Some upheld, recommendations

Summary

Mr C complained on behalf of Mr A. Mr C said Mr A suffered from spinal damage which had required an operation but his treatment at Raigmore Hospital had been significantly delayed following his referral as it was unreasonably downgraded from urgent to routine and because the board lacked surgical capacity. Mr C was concerned that Mr A had not been examined properly. Mr A eventually underwent surgery outside the board area. Mr A had then required a second operation, which he felt had also been delayed. During his treatment, Mr A had not been communicated with adequately and Mr C's attempts to make a complaint on his behalf had been frustrated by the board's failure to follow its complaints procedures appropriately. Mr C said there was concern the delay had affected Mr A's recovery.

We took independent advice from two medical advisers. They said Mr A was not an urgent case and it was appropriate for him to be seen as a routine referral. He had been examined appropriately and there was no evidence Mr A had suffered permanent damage between his referral and his first operation. The advice also stated the board lacked the capacity to perform this type of surgery within an acceptable clinical timeframe. It was also noted there was doubt over whether a second operation would provide Mr A with further significant improvements. The advice noted that the clinical correspondence with Mr A regarding his treatment had been of a reasonable standard.

We found that Mr A had experienced an unreasonable delay in the provision of his surgery, but that there had not been an unreasonable delay in providing his second operation. We accepted the advice that Mr A had received a reasonable standard of communication from the board. We concluded that the board had failed to follow its complaints procedure appropriately and there had been an unacceptable delay in responding to Mr C.

Recommendations

We recommended that the board:

• review the non-urgent referral process for cervical surgery to ensure the delays experienced in obtaining an appointment in this case are addressed;
• provide evidence they have reviewed the handling of this complaint to establish the cause of the delays; and
• apologise for the failure in providing timeous treatment.

Summary

Mrs C was unable to eat or drink without being sick in the early weeks of her pregnancy, and she complained that a midwife should have taken a urine sample for testing to look into this problem. Mrs C also felt unwell in the weeks following her return home after giving birth. Mrs C said the midwife incorrectly told her that a urine test result for infection was negative, when she was later told by a doctor that the result was not ready on the day the midwife spoke to her, and it turned out to be positive for infection. In addition, Mrs C complained about the board’s handling of her complaint.

We looked at Mrs C’s records and took independent advice from one of our nursing advisers. We found that the records made by the midwife were minimal and not accurate, and we noted the board’s acknowledgement that this was not a standard of care they would expect to see. We upheld this part of Mrs C’s complaint.

In their written response to Mrs C, the board acknowledged that the experiences with the midwife had caused Mrs C distress, and that there had been miscommunication and failures in record-keeping, for which they apologised. While we had some criticisms, which we made recommendations to address, we decided on balance that the board’s handling of Mrs C’s complaint was adequate and we did not uphold this part of Mrs C’s complaint.

Recommendations

We recommended that the board:

• provide us with evidence of the feedback given to the midwife involved and community midwives in general, and of how the issues around communication, planning and documentation have been addressed;
• ensure that references to the content of clinical records in written complaint responses accurately reflect the records; and
• ensure that discussions with relevant staff as part of complaints investigations are documented and included in the complaint file.

Summary

Mr C had assumed that his charitable organisation did not pay water charges as he said he was never issued with a water bill in any of the organisation's previous addresses. He said that when he received a letter from Business Stream saying that they believed his premises to be empty he phoned and advised them he had occupied the premises since January 2010. Business Stream issued a bill and directed Mr C to information about the 'Scottish Government Exemption Scheme'. However it was discovered that this scheme would not apply to him. Mr C complained and Business Stream's Chief Executive wrote to explain that Business Stream had made several attempts to make contact with him and could not have issued a bill sooner. Business Stream offered to reassess Mr C's charges backdated to January 2010 as a goodwill gesture. Mr C was unhappy with the decision and was unhappy that Business Stream had not replied to some of his letters.

Business Stream told us that they had located Mr C's organisation through the Scottish Assessors Association but could not issue a bill until they had confirmed it. They provided evidence that they had tried to make contact and it was only when Mr C phoned in response to their second letter that they issued a bill. We did not uphold Mr C's complaint that the bill had been unreasonably delayed. We did uphold his complaint that Business Stream had failed to properly handle his complaint as they failed to respond to some of his letters within their procedural timescales. They had already offered compensatory payment and goodwill gestures that we felt were reasonable. We asked them to remind their staff of complaints handling timescales.

Recommendations

We recommended that Business Stream:

• ensure that all relevant staff are reminded of complaints handling timescales; and
• share the outcome of this investigation with all relevant complaints handling staff.

Summary

Mr C complained that his prison allowed him to buy trousers that were not in keeping with the items prisoners were allowed to have, and that they did not tell him about a 12.5 percent additional charge. Mr C also complained that the prison did not take account of his skin condition when providing him with trousers.

We found that Mr C should have been aware that he was not allowed to buy black trousers. However, we also found that prison staff were supposed to check whether items ordered were permitted; had this been done, Mr C's order would not have been processed. Therefore, we upheld this part of Mr C's complaint. We did not recommend that the prison cover the cost of the trousers as Mr C could have returned them to the external company for a refund, but he chose not to.

In terms of the 12.5 percent additional charge, we were not satisfied that the prison had taken reasonable steps to ensure that Mr C was aware of charges for postal orders. The Scottish Prison Service could not provide evidence to support their view that Mr C had signed a disclaimer about the additional charge. Therefore, we upheld this part of Mr C's complaint.

We found that Mr C had not asked to be assessed by prison health centre staff for his skin condition, meaning no recommendation had been made by a healthcare professional about his condition. This meant the prison did not have to issue him with alternative trousers. We did not uphold this part of Mr C's complaint.

Recommendations

We recommended that Scottish Prison Service:

• refund the value of the 12.5 percent charge to Mr C.

Summary

Mr C complained to us that the Scottish Prison Service (SPS) had breached the prison rules by refusing him access to a phone whist staff were searching cells in his area of the prison. We found that the SPS were entitled to do this, under the relevant prison rules and directions, and did not uphold this aspect of Mr C's complaint.

Mr C also complained about the SPS's handling of his complaint about this matter. We found that the initial response to his complaint had been inadequate and had unnecessarily listed the phone calls that he had been able to make later that day. We also found that the chair of the prison's internal complaints committee (ICC) should have met Mr C to discuss his request for witnesses to attend the hearing about his complaint. In view of these failings, we upheld this aspect of Mr C's complaint.

Recommendations

We recommended that SPS:

• apologise to Mr C for the failure to handle his complaint appropriately; and
• make the staff involved in the handling of Mr C's complaint aware of our findings.

Summary

Mr C complained to us that the Scottish Prison Service (SPS) had failed to provide prisoners with adequate access to weights and cardiovascular (CV) equipment and facilities. This related to the two fitness rooms within a residential hall, a weights room and CV room and the access to the main prison gym. Mr C was concerned about the removal of the weights room and the lack of maintenance of the CV room equipment. He also complained that the SPS failed to provide prisoners with adequate access to the prison's main gym.

We found that there was different access to the main gym, but that the prison has the authority to offer this, as the prison rules allow for different provisions to be in place for prisoners located in different parts of the prison. We did not find evidence that the SPS failed to provide prisoners with adequate access to weights and CV equipment and facilities and did not uphold this aspect of the complaint. However, although the SPS's decision to remove the weights room was discretionary, we were concerned that there was a lack of clarity around the future use of this room.

Mr C also complained about the SPS's handling of his complaint. We found that, in general, the SPS had adequately investigated and responded to the majority of issues Mr C had raised, but we also found that they had failed to adequately respond to his complaint about a member of staff. We were also concerned that some information had not been detailed on the complaint form. In view of these failings we upheld this aspect of his complaint.

Recommendations

We recommended that SPS:

• apologise for the shortcomings that our investigation identified;
• remind staff that the reason for refusing a request for assistance should be recorded on the internal complaints committee response; and
• remind staff involved in handling this complaint that the issue complained about should be adequately investigated in line with prison rules and staff guidance on prisoner complaints and disciplinary appeals.

Summary

Mr C complained about a complaints review committee (CRC) hearing, which considered his complaint about the actions of social work services in relation to the care of his elderly mother.

Mr C complained that the CRC did not warn him before the proceedings that they would only consider those parts of his complaint that he raised in oral argument, that he was not given an opportunity to call council officers as witnesses, that his complaint was not summarised by the CRC chair as required by the council's procedures, that the CRC was biased towards the council, that the CRC unreasonably prevented him from presenting additional evidence, that the CRC did not seek an independent expert opinion on the complex technical issues involved, and that the CRC's decision notice failed to include relevant representations made by the council. Mr C also raised concerns that the council did not properly follow their procedure when reporting the CRC's findings to their Health and Care Committee, because they did not include Mr C's comments (as required by the procedure).

After investigating Mr C's concerns, we found that the CRC did not follow some parts of the procedure set out in the council's policy. The council explained that this happened because the policy was not consistent with the procedural guidance used in the hearing. We upheld two of Mr C's eight complaints and recommended that the council apologise to him and review their policies and procedures on CRCs to ensure consistency.

In relation to Mr C's other complaints, we found no evidence that the CRC had otherwise failed to follow its own procedures, that it was biased, or that Mr C was prevented from presenting evidence at the hearing or calling any witnesses he wished. We also found it reasonable that the CRC did not seek independent expert opinion on the complaint.

Recommendations

We recommended that the council:

• demonstrate to us that the discrepancies between the complaints handling procedure and their Note of Procedure have now been addressed;
• take steps to ensure that discrepancies do not arise in future between the different guidance documents relevant to CRCs;
• provide us with evidence that the discrepancies between the complaints handling procedure and the Scottish Government guidance and directions have now been addressed; and
• issue a written apology to Mr C for the failings our investigation found.

Summary

Mrs C's son, who had previously been educated elsewhere, wished to enter sixth year at the local council-run secondary school. The council said they would not allow this as Mrs C's son was of an age where, according to their view of relevant law, her son was an adult. Mrs C complained about the council's decision, and about their handling of her complaint.

We looked at the council's response to Mrs C's complaint and although she disagreed with their position, which was based on their interpretation of relevant law, the council had consistently explained to her that her son was considered to be an adult and, therefore, there was no duty on them to provide him with a place at the school. It was not our role to resolve differing interpretations of the law, or to interpret it ourselves. Therefore, we would not give a view on the correctness, or otherwise, in law of the council's position. We could not uphold Mrs C's complaint just because she disagreed with the council.

In terms of the council's administration of the complaint, we found they should have explained to Mrs C earlier what stage her complaint was at, and they should have proactively provided her with updates. This would have helped Mrs C know when to expect a reply from the council. In addition, the same council officer made the decision not to allow Mrs C's son to enrol in the school, and dealt with Mrs C's complaint at both stages of the complaints process. This was inappropriate, and the council accepted this and had a different officer review the complaint. We upheld this part of Mrs C's complaint.

Recommendations

We recommended that the council:

• remind staff responding to enquiries and complaints not to refer to procedures where no such procedures exist;
• remind relevant secondary school staff of the council's position on dealing with applications from adults wishing to return to secondary school;
• apologise for their failure to explain to Mrs C early in the process at what stage her complaint was being dealt with, and their failure to proactively update her on progress;
• remind their complaints handlers to explain to complainants early in the process what stage their complaint is at, and the relevant timescales that apply; and
• remind their complaints handlers that staff who were involved in the matter complained about, or involved at a previous stage of the complaints process, should not respond to (later stage) complaints.

Summary

Ms C, who is an advice worker, complained on behalf of her client (Mr A). Mr A was unhappy with the way the council dealt with his concerns about asbestos in his home, about them blocking access to an electrical socket when they altered his ceiling and about the way they handled his complaint.

Our investigation considered whether the council acted in line with legislation and their own policy when dealing with the asbestos. We found that they did and that they responded reasonably to every one of Mr A's requests to have the asbestos tested. We did not uphold this complaint.

We also considered whether Mr A was treated reasonably in relation to the problem with the blocked socket. We found that by arranging for the socket to be repositioned, then adhering to Mr A's wishes for the work to stop, and then reinitiating the work again when Mr A requested it again, the council acted reasonably. We did not uphold this complaint.

Finally, our investigation considered whether the council implemented their complaints procedure reasonably when handling his complaint. We found that the council took three times longer than they should have to provide their final response, did not update him throughout this time, failed to agree longer timescales and there were errors in the response given. We upheld Mr A's complaint about this.

Recommendations

We recommended that the council:

• issue a further apology for the complaints handling failings identified; and
• provide a copy of our decision to the member of staff who responded to this complaint on behalf of the council.

Summary

Mr C complained to us about the care and treatment his father (Mr A) received at the Southern General Hospital. Mr A was admitted to hospital following a failed catheter change with a medical history including angina, heart attack and chronic kidney disease. A urinary tract infection was suspected and Mr A's kidneys were also found to be working abnormally. Treatment with intravenous (IV) fluids (administered directly into the veins) and antibiotics was started. Due to Mr A's cardiac history, he was prescribed IV fluids at a reduced rate. Mr A became breathless and was treated for fluid overload. Mr A's condition deteriorated and after some delay he was transferred to the Coronary Care Unit (CCU). Mr A died some weeks later.

Mr C complained about Mr A's fluid intake and that there was an unreasonable delay in transferring him to the CCU. The board advised that both Mr A's heart and kidney conditions had been considered but that it can be difficult to balance treatment in these situations. They provided an apology that no parameters or guidance had been given around oral fluid intake. In relation to delay, the board advised that there had been a breakdown in communication between staff. They assured Mr C that their processes had been reviewed to ensure that this would not happen in future.

After taking independent advice from one of our medical advisers, who is a consultant physician, we found that Mr A's treatment in relation to fluids was consistent with established good practice and we did not uphold this part of the complaint. However, the second element of Mr C's complaint was upheld as our adviser was critical of the delays in referring Mr A to the CCU and we found that this should have taken place at an earlier stage than the board identified.

Recommendations

We recommended that the board:

• make staff aware of the need to consider whether parameters and guidance for oral fluid intake may be required in specific cases;
• apologise to Mr C for the delay in referring Mr A for a cardiology assessment;
• draw the findings of this investigation to the attention of appropriate staff; and
• provide full details of their referral escalation process and confirm how awareness of this has been raised with staff.