not find evidence that the risks were adequately discussed with Mr A and so we upheld this aspect of the complaint.

Our adviser confirmed that the complications encountered were recognised complications of this type of surgery, and did not consider that anything could reasonably have been done to prevent them in Mr A's case. In addition, our adviser considered it unlikely that Mr A's foot drop was related to the surgery. We accepted this advice and did not uphold the remaining aspects of the complaint.

Recommendations

We recommended that the board:

• review their handling of this case with a view to improving the process for obtaining consent and, in particular, consider whether the consent form could benefit from revision; and
• apologise to Mr A for the failings in the process for obtaining his consent.