Some upheld, recommendations

Summary

Mrs C complained to us about her dissatisfaction with the council's investigation into her complaints about bullying of her children at their former school. She said that the school had failed to make her aware of their anti-bullying policy; had not contacted her when one of her children was hit during a playground incident; failed to properly manage bullying against another of her children; and that the head teacher had not tried to speak with Mrs C's husband when he notified the school that the children would not be returning. Mrs C told us that the head teacher's own investigation had contained glaring inaccuracies, but the council had not upheld her complaints.

Our investigation found that Mrs C had been made aware that the school had an anti-bullying policy, as it was summarised in the handbook that she would have received when her children were enrolled. We did not uphold that complaint, although we made a recommendation. We also did not uphold the complaint about the council's investigation of Mrs C's complaint about the head teacher. They had found that the head teacher dealt appropriately with the matter, and we agreed that this was something for the council to decide.

We did, however, uphold her complaints about the investigation into lack of communication and failure to manage bullying. On communication, we found that the investigation was flawed, as the council's files showed that they initially found fault with the school's handling of the playground incident, but then changed their decision and did not uphold the complaint. We found no evidence of new or further information having been provided before the decision was changed, and we took the view that the investigation relied too heavily on interviews, and did not seek to verify the facts with evidence. On bullying, we found that the council's investigation placed too much reliance on the head teacher's assurances that the school had properly managed the bullying. Again, the investigation had not tried to verify this as they should have done by checking the school records etc.

Recommendations

We recommended that the council:

• reinforce with the school the need to ensure that both the council's and the school's own policy on anti-bullying are being complied with;
• apologise to Mrs C for the council's failure to investigate her complaint about this issue properly and fully, and the failure of the school to notify her when the incident occurred;
• consider how best to ensure in the light of our findings that the process for investigation into reports of bullying is clearly set out, including parental involvement, and full records are kept of the investigation and its outcomes;
• apologise to Mrs C for the council's failure to investigate her complaint about the bullying of her child not being managed properly and fully by the school; and
• remind staff of the importance of considering records and evidencing decision-making at Stage 2 of the council's complaints procedure.

Summary

Mr C's father (Mr A) suffered from lung cancer, and was being treated with palliative erlotnib therapy (a drug used to treat some types of cancer) by a consultant at Ninewells Hospital. Mr A became ill while on holiday with his family and was admitted to hospital. When the family returned home, Mr A was transferred to Ninewells as he was too ill to go home.

At a meeting with Mr A and his family, the consultant decided to discontinue the erlotnib therapy and focus on symptom control. Medical staff recommended that Mr A be transferred as an in-patient for palliative care, but Mr A and his family decided that he wished to be discharged home. A package of care was requested to support this, but Mr A passed away on the morning of his planned discharge.

Mr C complained to the board that they had failed to arrange a care package in time to enable Mr A to die at home, as he had wished. Mr C also raised several concerns about Mr A's care, record-keeping and communication with hospital staff. The board responded four months later. Staff from the board then met with Mr C and his mother, and agreed what they would do in response to the complaint. In response to Mr C's enquiries, the board wrote to him about the outcomes of these actions. However, Mr C remained dissatisfied with their response, and their handling of his complaint, and complained to us.

After taking independent advice from our medical and nursing advisers, we upheld some of Mr C's complaint. We found that the board had handled his complaint poorly, and had not complied with their own complaints handling procedure or NHS guidance. We also found evidence of poor communication and record-keeping. However, we did not find evidence that Mr A's medical and nursing care was unreasonable. We also found that hospital staff had taken reasonable and timely steps to try to help Mr A achieve his wish to die at home, although this did not happen.

Recommendations

We recommended that the board:

• issue a written apology to Mr C and his family for the record-keeping failings our investigation identified;
• provide us and Mr C with a copy of the quality improvement loop developed for addressing issues with documentation, and details of the Nursing and Midwifery Council code of conduct and accountability sessions arranged to reinforce the need for accurate record-keeping;
• raise our findings in relation to record-keeping with the doctor concerned, for reflection;
• review their complaint management procedure and practices to ensure they comply with the NHS 'Can I help you?' guidance in relation to responding to complaints within 20 days of receipt of the complaint (including where the complaint is received by phone) and informing complainants that they may approach the SPSO if the final response is not provided within 20 working days;
• review guidance and/or template letters for acknowledging and responding to complaints to ensure that all letters include an accurate date (including year), acknowledgement letters provide accurate information on who will sign the final response, and letters for complaints which will exceed the 20 working day time-frame provide an updated time-frame and inform the complainant that they may now approach the SPSO; review processes for ensuring that they meet any commitments made to contact the complainant following the resolution of the complaint (for example, to advise when outcomes or agreed actions are completed); and
• remind complaints handling staff of the need to accurately record the date a complaint is received (including where the complaint is made by phone or in person), the requirement in the board’s procedures for a deputy to be appointed where staff involved in a complaint will be absent, and the SPSO guidance on apologies - in particular that apologies should identify and acknowledge what mistake has been made, as well as the impact on the person being apologised to.

Summary

Mr C complained about the care and treatment he received from the board when he was admitted to prison. He said that he had consultations with two psychiatrists, but the consultations were too short for them to make reasonable decisions about his medical treatment. We found that there was evidence to show that the assessment completed by one of the psychiatrists was reasonable and that she was able to make decisions based on this. However, the evidence the board sent us had no record of the review by the second psychiatrist, so we were unable to say whether this review was reasonable, and we upheld this aspect of Mr C's complaint.

Mr C also complained that the board failed to prescribe a benzodiazepine class drug (drugs used to treat anxiety, insomnia, and a range of other conditions) that he had been receiving when he was admitted to prison. There was no evidence, however, that staff were made aware that he was receiving this medication at the time. It was also reasonable that they did not prescribe the drug when they were told about it, because there were other ways in which they could manage Mr C's symptoms. He also complained that the board had delayed in providing him with tablets that he had been prescribed to help him sleep, and that he had not received these on some of the dates the board recorded he had been given them. In addition, he complained that it was difficult to get the board's complaints forms. As we found no evidence to support these aspects of Mr C's complaint, we did not uphold them.

Finally, Mr C said that he had to wait some months for a mental health review. We upheld this aspect of his complaint, as we found that an appointment with the mental health team had been arranged, but was cancelled because he was at court that day. The appointment was not rearranged until Mr C complained about the delay more than three months later.

Recommendations

We recommended that the board:

• remind the psychiatrist of the need to ensure that appropriate records of consultations are kept in line with General Medical Council guidance;
• make prison healthcare staff aware of our finding that the delay in rearranging Mr C's appointment was unacceptable; and
• issue a written apology to Mr C.

Summary

Mr C complained about the care and treatment given to his father (Mr A). He said that the board failed to admit Mr A to hospital on two occasions, did not provide him with appropriate medication and infection control measures, and did not communicate appropriately with Mr A's family.

During our investigation, we took independent medical advice from an emergency medicine consultant, a consultant physician and a consultant microbiologist. The advice we received was that the decisions not to admit Mr A to hospital were reasonable, and that Mr A received appropriate medication on both occasions. However, we were concerned that on the first occasion the commencement of antibiotics (drugs to treat bacterial infection) was poorly managed, although we also noted that the board apologised and took action to address this. Our emergency medicine adviser said that there were no failings that would have impacted on the outcome, but commented on the board's action in relation to screening Mr A for sepsis (blood infection) and we made a recommendation about this.

We found that the antibiotics given to Mr A before he was admitted to hospital were appropriate. He also received appropriate antibiotic therapy when he was admitted and this was revised appropriately during his stay in hospital. Our consultant physician adviser said that the decision not to isolate Mr A when he was first admitted was reasonable and that he was later treated with appropriate infection control measures.

We were concerned that there were failures in communication with Mr A and his family, although we were aware that the board had accepted that in several areas communication had not been as they would have expected, and had apologised for this. We also noted that they had taken action to improve communication between medical staff and between hospital staff and relatives. We did not, therefore, find it necessary to make recommendations about this.

Recommendations

We recommended that the board:

• ensure that relevant staff members are made aware of our adviser's comments in relation to sepsis screening and given the opportunity to reflect on these for future practice.

Summary

Mrs C complained that her physiotherapist had not referred her for an MRI scan (a scan used to diagnose conditions that affect organs, tissue and bone). As the physiotherapist had not done this, Mrs C arranged one privately, which did not reveal any abnormalities. Mrs C then sought to recover the cost of her private MRI scan from the board.

As part of our investigation we took independent advice from one of our medical advisers. She said the physiotherapist's decision to refer Mrs C to the pain clinic and not for an MRI scan was reasonable. This was because the notes did not indicate that Mrs C's condition required a referral for an MRI scan, in line with the relevant guidance. Although we took Mrs C's concerns into account, our role was to determine the reasonableness of the care and treatment she received. In light of the clear advice we received that the board had acted reasonably and in line with the appropriate guidance, we did not uphold Mrs C's first complaint.

Mrs C was also unhappy at the time the board took to respond to her complaint. Mrs C had contacted them over a period of months and the paperwork showed they had failed to meet their timescales or keep her updated. We upheld this complaint and made two recommendations.

Recommendations

We recommended that the board:

• apologise to Mrs C for the delay in responding to her complaint; and
• review their handling of Mrs C's complaint and feed back to relevant staff to prevent this from happening in future.

Summary

Miss C, who is an advocate, complained on behalf of her client (Mrs A) about the nursing and medical care provided to Mrs A's late husband (Mr A) at Dumfries and Galloway Royal Infirmary after he was admitted for a below-knee amputation. Mrs A was concerned that staff had not been monitoring Mr A's urine output or identified that fluid had been building up in his lungs. Mrs A felt that this caused Mr A to suffer a heart attack. After Mr A was discharged from hospital, Miss C complained to the board, however, there was a significant delay in the response being provided, by which time Mr A had died suddenly.

We took independent advice from two medical advisers, one a nurse and the other a consultant nephrologist (specialising in kidneys). We found that Mr A had a medical history of diabetes with multiple complications that had caused kidney damage in the past. Given this history, the medical complications he suffered (including a deterioration in kidney function, fluid collecting in the lungs, and a heart attack) were not unexpected. We did not find that the complications were a result of poor care and treatment, and so we did not uphold the complaint about medical care. However, there was no clear evidence to show that Mr A had been advised about the possible risk of cardiac problems given his medical history and we drew this to the board's attention. We also found that the nursing staff had not properly completed the fluid balance charts on a number of occasions, albeit the medical staff had carried out daily examinations for signs of fluid accumulation and managed the fluids and Mr A's medication appropriately. Therefore, we upheld Miss C's complaint about the nursing care Mr A received. We could not say for certain what had actually caused the heart attack but we made recommendations to address the failings in record-keeping.

In relation to complaints handling, the board accepted that they had delayed unreasonably in responding to the complaint. We were critical that there was a 13 week delay and made a number of recommendations to address the matter.

Recommendations

We recommended that the board:

• carry out an audit of patient medical records for the wards involved to ensure that fluid balance charts are being accurately completed;
• review their complaints procedure with a view to ensuring measures are in place to update complainants regularly in line with the guidance in the event that the 20 working day timescale cannot be met;
• remind all relevant staff dealing with complaints of the importance of updating complaints with the reason for any delays and their entitlement to contact us if the delay exceeds 20 days;
• apologise to Mrs A for the failings identified in the nursing care provided and complaints handling;
• take steps to ensure that the target timescale for dealing with complaints is met wherever possible; and
• ensure the nursing staff involved in Mr A's care are made aware of the importance of adequately assessing, monitoring and recording fluid balance.

Summary

Mr C complained on behalf of his late wife (Mrs C) about the care and treatment she received in University Hospital Ayr when she was admitted there apparently suffering from epileptic seizures. He complained that staff had not taken reasonable account of Mrs C's stress and anxiety when she was first admitted to hospital, and that she had not received adequate care and treatment on the ward.

We took independent advice from two of our advisers - a nursing adviser and a neurology adviser (a specialist in the science of the nerves and the nervous system, and of the diseases affecting them). Our neurology adviser said that Mrs C was suffering from a complex, unusual condition, which the neurologist involved in her care did not diagnose at first. Mrs C's initial diagnosis was incorrect, but had been difficult due to her unusual condition and existing medical conditions. Nursing advice indicated that staff noted Mrs C's anxiety, and took appropriate action to try and alleviate this, although Mrs C should have been given the option of treatment for nicotine withdrawal when she was first admitted. We concluded that, overall, the care and treatment she received was reasonable, and that staff responded to her situation appropriately.

Mrs C was later transferred to Girvan Community Hospital. Mr C complained that, while she was there, Mrs C's medication was altered without his knowledge, leading him to continue to give her particular medication while she was at home at weekends, although she was no longer taking it in hospital. During this period, Mr and Mrs C felt that the medication had a positive effect on her and, when it became apparent that the hospital had stopped it, they asked for it to be reinstated. This request was declined, and Mr C was unhappy about this.

Our adviser noted that the medication was no longer clinically necessary, given Mrs C's second diagnosis, and on this basis it was reasonable to withdraw it. However, he said that it would have been appropriate for staff to have given greater consideration to reinstating the medication when Mrs C clearly indicated that was what she wanted. He was also critical of the lack of evidence of any discussion with Mr and Mrs C before or after the withdrawal of the medication.

Recommendations

We recommended that the board:

• remind staff of the importance of discussing nicotine withdrawal and any available treatment options at the time of admission and as appropriate thereafter;
• remind staff of the importance of discussing changes in medication with patients and their relatives, and documenting these discussions;
• take steps to ensure that Girvan Community Hospital provide up to date information to carers in relation to medication when patients are allowed home during an admission to hospital; and
• apologise to Mr C for their failure to discuss medication with him, to respond appropriately when Mrs C indicated her desire for the medication to be reinstated, and for the distress this caused Mr and Mrs C and their family.

Summary

Mr and Mrs C have a workshop attached to their house. After receiving advice from the Central Market Agency, who hold records of the licensed water supplier of every business customer in Scotland, Business Stream became aware that there was a liability for commercial water services at the site. However, Business Stream only became aware of who occupied the property when they undertook an audit and then issued a bill to Mr and Mrs C for water charges, which they backdated to October 2010.

Mr and Mrs C complained to us that Business Stream had acted unreasonably in the delay in telling them that charges were due; levied charges for water services they had never had; failed to provide consistent and clear advice about the charges; and failed to respond promptly to their complaint.

We found that there was a responsibility on both Mr and Mrs C and Business Stream in relation to billing for water services. On Mr and Mrs C’s part it was to tell Business Stream that they occupied the premises, and on Business Stream's part it was to act promptly when they receive details of business premises where there have not been previous water charges. Business Stream told us that they accepted that their process could have been better, but they had taken action to make improvements. Overall we did not uphold the complaint, taking into account that Mr and Mrs C would have been billed earlier if they had approached Business Stream about providing water and waste water services.

We found that Business Stream had made appropriate enquiries with Scottish Water about Mr and Mrs C's liability, and had asked for payment based on the advice they received. However, we found that there had been confusion and inconsistency in the advice given about the charges due, for which Business Stream had apologised, and agreed to credit Mr and Mrs C's account with a small payment in line with their commitment to meet a certain level of service.

We also upheld the complaint about the complaints handling, having found that there was a failure to respond to a request for a phone call from a manager. In recognition of this, Business Stream agreed to a further small payment in line with their services standards.

Recommendations

We recommended that Business Stream:

• make the two payments offered to Mr and Mrs C in recognition of the failure to meet commitments under the service standards.

Summary

Mr C complained about the way the council handled his request for information about building standards. He felt the council had been unreasonably obstructive. We found that it took the council more than four months to acknowledge Mr C's request for information and over six months to respond. This was unacceptable. Although the council had apologised for the delay they had not acknowledged the considerable time and effort Mr C and his MP had to go to before getting a response. We asked the council to offer an apology which took account of this. The council told us the delay happened at a time of staff transition. We concluded that even during a time of reorganisation or transition the council should put arrangements in place to deal with incoming letters. We asked the council to carry out a review to check that suitable arrangements for handling correspondence within their building standards team were now in place.

We did not find the content of the council's response to Mr C to be unreasonable. The information Mr C requested was readily available and free to view online. Nevertheless, when asked to reconsider, they did provide the hard copy information Mr C had asked for.

Recommendations

We recommended that the council:

• provide an apology which recognises the significant time, effort and inconvenience caused by the repeated failure to reply to correspondence over a six month period; and
• review the procedure within building standards for dealing with incoming correspondence to ensure it is now sufficiently robust and report back to us.

Summary

Mr C was contacted by the council regarding outstanding council tax arrears in 2009. He began a payment plan with one of the council's debt collection companies (company 1) and continued to pay them until December 2013. In December 2013 Mr C was contacted by another of the council's debt collection companies (company 2). They told him that his arrears were with them and said he needed to set up a payment plan with them.

Mr C contacted the council to confirm that he should pay company 2, rather than company 1 as he had been doing previously. The council responded telling Mr C that his arrears had been passed to company 2 much earlier than December 2013.

Mr C complained that the council had not kept him reasonably informed about where his arrears were and whom he was meant to pay. He also complained that company 1 had not cancelled his original payment plan when his arrears had moved.

Our investigation found that the council could not provide evidence that Mr C had been told about the change of debt collection company from company 1 to company 2. They had also given contradictory information about when Mr C's debt had moved and where to. Because of this, Mr C was not sure whether the council had received all the payments he had made. They also had not followed their complaints handling procedure in responding to his complaint. We upheld Mr C's complaint that the council had not kept him reasonably informed about his arrears and made recommendations to address this.

However, we found that according to the terms of the contract company 1 and company 2 have with the council on collecting arrears, the responsibility to notify the customer of a change in arrangements lies with the new company rather than the old. As such, we did not uphold this aspect of Mr C's complaint.

Recommendations

We recommended that the council:

• arrange a meeting with Mr C to clarify what payments have been received and what arrears they have been applied to;
• remind relevant staff of the importance of investigating complaints thoroughly, with regard to all relevant evidence;
• review data sharing agreements with debt collection companies to ensure access to evidence for complaint investigations; and
• apologise to Mr C for the failings identified.