Some upheld, recommendations

Summary

Ms C complained about the council's handling of a planning application, for which they had granted permission. She complained that the council had misled the development management sub-committee by the wording of the report of handling. She also said they had gone against the local plan and had not considered all the material planning issues.

The council admitted that some of the wording in the report of handling could have been clearer and more accurate. However, they said they did not believe that this led the sub-committee to make a decision that they would not have made with the more accurate wording. The council said they had considered all the material issues and did not believe the planning permission granted breached the local plan.

We took independent advice from one of our planning advisers, who agreed that some of the wording could be improved. For this reason we upheld this complaint and made a recommendation. The adviser did say however, that they did not believe this led the sub-committee to make a decision contrary to the one they would have made if the report was more accurate.

The adviser was satisfied that the council had not breached the local plan and had the relevant powers to make the discretionary decisions involved in this case. The adviser also found that the council had considered all the material issues that they would be expected to consider. We accepted this advice and did not uphold these complaints.

Recommendations

We recommended that the council:

• conduct further training on report writing.

Summary

Mrs C raised a number of complaints about the council’s handling of a neighbouring planning application. She was unhappy with the positioning of the driveway, the material used for the boundary wall and the fact that the council had not taken enforcement action over certain matters.

Our role was to consider the council’s administrative handling of the matter. We could not question their discretionary decision-making unless something had gone wrong in their decision making process (such as a failure to act in line with a relevant policy or procedure). As part of our investigation we took independent advice from one of our planning advisers, who confirmed that the council had acted within their discretionary powers with the driveway and the boundary wall, and that the evidence did not point to the council needing to take enforcement action over the issues Mrs C raised. We did not uphold these complaints.

Mrs C had also complained that the council took too long to have a neighbour’s security camera removed (she was concerned that it affected her privacy). The council felt they had acted in line with their enforcement charter and had taken the appropriate steps. Although the camera had since been removed, our adviser felt the council could have done more sooner. We recognised the importance of Mrs C’s privacy and noted that the enforcement charter, while explaining that the council would normally try to negotiate a solution, said that they would treat matters affecting privacy as priorities. Although we accepted that the council’s standard practice was to negotiate and that a solution appeared to have been found, we considered that the time taken – which appeared to have been several months – was unreasonable in the circumstances. We upheld this complaint.

Recommendations

We recommended that the council:

• apologise for the length of time it took for one particular camera to be removed;
• remind staff of the importance of privacy concerns – in line with their enforcement charter - when considering possible planning breaches;
• confirm that they will now take steps to determine the CCTV application and the timeframe for this; and
• take steps to investigate whether the neighbouring property has been brought into use in line with the relevant planning condition and following this, confirm with Mrs C and us their position on the issue of the screening.

Summary

Mr C complained that he was refused the right to buy his council house. He moved there from another council property in 2004, which meant that his right to buy entitlement changed from ‘preserved’ to ‘modernised’. Mr C tried to buy his house in 2007. However, this was days after his area was classed as pressured, which meant that the modernised right to buy was in fact suspended. Despite this, the council initially – wrongly - accepted his application but Mr C withdrew because he could not afford to proceed. However, he now again wished to buy his house. The council acknowledged that they had wrongly accepted his application in 2007 but said their lawyers would have identified that the house could not be sold, had Mr C proceeded to the next stage. In addition, as the whole of Perth and Kinross became a pressured area in 2012 Mr C still could not buy his house.

Our investigation found that in June 2006 the council told tenants (including those in Mr C’s postcode) that they planned to apply for pressured area status there with effect from 2 February 2007 and explained what this meant for modernised right to buy tenants. This also happened in 2012. Although Mr C said he had documents saying that he could buy his house after five years, he could not provide copies and the evidence indicated that his 2007 application was made after the suspension was in place. Although he withdrew that application, the evidence did not show that the council told him then that the sale could not have gone ahead anyway. We felt they reasonably could have been expected to do this. However, it was a fact that the suspension was in place when he applied to buy his house in 2007 and was later extended. While we recognised how significant this was for Mr C, our role was to consider whether the council had done anything wrong. Taking everything into account, we did not consider he was unreasonably denied his right to buy and we did not uphold this complaint.

Mr C also complained that the council had not maintained the property in line with their standards. He raised particular concerns about his doors and windows as he did not feel he was treated the same way as other tenants. The council told Mr C they had to ensure his property was wind and watertight and maintained to an acceptable standard. His windows and doors were fitted in 1988 and, under the standard life-cycle for these, were due for renewal in 2018. They also said Mr C's property was included in the council’s recent upgrade programmes and they planned to review his windows, doors and central heating as part of the upcoming repair programme. Although Mr C was entitled to want them replaced sooner, the evidence did not point to maladministration and we did not uphold this complaint.

Mr C had a third complaint, about the water supply to his home. The evidence indicated this was an unusual situation, where the council were Mr C’s landlord but his water was supplied privately. This meant the council had one role as the local authority and another as Mr C’s landlord. The paperwork showed they tested his water supply in line with their role as local authority and notified him where samples failed. As landlord, they installed water filters and, following Mr C’s complaint, they visited his property and arranged a water assessment and service call for the filters to be changed. The council said they arranged an annual test and provided a copy of a request for a full water treatment risk assessment. The evidence showed that Mr C had long running concerns about his water (he was in contact for an extended period) and the evidence showed that the council took steps to address this. However, it was unclear whether they had confirmed to him the extent of their obligations as landlord or whether these were met. Although we noted the unusual nature of the situation, we decided that the evidence indicated that the council’s handling of the matter fell below a reasonable standard. We upheld this complaint and made a recommendation.

Recommendations

We recommended that the council:

• provide evidence to us that they have taken appropriate steps to provide Mr C, as their tenant, with a wholesome water supply.

Summary

Mr and Mrs C complained on behalf of their son (Mr A) about recharges made for alterations and damage to a property when the tenancy ended.

Mr and Mrs C had jointly signed the original tenancy agreement with the council in 1989. In 2008 they took on the care of a severely disabled foster child on behalf of the council, but had to move to a suitably adapted property. The tenancy agreement of the property they had lived in with Mr A was assigned from Mr and Mrs C to the joint names of Mr C and Mr A; the tenancy agreement was assigned again in 2009 solely to Mr A. The council deemed the property had been abandoned by Mr A in 2013 and levied recharges for various items, including the reinstatement of kitchen and bathroom fittings which had been put in by Mr and Mrs C prior to 2008.

The council said that as the tenancy had been assigned to Mr A, he automatically became responsible for any damage caused. The tenancy agreement signed in 1989 stated that any damage caused by fault or neglect of tenants had to be either put right or the council would charge for doing so. In relation to alterations, the tenancy agreement stated that these had to have prior approval from the council, but did not make it clear what the consequences would be of not getting approval. The current tenancy agreement in use by the council states that unauthorised alterations should be removed, or the council would charge for doing so.

Our investigation found that the tenancy agreement signed in 1989 did not make it clear that the council would regard unauthorised alterations as damage liable to recharge. We also found that opportunities had been missed in 2008 and 2009 to make Mr and Mrs C aware that the alterations they had made would be rechargeable; and to give Mr A the opportunity to say that he accepted the property, with the alterations, in 2009.

Recommendations

We recommended that the council:

• review its assignation documentation to ensure that, for the future, it is made clear to tenants that all of the conditions of the original tenancy agreement still refer and, if necessary, is updated to the current version;
• reconsider the recharges made for replacing the kitchen, bathroom and wood panelling;
• review its procedures for assignations of tenancy agreements to ensure that all parties are made aware of, and/or reminded about, the requirement to remove improvements made and/or restore properties to a lettable standard; and
• issue a written apology to Mr and Mrs C for the failings identified during this investigation.

Summary

Mr C complained that the board unreasonably advised the Scottish Prison Service (SPS) that it was safe for him to be subject to metal detecting equipment, although he has an implantable cardioverter defibrillator (ICD) (a device that regulates irregular heart rhythms). Mr C also complained about the board’s handling of his medication. He said that staff altered his medication inappropriately, and made mistakes in administration. He also said that there was no reason for his medication to be supervised (taken in front of prison staff, rather than given into the patient’s keeping), as it was degrading to be required to open his mouth to show he had taken the medication, and this supervision resulted in him being harassed and bullied for his medication.

After investigating Mr C’s complaints and taking independent medical advice from several specialists, we upheld Mr C’s complaint about the administration of his medication. We found that, although a doctor decided to stop Mr C’s naproxen (a drug used for pain relief and anti-inflammation, which can contribute to poor kidney function), Mr C’s prescription record (kardex) was not updated to reflect this. This was because the kardex had to be recalled from the prison halls, and a different doctor was on duty when the kardex was returned to the health centre. As a result, Mr C was inappropriately given a further dose of naproxen in the next weekly medications. We also found that it was unreasonable for a hospital doctor to decide to restart Mr C’s naproxen, although his clinical history showed that this had been stopped due to poor kidney function. Finally, we found that Mr C had been given incorrect dosages of medications on one occasion.

We did not uphold Mr C’s complaint about security screening. Although health centre staff gave slightly different advice about this to prison staff at different times, we found that all of the advice given was reasonable. We also did not uphold Mr C’s complaint about supervision of some of his medications (dihydrocodeine and tramadol – both prescribed for pain relief). In relation to dihydrocodeine, we found the board had complied with their local process for administering medication to prisoners who had recently arrived at the prison. In relation to tramadol, we found that the board’s decision to administer this as supervised was reasonable, as tramadol is an abusable drug and the medication was supervised for Mr C's own safety and for general prison safety. We also found that it was reasonable for nurses to ask Mr C to open his mouth to show that he had taken the medication, as they needed to ensure that he took his prescribed medication and that this was not diverted, and the nurses were supported by prison staff who are able to request this kind of search under the prison rules.

Recommendations

We recommended that the board:

• issue a written apology to Mr C for the failings our investigation found;
• remind nursing staff of the need for care to be taken in administering and recording medications correctly;
• ensure there are clear and robust procedures for updating prescriptions to reflect GP decisions, including where kardexes need to be recalled from halls and/or where a different GP may need to amend the prescription; and
• raise our findings in relation to the restarting of naproxen to the attention of the relevant doctor for reflection as part of his next annual appraisal.

Summary

Miss A had provided a urine sample at the practice which was to be sent away for testing. Mrs C, who complained on behalf of Miss A, said that when a colleague called to check on the results for Miss A, the practice said that they could not trace the sample. Mrs C complained to the practice in August 2014 and received a response in October 2014. Mrs C complained to us that the practice had failed to properly process Miss A's urine sample and failed to properly handle her complaint.

We took independent medical advice from our GP adviser, who said that there was no recognised system to check that samples had left the practice and arrived at the laboratory, and that the sample going missing was likely due to an administrative difficulty which would be difficult to trace the origin of. In addition our adviser said that the response from the practice was reasonable and Miss A had come to no harm. Therefore, we did not uphold Mrs C's complaint about the loss of Miss A's urine sample.

We upheld Mrs C's complaint about the practice's handling of her complaint. We found that the practice had failed to observe their own policy in terms of timescales for responding to complaints, and had not made any apology for the delay in their response.

Recommendations

We recommended that the practice:

• issue Mrs C with an apology for failing to properly handle her complaint;
• ensure that all staff are made aware of the contents of the NHS Scotland 'Can I Help You?' guidance and use this to review their own procedure; and
• share the outcome of this investigation with all relevant complaints handling staff.

Summary

Mr C complained about the medical treatment he had received in prison and, in particular, about delays he had faced in getting medication. We took independent advice from one of our medical advisers, who is an experienced GP. Although there was no evidence that there was a three-week delay in prescribing his medication when he first arrived in the prison, the doctor failed to discuss with Mr C his decision at that time not to prescribe medication Mr C had previously been receiving on repeat prescription before entering prison. We found that this had been unreasonable, although, the doctor did subsequently decide to prescribe the relevant medication to Mr C. However, there were then delays in giving Mr C some of his medication due to staff shortages. Mr C was subsequently found to be stockpiling the medication. We found that it had been reasonable for staff to remove Mr C's stockpile of the medication, however, it was unreasonable that this medication was then stopped without a discussion about putting an alternative in place. In view of these failings, we upheld this aspect of Mr C's complaint.

Mr C also complained that the prison health centre had failed to appropriately maintain his medical records. We found that his records had been well-maintained and we did not uphold this aspect of his complaint.

In addition, Mr C said that the board's response had failed to address his complaint appropriately. We found that the board's response failed to indicate that an adequate investigation had taken place and that it failed to address the issues Mr C had raised. We also upheld this aspect of his complaint.

Recommendations

We recommended that the board:

• review the prison's processes for repeat prescriptions in order to try to ensure that all patients receive their repeat prescriptions in a timely fashion;
• remind the GP in the prison health centre that he should discuss changes in prescriptions directly with patients;
• provide evidence to confirm that steps have been taken to ensure that complaints from prisoners are investigated and responded to in line with the Scottish Government's guidance; and
• issue a written apology to Mr C for the failings identified.

Summary

Mrs C said that although her husband (Mr C) first attended Wishaw General Hospital for investigations in February 2013, it was not until early June 2013 that he was advised that he had a terminal illness. Mr C died a few weeks later after receiving his diagnosis.

Mrs C complained about the care and treatment Mr C received and that it had taken an unreasonable time to provide him with a diagnosis. She said that communication, particularly with the family, had been poor.

We took independent advice from consultants in colorectal surgery and radiology, and also from one of our nursing advisers. We found that Mr C's medical care and nursing treatment had been reasonable so we did not uphold Mrs C’s complaints about this. However, there had been a delay in making a diagnosis because a scan taken in April 2013 had shown subtle changes that had been overlooked. As a consequence, Mr C could have been diagnosed earlier (although, his outcome would have remained the same) and his palliative care started sooner. Our investigation also showed that communication with the family had been poor causing even further distress to the family at a difficult time. In light of what we found, we upheld Mrs C’s complaints about the board’s communication and the delay in diagnosis.

Recommendations

We recommended that the board:

• make a formal apology;
• confirm to us that as a consequence of their discrepancy meeting, they are satisfied that there is an increased liklihood of such an abnormality being detected in the future;
• make specific recognition of the failures in communication by way of a formal apology; and
• provide us with details of specific actions they have taken to show that staff have learned from the shortcomings in this case.

Summary

Mr C complained to the board about the care and treatment that his wife (Mrs A) received. Mrs A was being investigated for lung disease when an error in interpreting a scan referral in December 2011 resulted in a delay in the diagnosis of lung cancer. Mrs A underwent surgery to remove a tumour in June 2012 but was not considered to be suitable for chemotherapy. Mrs A attended at follow-up appointments with the board where weight loss was noted. In May 2013 it was discovered that Mrs A had cancer in her right kidney. Although she was initially given a diagnosis of primary kidney cancer, tests found that it was in fact the spread of lung cancer and her treatment plan was changed accordingly. Following a stay in a hospice, Mrs A was admitted to hospital and passed away in October 2013.

Mr C complained about delays in diagnosing his wife's cancer, the incorrect diagnosis of primary kidney cancer and the standard to which the board had kept Mrs A's medical records. After taking independent advice on this case from a consultant physician and a consultant specialising in cancer care and treatment, we upheld Mr C's complaint regarding delay in diagnosis. Our cancer specialist adviser said that the initial delay could have affected Mrs A's prognosis. Issues with record-keeping around the completion of DNACPR (do not attempt cardiopulmonary resuscitation) forms were highlighted and consequently, Mr C's complaint about record-keeping was also upheld. However, we did not uphold Mr C’s complaint about the diagnosis of primary kidney cancer as we were advised that this was a difficult diagnosis to make.

Recommendations

We recommended that the board:

• apologise for the delay in diagnosing Mrs A's cancer, particularly its spread in 2013;
• take steps to contact the locum consultant to ensure he is fully aware of our findings;
• ensure that this case is included for discussion at the relevant consultant's next appraisal;
• raise awareness of this case amongst staff involved in the booking of imaging to highlight the potential impact of errors;
• review how the care of patients requiring input from multiple specialities is managed and led;
• make staff aware of our findings in this case to allow reflection on the impact inaccurate diagnoses can have on patients and their families; and
• ensure that this case is included for discussion at the relevant doctor's next appraisal.

Summary

Mr C said he had been referred to the ear, nose and throat clinic by his GP. He had been offered an appointment at a Raigmore Hospital which was too far from his home and had requested an appointment at Belford Hospital closer to where he lived. Despite this he had been offered a second appointment at Raigmore Hospital, before being offered an appointment at Belford Hospital. Mr C complained he was seen outside the waiting time guarantee of 18 weeks from referral to treatment. Mr C also complained that he had been offered an appointment with psychological services some 18 months after his referral, which also breached the referral to treatment target.

We found the offer of an appointment to Mr C of an appointment at Raigmore was within the board’s published policies for appointment management. The board had mitigation in place due to the distances patients had to travel to attend these appointments. When Mr C refused this appointment, he was no longer covered by the Scottish Government waiting time target, so we did not uphold his complaint about delay for the ear, nose and throat clinic. We found there was an unreasonable delay in providing an appointment with psychological services and upheld his complaint about this. The board had, however, provided evidence that they had made significant improvements to their waiting list management and that waiting times had consequently been substantially reduced.

Recommendations

We recommended that the board:

• apologise for the failure to properly explain the actions they had taken to improve patient access to psychological services.