Some upheld, recommendations

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.

Summary

Mr C submitted a quote to the council to provide them with equipment for a piece of work they were doing. He explained that he prepared a specification and submitted the quote on the basis that he would be considered a 'specialist supplier' and that, as a result, no other tenders would be sought for this work. He made clear in his quote that it included a fee for the preparatory work which would only be payable in the event that he was not considered a 'specialist supplier'. He said that the council subsequently sought two further quotes and awarded the tender to another party. He complained to us that the council had said he would be considered as a specialist supplier and yet they awarded the contract elsewhere, that they did not treat all three companies who tendered in a consistent way, and that they refused to pay his fee.

The council said that Mr C was never told he would be the sole bidder and that they were unable to tender in this way. They said that they did treat all three companies consistently and that they would not pay the fee as they did not agree to the specialist supplier status.

We could not say whether Mr C was advised that he would be considered a specialist supplier. We did find, however, that the council had not followed the correct procedure as they approached him for a quote before seeking two further quotes. They should have obtained all three simultaneously. We also found conflicting comments about the extent to which Mr C's tender was used to develop the brief and specification for the other quotes, and we questioned the council's assumptions that tenderers may not be able to complete the work within the deadline. We also noted that they did not notify Mr C of the outcome of the tender. As the council had not followed the correct process when tendering for the contract and as, on balance, we were not convinced that all tenderers were treated in the same way, we upheld this aspect of his complaint. We recommended that they review their procedures for tendering, apologise to Mr C and pay his fee.

Recommendations

We recommended that the council:

• confirm to us that steps have been taken to ensure that future procurement/tendering processes will be carried out in a fair and consistent manner;
• pay Mr C the requested service fee for their specification and design work; and
• apologise to Mr C for the process failings which this investigation has highlighted.

When it was originally published in January 2015, this case was wrongly categorised as 'fully upheld'.  The correct category is 'some upheld'.

Summary

Mr C complained to the council that they had not taken action in response to reports of health and safety issues at a residential caravan site, including abandoned vehicles, and piles of wood and debris that could be a fire hazard. The council first handled Mr C's complaint as a service request. He then wrote to the council again, asking for his original letter to be treated as a complaint. The council told Mr C that he would need to agree with them what he was complaining about and that after this they would respond to his complaint within 20 working days. The council met with Mr C three weeks later and agreed the points of the complaint. They investigated his complaint and gave him a response another four weeks later.

Mr C was not satisfied with the council's response, and brought his complaint to us. He complained that they had failed to deal with his complaint in line with their procedures, failed to take action in response to health and safety concerns at the site, and failed to consider formal action under the legislation to revoke the site owners' licence.

We investigated Mr C's complaint, and found that the council had not dealt with it in line with their procedures. They had wrongly interpreted the complaints handling timescales and there were unreasonable delays in responding to him. They also gave some incorrect information in their investigation report and failed to clearly respond to all of the agreed points of complaint. We also found, on balance, that they had not taken reasonable action in response to Mr C’s concerns about health and safety. While they had responded well to these at first, there was no evidence that they then followed up appropriately on the measures they put in place. However, we found that the council had not failed to consider taking action under the legislation, as they were waiting for action by a third party, which could resolve the issues, before considering formal action themselves.

We issued a decision in which we recommended, amongst other things, that the council consider developing a policy in relation to their health and safety enforcement obligations. In response, the council provided copies of several policies relating to health and safety, which they had not provided before. We pointed out that they should have sent us these during our investigation, and we issued a revised decision on the complaint, with new recommendations.

Recommendations

We recommended that the council:

• remind staff of the requirements of the model complaints handling procedure in relation to timeframes;
• raise the complaints handling failings our investigation identified with the relevant staff to ensure a similar situation does not re-occur;
• apologise to Mr C for the failures our investigation identified;
• demonstrate to us that action has been taken in relation to the health and safety concerns Mr C raised;
• remind staff of the requirement in the enforcement policy to inform a person requesting action of the outcome of their request, including where the officer feels that no action is required, or the request is not justified;
• review the enforcement policy, to ensure that there is no unintentional overlap with the complaints handling policy; and
• undertake an internal audit to ensure that requests for action on health and safety issues and reports of accidents are handled in line with the enforcement policy and service delivery plan, including record-keeping requirements, and notify us of the findings.

Summary

Ms C complained that her child had been racially abused by another pupil at school. Ms C said the school had not contacted her on the day of the incident – unlike the other child's parents - and she found out about it from her child that evening. Ms C said she spoke with the head teacher the next day, who confirmed that the other child involved had been punished but would not confirm the specific punishment. Ms C also complained that her younger child had also suffered from bullying on a number of occasions.

Although we fully recognised the significance of Ms C's concerns, the law does not allow us to consider complaints about conduct, curriculum or discipline within schools. This meant our role was to consider whether the council had followed the relevant policies, one of which said that both sets of parents should have been told about the incident. Although Ms C said the school did not contact her, the council said the school had tried to do so without success. While the school's paperwork appeared to indicate that they had tried to phone Ms C, the policy was clear that she should have been informed. Had they been unable to contact Ms C on the phone (or leave a message asking her to contact them), we considered the school could reasonably have sent a brief note home with Ms C's child asking Ms C to contact them or, alternatively, they could have sent a letter. Either of these steps would have demonstrably satisfied the policy and so, taking everything into account, we upheld this complaint.

Ms C told us she had no supporting evidence for her second complaint. The council said the school confirmed there had been no reports (either from Ms C or her children) of any other incidents involving Ms C's children and the head teacher said Ms C had not reported bullying of her younger child, prior to her written complaint. There was no additional evidence of bullying or racial abuse for us to consider and, although we recognised the seriousness of the underlying allegations, we could not establish, on the basis of the evidence available, that the issue with Ms C's younger child was raised with the school. We did not, on balance, uphold Ms C's second complaint.

We made three recommendations with a view to ensuring good record-keeping in the future.

Recommendations

We recommended that the council:

• consider amending their policy to require a record of attempts to contact parents by phone be made;
• remind staff if they cannot contact a parent over the phone they consider contact by other means; and
• remind staff of the importance of completing the relevant forms in terms of their policy.

Summary

Mr C had a fall at home. An ambulance crew attended and examined him for a possible dislocation of the shoulder. It was decided that he did not need to be admitted to hospital, as there were no indications that his shoulder was dislocated. Three days later Mr C contacted his GP, who came out to see him, and advised that he attend A&E. Mr C did this and was found to have a dislocated shoulder.

Mr C complained that he was not given a reasonable assessment by the ambulance crew. He also said that when he had complained, the Scottish Ambulance Service (the service) had told him that a clinical review of his treatment would be carried out. However, he had not heard anything further about this.

The service told us that they thought Mr C may have experienced another fall in the intervening days between being seen by the ambulance crew and the visit from his GP.

We took independent advice from one of our GP advisers about Mr C's injury and assessment. The adviser said that it was not possible from the medical records to say with certainty when Mr C's dislocation injury occurred. The adviser also said that there was nothing in the ambulance crew's report to suggest the assessment Mr C received was unreasonable so we did not uphold this aspect of Mr C's complaint.

We did, however, have concerns about the clinical review that the service said they would carry out. This was conducted nine weeks after the complaint response letter to Mr C and five days after we initially contacted the service about Mr C's complaint. We were concerned that there was no formal procedure and that it may be unclear to complainants whether or not they are still in the complaints process or not. We upheld this complaint and made recommendations.

Recommendations

We recommended that the service:

• review procedures for clinical reviews, having regard to our findings; and
• apologise to Mr C for the delay in conducting and communicating the clinical review outcome.

Summary

A number of years ago, Mr C had an operation on a hernia (a condition where an internal part of the body pushes through a weakness in the muscle or surrounding tissue wall). A few weeks after the procedure, he thought that mesh involved in the operation had burst so his GP referred him back to hospital. Mr C was examined but there was no sign of a recurrence of his hernia. Mr C continued to complain about his suspicions but nothing was found. More recently, when clinicians were exploring other possible reasons for his pain, he was sent for an ultrasound scan (a scan that uses sound waves to create images of organs and structures inside the body). This showed a suspicion of a possible recurrent hernia, although again examination did not reveal this. Mr C said that if clinicians had listened to him at the outset and given him a scan, as he said he requested, he would not have spent years in pain receiving treatment which he said had been unsuccessful.

We obtained independent medical advice from one of our advisers, who is a consultant surgeon. The adviser said that Mr C's care and treatment, including physical examinations, was reasonable and that clinicians acted appropriately in the circumstances. While Mr C said that he had requested an ultrasound after his hernia operation, there was no evidence of this. There were other possible reasons for his pain and these were explored appropriately. Furthermore, the detection of the type of hernia Mr C had, especially a recurrent one after the previous surgery, was difficult. We did not uphold Mr C's complaint about his care and treatment.

Mr C also complained about the board's handling of his complaint. We found that, in basing their response solely on information received from the surgeon that Mr C complained about, the board had not thoroughly investigated the complaint. We upheld his complaint about this and made recommendations.

Recommendations

We recommended that the board:

• make a formal apology to Mr C for their failure in this matter; and
• further consider the terms of their complaints policy and review their internal investigation processes.