Some upheld, recommendations

Summary

Ms C complained that, during her pregnancy, the board failed to give her reasonable care and treatment and that there was a failure to diagnose placental insufficiency (a complication in pregnancy where the placenta is unable to deliver an adequate supply of nutrients and oxygen to the fetus), or that her baby was too small. Ms C's baby was stillborn.

We took independent medical advice from a consultant obstetrician, who told us that while ultrasound (a scan that uses sound waves to create images of organs and structures inside the body) provided the best estimate of fetal size, unfortunately it was not always accurate. Other tests (including measurements of the abdomen and blood flow in the umbilical artery) did not always pick up that a baby was small. Scans and other tests were also used to detect problems with the placenta but again were not foolproof. In Ms C's case, as she had already had two healthy births and had no apparent risk factors, all appropriate and reasonable steps were taken to properly monitor her pregnancy. While our adviser noted that with earlier delivery the baby would likely have survived, there was no indication for her to have been delivered earlier. Based on the evidence, we did not uphold Ms C's complaints about her care and treatment.

Ms C also complained about the way her complaint was handled. We upheld this complaint, as we found that there had been numerous delays, and that these had added to her distress.

Recommendations

We recommended that the board:

• make a formal apology for their delay and for any further distress caused; and
• remind those staff involved in responding to complaints (including any clinical staff) of the necessity of providing timely replies and demonstrate to us how this was done.

Summary

Ms C complained on behalf of her client (Mr A) who suffers from a delusional disorder (a mental health disorder where sufferers hold irrational beliefs). Mr A went to A&E in Lorn and Islands Hospital as he wanted them to check a mark on his leg. Staff were concerned about his mental wellbeing and spoke to the duty psychiatrist at another hospital who decided that he should be transferred and admitted there. In the event that Mr A was unwilling to go, it was agreed that his admission be facilitated with the use of an Emergency Detention Certificate (EDC). Documentation had to be completed for this and, before arrangements could be made for transfer, Mr A left Lorn and Islands Hospital. He was later brought back, handcuffed, by the police, sedated and transferred.

Ms C complained that Mr A was not adequately assessed at A&E. She also said that staff did not follow the correct process/procedures in relation to the EDC and there was unreasonable delay in transferring Mr A between hospitals. She subsequently complained of the delay in responding to her complaint about this.

We took independent medical advice from one of our psychiatric advisers. We found that, while it had been reasonable to prioritise Mr A's mental health over his concerns about his leg, the board had not first tried to establish whether he was a risk to others or himself, nor attempted to discuss his condition with his usual psychiatrist and review his records before deciding that he needed to be tranquilised. They also failed to follow the correct procedures (in terms of assessment and proper completion of the appropriate forms) for issuing an EDC. This led to Mr A being sedated against his will. Furthermore, the board delayed in dealing with Ms C's complaints. We, therefore, upheld these complaints.

Ms C had also complained that the board delayed in transferring Mr A between hospitals, but we did not find evidence to confirm this, and did not uphold her complaint.

Recommendations

We recommended that the board:

• apologise to Mr A for the shortcomings in assessing him;
• ensure that the circumstances of the complaint are brought to the attention of the on-call psychiatrist and ensure that it is considered at his next formal appraisal;
• make a formal apology to Mr A for failing to follow correct procedures;
• review the training given to medical staff working in A&E to ensure that they understand what is required before detaining people under an EDC and how to complete the appropriate paperwork;
• should formally apologise to Ms C and Mr A for their failure to respond in a timely manner; and
• should emphasise to the staff involved in this complaint the importance of responding to complaints in accordance with the board's stated response times.

Summary

Mrs C's stepfather (Mr A) was diagnosed with advanced bowel cancer in 2011 and had chemotherapy (a treatment where medicine is used to kill cancerous cells). In 2012, he was admitted to Aberdeen Royal Infirmary twice. Mrs C said that during the second admission a doctor told Mr A his chemotherapy had been positive but that he would not receive any more in view of problems with blood clots. Mrs C said that they later found out that it was stopped because his cancer had progressed. Mr A was admitted to hospital for a third and final time several weeks later. Mrs C said that staff failed to provide a discussed and implemented care plan about support throughout Mr A's illness and end of life care. She said that Mr A wanted to be with his wife (Mrs A) and receive end of life care at home, but was not consulted about his wishes or where he preferred to die. Mrs C said a doctor said that the aim was to get Mr A's pain under control and discharge him home. However, Mrs A received a phone call several days later telling her that he would be transferred to Peterhead Community Hospital under the care of his medical practice. Mrs C said that Mrs A was not told before the transfer that her husband was deteriorating significantly. He died six days later.

Mrs C said that clinical staff at Aberdeen Royal Infirmary failed to involve Mr A and his family in the transfer decision and failed to discuss the likely outcome for him, or the possibility that he could be cared for at home. In relation to her complaint about nursing staff at the community hospital, Mrs C said that they failed to provide a reasonable standard of care in terms of communication, personal care and dignity.

After taking independent advice from two of our advisers - a GP and a nurse - we found that staff failed to involve Mrs A and the GP in the decision to transfer Mr A to the community hospital. Given Mr A's condition, we were also concerned that he was not in a position to have an informed and reasoned discussion with medical staff about the transfer or to let them know his end of life care wishes. Although there was evidence that the likely outcome was discussed with Mr A and his family, there was no detailed record of Mr and Mrs A's understanding of this, as there should have been. Nor was there an anticipatory care plan which would have contained their wishes about where Mr A would prefer to die.

In relation to Mrs C's complaint about Mr A's personal care in the community hospital, we could not reconcile the differing accounts of what happened. Our nursing adviser said that the overall standard of care was reasonable, although in the absence of evidence we could not reach a judgement on Mr A's levels of hydration (fluid replacement). Having considered the medical records, we were satisfied that these clearly showed that the level of communication about Mr A's condition was reasonable. Similarly, we were satisfied that the care and support from district nurses was reasonable although there was no evidence that staff completed or referred to an end of life care plan. However, our nursing adviser said that a district nurse would not be expected to write an end of life care plan alone.

Recommendations

We recommended that the board:

• bring the failures our investigation identified to the attention of the relevant health care professionals involved in the transfer decision;
• provide evidence of how they intend to address the failings in relation to anticipatory care planning for end of life;
• bring the failures our investigation identified to the attention of the relevant health care professionals involved in discussions with Mr A and his family, and ensure they are raised as part of their annual appraisal; and
• provide the results of their review into their processes and procedures around communication and end of life care.

Summary

Mrs C had a history of longstanding abdominal (stomach) pain. She complained that, despite an operation, she had never been given an explanation for her pain or for the procedures she had subsequently undergone and she had not been given a definitive diagnosis. Mrs C said that she remains in pain and suffers panic attacks and depression. She complained to the board who said that there was no surgically treatable cause for her ongoing pain and symptoms, and that she had been referred to a pain clinic to try to help her. They did, however, acknowledge some problems with communication and said procedures had been put in place to avoid this happening again.

We took independent advice from a surgeon about this case. Our adviser said that since her operation all Mrs C's treatment had been reasonable and appropriate. Despite many investigations, however, it had not been possible to determine the exact cause of her pain, and our adviser confirmed that there was no surgically treatable cause. However, there was evidence that communication between the board and Mrs C was confused and that there had been a delay in informing her of the outcome of a scan, so we upheld this aspect of her complaint.

Recommendations

We recommended that the board:

• make a formal apology to Mrs C for their shortcomings; and
• confirm to us that they are satisfied that the new procedures put in place will prevent such a recurrence.

Summary

Mr C was a college student, studying for a degree offered by a university in collaboration with the college. Mr C complained that the college did not provide him with support on the day of his final degree exam, as had been agreed. Mr C was also unhappy with how they dealt with his complaint.

Mr C said a college tutor told him they should meet up 15 minutes before the exam, so the tutor could tell him where the exam was being held. The tutor said they did not make this arrangement. We did not find any written evidence that the arrangement had been made. In any event, Mr C found the exam room on time, and during the exam was provided with the support that had been agreed with the college. We, therefore, did not uphold this complaint.

We found that the college carried out a thorough investigation of Mr C's complaint. However, their letter to him did not deal with the specific issues he raised and did not explain why they decided not to uphold his complaint. This is not good practice, and not in keeping with the model procedure developed by our Complaints Standards Authority. In addition, the college did not explain to Mr C that they were dealing with his complaint at stage two of their procedure. Therefore, we upheld this complaint.

We also found, as the college did during their investigation, that there was a lack of clarity about telling students where their exams were being held, and so we made a recommendation to deal with this issue.

Recommendations

We recommended that the college:

• revise their procedures to ensure that all students on the collaborative programme receive information, from a specified source, about the location of their examinations in good time, in line with the university's expectations;
• provide us with a copy of their further guidance for staff on more formality in relation to email responses; and
• remind relevant staff that complaint responses must be in line with the model complaints handling procedure.

Summary

Mr C complained that a prison manager had refused to contact the on-call doctor after Mr C was sick and got something stuck in his throat, causing him chest pain. Mr C said that the prison did not act in accordance with the prison rules because a healthcare professional must be notified of any prisoner whose physical or mental condition appears to require attention. He also complained that staff removed various items from his cell contrary to the prison rules that set out that sufficient bedding must be provided for a prisoner's warmth and health. He said he was cold during the night and suffered pain the next morning.

In responding to the complaint, the prison governor explained that Mr C was being managed under a suicide risk management strategy because of self-harming, which meant staff had to carry out 15 minute observations in accordance with his care plan. As Mr C had hidden under the bed, staff had to remove various items that were considered potentially harmful. This allowed staff to maintain their duty of care to him by being able to freely observe him.

We found that the officers who were observing Mr C raised an incident report that he had handed them an item which he had apparently vomited. However, there was no evidence to show that they had witnessed him being sick or were aware of anything stuck in his throat. Nevertheless, we were concerned that staff did not check in more detail and question why Mr C had the item, given that for safety reasons he was not allowed anything in his cell at this time. Had staff properly investigated this, it is likely they would have established what had happened and so, on balance, we upheld the complaint.

We did not find any evidence to show that the prison acted unreasonably in removing items from Mr C's cell, as staff were required to clearly observe him for his safety, in line with his care plan. We were, however, critical that the governor had not responded to Mr C's complaint about staff not contacting the on-call doctor and made recommendations about this.

Recommendations

We recommended that the Scottish Prison Service:

• take appropriate steps to ensure similar incidents are fully investigated and documented in the observation records;
• share our findings with the governor to ensure that full responses are provided to complaints; and
• apologise to Mr C for the failings we identified.

Summary

Miss C was the victim of a road accident in 2009. Charges were brought in relation to the accident and Miss C was cited to appear in court. Due to an error by the Procurator Fiscal in court in August 2010 the case was not called, and proceedings could not be re-raised because of the time that had elapsed. Miss C made enquiries about the progress of the case and, for the next five months, was advised that it was being rescheduled. At the end of January 2011, however, she was advised that the case had ended the previous August. Miss C complained to COPFS about this and received a final response in April 2013. She was dissatisfied with the response and raised her complaints with us.

We did not uphold Miss C's complaint that COPFS had not reasonably advised her of the progress of the case as there is no requirement for them to do this, and she was advised that she did not need to attend court in August 2010, although she was given incorrect information about the reason for this. We did, however, uphold her complaints that COPFS did not reasonably advise her of the conclusion of the case, provided inaccurate information to her between August 2010 and January 2011 and did not respond reasonably to her enquiries and complaints from January 2011 onwards.

Recommendations

We recommended that COPFS:

• provide us with evidence that all staff were reminded about the provision of appropriate and accurate information to those involved in cases, and that notes of all phone conversations are now added to case records so it is possible to ascertain who provided information to enquirers;
• provide us with evidence of how their move to scanning correspondence has improved their handling of general correspondence; and
• consider, as a tangible expression of regret in exceptional circumstances, making a small payment to Miss C in recognition of the unnecessary costs, inconvenience and upset caused by their administrative errors.

Summary

Mrs C complained that, after she objected to her neighbour's planning application, the council allowed significant amendments and changes to it without telling her or allowing her to comment again. They approved the changed application, and Mrs C said that this seriously compromised her privacy. She also complained about the information the council provided in responding to her concerns and about the way they handled her complaint.

We obtained independent advice on this case from one of our planning advisers. Our investigation found that, because of Mrs C's original objections to the planning application, the council required the applicant to make changes to ensure that Mrs C's property was not overlooked. These changes were not, however, significant in terms of planning legislation and were to ensure that the development complied with the council's guidelines. The law did not require the council to advise Mrs C about the variations, there was no requirement for her to be re-notified about them and we found no evidence of any shortcoming in the way in which the planning application was handled. However, we found that a report of handling was not included in the planning register, which is a statutory requirement, and so we upheld the complaint. There was no evidence to suggest that any of the information from council officers was faulty, although their complaints handling was poor, as she was not correctly signposted to the next stage and their final letter to her was not sufficiently specific.

Recommendations

We recommended that the council:

• provide us with evidence that the software problems that caused the situation with registration of the report of handling have now been remedied to their satisfaction;
• make a formal apology for the failures identified; and
• ensure that the officers concerned are aware of the necessity of complying with the council's stated complaints process.

Summary

Mr C complained about the council's handling of a planning application for a development in his area. He was concerned about the council planning and transportation officers' relationship with the developer and their agent, and believed that officers had acted inappropriately by advising the developer/agent how to circumvent the local plan for the area. Mr C said the planning department had misinterpreted Scottish Government guidance on whether a transport assessment was required for the development and that the planning and transportation departments colluded with a developer's agent to avoid a full traffic assessment.

We obtained independent advice on the case from a planning adviser. Our adviser said that Scottish Government guidance and planning policy made it clear that pre-application discussions between a developer and a council were actively encouraged, and were viewed as adding value at the start of the development management process. The fact that pre-application discussions took place between the developer's agent and the council in this case was, therefore, entirely reasonable.

We found no evidence of the planning department using inappropriate language in communications with the developer or that they became too friendly with the developer or their agent. Not did we find any evidence that the department exceeded their remit in the advice they provided on the local plan. To ensure transparency in the planning process, however, we considered that meetings with developers, including welcome meetings, should be minuted. We found that, on balance, the transport department did not collude with the developer's representative to avoid a traffic impact assessment.

In terms of the requirement for a transport assessment, we concluded that the interpretation of planning guidance was a matter of professional judgment for the council as planning authority. However, before exercising that judgement, the planning committee should have had full information to ensure that their decision was both transparent and well documented. This was a major planning application and the issue of increased traffic was a key matter. We considered that the information was incomplete, both in the report to the committee about the Scottish Government guidance on such assessments and in an external consultants' assessment commissioned by the council on the transport methodology used.

Recommendations

We recommended that the council:

• amend their website to ensure that it accurately reflects the content of their complaints procedure on planning complaints;
• feed back our decision on this complaint to the officers involved to prevent the failings identified occurring in future;
• make sure that their planning and transport departments ensure that relevant Scottish Government guidance and its application is clearly represented in planning reports; and
• provide Mr C with a written apology for the failings identified.

Summary

Some years ago, Mr C received a lifetime ban from council facilities. He complained to us that this was unfair, and that the council had a duty to provide him with access to such facilities.

We upheld his first complaint, as our investigation found that the council should have offered Mr C a date when the ban would be reviewed. We noted that the council had agreed to meet Mr C to review the ban and that they had noted the gap in their policy, and were also reviewing this. However, we saw no evidence to suggest that the council had a duty to provide Mr C with access to leisure facilities, and did not uphold this aspect of the complaint.

Recommendations

We recommended that the council:

• provide us with a copy of the updated policy, considering the failings identified; and
• apologise to Mr C for the failings identified.