Some upheld, recommendations

Summary

Mr C complained about the care and treatment his late brother (Mr A) received from the medical practice. Mr A had been suffering from a cough, shortness of breath and chest pain and died of a pulmonary thromboembolism (a blood clot which forms at one point in the circulation, becomes detached and lodges at another point) in April 2014. Mr C said that he believed the practice had contributed to the death of his brother.

Mr C complained that Mr A's GP did not treat his condition as worsening on his last visit to the practice. He also said that the day before Mr A's death, a receptionist had not allowed Mr A to speak to, or see, a GP when he called the practice to get the results of tests.

Mr C complained to the practice but was unhappy with the response he received. He said that there were several things which he felt were inaccurate or incorrect in their response. Mr C questioned why the GP had not considered or recognised that Mr A's condition was worsening and disputed the practice's version of what was said during the phone call with the receptionist.

We took independent advice from one of our medical advisers, who is a GP. We found that the medical records depicted a series of events consistent with a chest infection with some additional signs which needed further investigation and that the appropriate tests had been arranged, so we did not uphold Mr C's complaint about his brother's treatment.

However, our adviser also said that the role of reception staff is to facilitate communication between a patient and a GP, and, therefore, they should not be making a decision that a patient who has specifically asked to speak to a GP should not have this option. Our adviser said the information should be passed to the GP who has clinical knowledge and responsibility for patient care to make the decision as to how to proceed. On this basis, we upheld the complaint about the care given to Mr A by the practice.

Recommendations

We recommended that the practice:

• carry out a significant event analysis paying particular attention to their system of contacting an on-call doctor;
• ensure GPs involved in Mr A's care discuss this complaint at their next appraisal;
• apologise to Mr C for the failings identified;
• establish, using the practice's appointment system, which receptionist spoke to Mr A on the date in question;
• review the details of the GP's complaint response in relation to the information received from reception staff, and write to Mr C to explain the findings;
• review and revise where appropriate the practice system for passing requests by patients to speak to a doctor; and
• consider enhanced staff training for the receptionists in terms of their interactions with patients and practice guidelines on responding to patients who request to speak to a doctor.

Summary

Mrs C complained that the college failed to explain why, after an admission interview, she was sent texts telling her that she had missed her interview, that the course was full and she did not have a place. She phoned to ask what had happened, and was not satisfied with the college's response. The college admitted that as a result of human error, text messages had been sent to people who should not have got them and they had apologised for this. We investigated and did not uphold her complaint, as we found that the college had adequately investigated it. They explained why this had happened and what they had done to stop it happening again. We considered the college's response to be reasonable.

Mrs C also complained that the college failed to explain the bursary application process to her, and did not assist her during the process. She met with staff on several occasions about her application, and also emailed and wrote to the college. We found that when she met with staff they explained the information needed to process her bursary application and that she did receive appropriate assistance. However, we upheld her complaint about the explanation, as they did not provide the information in writing or ensure that she had access to the relevant student handbook.

In addition, Mrs C was unhappy with the college's investigation of her complaint. She was concerned that it had not been investigated in an impartial way, because it was investigated by a member of staff who was part of her complaint. We upheld this complaint as we agreed that her complaint should have been investigated by another member of staff to ensure that the decision was as impartial as possible. We also noted that the final response was not signed off by the college vice-principal, as required by the college's complaints handling procedure.

Overall, Mrs C felt that the college had discriminated against her because she was not born in the United Kingdom. After reviewing the information provided about her other complaints, while we noted the college's failings in relation to Mrs C's situation, we did not find evidence of discrimination.

Recommendations

We recommended that the college:

• ensure that students making enquiries about bursary applications have access to the student handbook on Education Maintenance Allowance, and that staff highlight the relevant sections when students request information; and
• ensure that staff are aware of their responsibilities in relation to the complaints handling procedure, and that senior staff are considerate of any conflicts of interest and handle these appropriately.

Summary

Mr and Mrs C objected to their next-door neighbour's planning application for an extension. The council granted the application, and Mr and Mrs C complained to us that the application process had been handled unfairly. They raised a number of concerns, including that some information on the application was inaccurate and/or provided after the deadline for comments; that the council had not responded to their correspondence asking questions about the planning application process; that the application had been decided by an officer using delegated powers, when it should have been decided by a committee; and that the officer had failed to take relevant planning considerations and guidelines into account in deciding the application.

After taking independent advice from one of our planning advisers, we upheld one of Mr and Mrs C's complaints - that the council failed to respond to their correspondence asking questions about the planning process. We found that, although the council upheld the complaint about this, they had not apologised or made any recommendations to improve their practices, and we were critical of this failure to learn from what had happened.

We did not uphold the other complaints, as there was no evidence that the council had failed to comply with relevant procedures in allowing additional information to be provided after the deadline for comments, or in deciding the application using delegated powers. While there were minor inaccuracies in the plans the council used, we found that it was reasonable for them to rely on these as the inaccuracies were not so significant that they would affect the decision. The officer had also undertaken a site visit and taken photos to ensure they had accurate information about the site and its surroundings. We also found evidence that the council had taken all of the relevant planning considerations and guidelines into account.

Recommendations

We recommended that the council:

• issue a written apology to Mr and Mrs C for failing to reply to their correspondence;
• review the guidance to case officers to ensure that members of the public receive a response to any questions of fact about planning applications; and
• remind complaints handling staff of the importance of addressing any failings identified in complaints investigations, including by apologising where appropriate.

Summary

Mr and Mrs C made several complaints to the council about the way their child, who has autism, was dealt with at school, in particular where physical intervention had been used. The council investigated and fully or partially upheld many of their complaints. Mr and Mrs C were not, however, satisfied with how the investigation was conducted or the outcome. They complained to us about the investigation and the remedial action taken by the council as a result of the complaints.

Our investigation found that the handling of their complaints was unsatisfactory, in that the council should have taken control more promptly, there were matters that could have been agreed and investigated (as outlined in the council's complaints procedure) at a much earlier stage, and it appeared that the council took no action on the complaints during a period of some eight months. We upheld Mr and Mrs C's complaint, noting that much of the delay was due to the complexity of the issues involved, the large volume of documents that needed to be reviewed and the fact that additional complaints were added during the process.

We also noted that it was originally agreed that an internal investigation would take place as an initial fact-finding exercise, followed by an external investigation. However, after some 250 hours of work, the internal investigation had identified failings in several areas and the majority of Mr and Mrs C's complaints had been either fully or partially upheld. The council, therefore, decided to concentrate on addressing the issues this raised, rather than expending further resources on an additional external investigation. Our view was that this decision was reasonable and proportionate, although it was obviously disappointing for Mr and Mrs C.

On the issue of the remedial action, Mr and Mrs C complained that they had only been provided with a copy of an action plan. Our investigation found, however, that they had been kept updated on the progress of the plan through meetings with the director of the relevant service and a letter from the council's chief executive. We found that the majority of the action points had been implemented but that a few (with city-wide implications) are still ongoing, which we considered reasonable.

Recommendations

We recommended that the council:

• in line with the requirements of the model complaints handling procedure they adopted, demonstrate they have learned how to take responsibility for establishing and managing complaints successfully;
• confirm the learning and improvement measures identified as a result of the findings in relation to two of Mr and Mrs C's complaints, and how these have been implemented;
• provide Mr and Mrs C with a copy of the arrangements for the council's co-ordinated support plans;
• contact Mr and Mrs C to arrange a meeting to share new documents relating to the council's physical intervention policy; and
• issue a written apology to the family for not handling one of their complaints appropriately.

Summary

Mr C complained that the council had not dealt properly with his application for planning permission. He said that they had unreasonably declined to engage with him and respond to his pre-application enquiry, dealt with this as if it was a planning application for detailed consent (when it was for permission in principle), and that the reply to his complaint wrongly said that they had asked him for drawings of the elevation of his proposed building as part of the assessment of his planning application.

We found that the council had responded to Mr C's pre-application enquiry and, although it might not have met his expectations of engagement with them, it did provide relevant advice. This service is discretionary and it was for the council as planning authority to decide what resources they spent on it. We found nothing to suggest that they had dealt with Mr C's application as if it was for detailed consent rather than in principle. However, it was unclear whether they had given him advice about providing drawings of the elevation of the proposed building, which suggested that their reply had been incorrect, and we upheld this element of his complaint.

Recommendations

We recommended that the council:

• remind staff of the importance of keeping a record of phone calls they have with customers; and
• review their response to Mr C's complaint about the drawings, and provide either an apology and correction, or details of when and by whom such a request was made.

Summary

Ms C was considering making an offer to buy a property and called the council to ask if the property was eligible for a parking permit. When she was told that it was, she asked that they confirm this by email. Ms C received an email shortly afterwards, and instructed her solicitor to submit an offer. She then read the email and discovered that it did not confirm that the property was eligible for a permit. She got in touch with the council, who said that the property was not eligible for a permit, but accepted that she had previously been given incorrect information. Ms C also believed that the council promised her compensation during a phone conversation, but then did not offer this. Ms C complained but the council remained of the view that compensation was not merited.

Ms C complained to us and we reviewed the available recordings of phone conversations. We upheld her complaint that the council had given her incorrect information about the criteria for the issuing of parking permits. However, we found no evidence that she was promised compensation, and did not uphold this complaint.

Recommendations

We recommended that the council:

• remind all relevant staff of the criteria for the issuing of parking permits.

Summary

Mrs C complained that the council had not followed proper planning procedures when they approved the building of a house on a site near her property. Mrs C said that proper consultation had not taken place and that the objections she and others raised at planning committee were not reasonably considered. She also complained that the decision was not in line with the development plan for the area, and that this was not adequately explained and recorded by the council.

Our investigation considered all the correspondence between Mrs C and the council and their responses to her complaints. We also examined relevant planning regulations, policies and development plans, and the papers presented to the committee that approved the planning application, including the planning officer's report and the minutes of the committee meeting. We also took independent advice from one of our planning advisers. We did not uphold Mrs C's complaint about lack of community involvement and consultation, but we did uphold her complaint that the council did not properly follow procedure. We found that the planning application approval was not accurately documented as a departure from policy, as required by regulations, and we made recommendations to address this.

Recommendations

We recommended that the council:

• apologise for not clearly recording the approval as a departure from policy; and
• consider how best to ensure such exceptional planning approval decisions are accurately documented.

Summary

Mr C complained to the council's environmental health department about an out-of-date food product he had bought in a supermarket. He was unhappy with the way the council handled this, and complained to us of delay and failure to deal with his complaint properly and fully.

Our investigation found that there had been an initial delay, and the council had not responded within two working days - the timescale required under their complaints handling procedure. However, in their investigation the council acknowledged this and had already apologised to Mr C for it. We found that their investigation into the food safety issue was thorough and followed council procedures and relevant legislation, and that they had sent Mr C a detailed decision letter. Overall, we did not find evidence of unreasonable delay. Our investigation did, however, find that they had not responded fully to Mr C's further representations, including that they notified the supermarket of their decision before telling Mr C.

Recommendations

We recommended that the council:

• offer a formal apology to Mr C for failing to address all of his points fully; and
• review their practices on the timing of informing parties of the decision taken by the council with regard to complaints about food safety issues.

Summary

Mrs C's children had been placed on the child protection register, and she complained that the head teacher at her son's school had made unsubstantiated allegations to the council's social work department about her parenting ability. Mrs C also complained that the head teacher had unreasonably failed to ask for the social work department's record to be corrected, despite later claiming that her remarks about the situation had been recorded inaccurately. The head teacher had also refused to meet with Mrs C to discuss her complaint.

The council said that as the head teacher disputed the accuracy of the records and as she had not had the opportunity to view them before Mrs C complained, the council did not consider them accurate. They said, however, that the remarks were not the substantive reason for placing Mrs C's children on the register. The council's investigation found that the head teacher's decision not to meet with Mrs C was based on advice from senior colleagues in the education department. The council also said that due to the personal nature of Mrs C's correspondence, the education department had been preparing to deal with the matter as a formal complaint, but this was overtaken by events, when Mrs C formalised her complaints. They said they recognised that it was inappropriate for formal records of conversations not to be agreed by all parties, and so they had taken steps to improve inter-department communication. They were, however, unable to share with Mrs C any details of actions taken in respect of the head teacher.

Our investigation found that it was not possible to determine the accuracy of the record, as it was disputed by the head teacher. The evidence did, however, show that the head teacher's remarks were not the reason that the children were placed on the register. We found that the education department had failed to request that the record be amended, despite being aware that the head teacher disputed the remarks attributed to her, and that child protection proceedings were underway. We also found that, although the council should have told Mrs C why the head teacher would not meet with her, the decision not to do so was one that the head teacher was entitled to make, and was not something that we could look at.

Recommendations

We recommended that the council:

• consider adding an addendum to the social work department file to confirm the head teacher disputes the statements attributed to her; and
• apologise for the failure to correct the social work department record at the earliest available opportunity.

Summary

Mrs C complained to us about the care and treatment provided to her late father (Mr A) before his death. Mr A had been admitted to Wishaw General Hospital with mobility problems. He was known to have a number of medical conditions, including cancer and cirrhosis (scarring of the liver due to liver disease). He was diabetic and had right pleural effusion (a collection of fluid between the lung and chest wall). He was initially given diuretics (substances that increase urine excretion) for the plural effusion, but it was then agreed with the family that these would be stopped. Mr A was then transferred to a hospice. His condition improved and he was discharged home. However, several weeks later, he was readmitted to the hospital. He stayed there for two weeks before being transferred to an NHS long-term care facility in a care home. Mr A died in the care home a month later. Mrs C complained about Mr A's clinical treatment in the hospital and the care home. Although we cannot normally look at complaints about care homes, we were able to investigate in this case, as Mr A was in an NHS long-term care facility.

We took independent advice from one of our medical advisers. We found that Mr C had received reasonable treatment for MRSA (meticillin-resistant staphylococcus aureus, a bacterial infection that is resistant to a number of widely used antibiotics) in the hospital and that communication with him and his family there was reasonable. We also found that there had been regular consideration of Mr A's symptoms in the care home and there were appropriate responses, in terms of treatment and communication with the family. It had also been reasonable for staff in the care home to withdraw Mr A's insulin. However, we found that a decision was made in the hospital that the fluid in Mr A's chest was related to his cirrhosis. This was done without more consideration of contrary evidence that this could have been a pleural effusion related to his cancer. There was no evidence that the doctor who prescribed the diuretics for this had considered the pleural effusion in sufficient detail. (There was, however, no suggestion that Mr A's health was unduly affected by this treatment.) This was a balanced decision, but in view of this specific failing and taking into account that the pleural effusion was the main abnormality on admission, we upheld this aspect of Mrs C's complaint.

Mrs C also complained that staff had failed to respect the wishes of Mr A and his family that diuretic medication and morphine were not to be administered. Mrs C had sent the board an email requesting this whilst he was in the hospital. Her request was shared with medical staff and after this Mr A was not given these again in hospital. However, when he was admitted to the care home staff started to give him morphine again. Although we found that it had been reasonable to provide Mr A with small doses of morphine to manage his pain, in view of the request in the email, this should have been discussed and agreed with the family. This did not happen, because hospital staff did not communicate that request to the care home. In view of this communication failure, which occurred at a difficult time for the family and was about an issue they had already raised, we upheld this complaint.

Mrs C also complained about the nursing care provided to Mr A in the hospital and the care home. However, we found that this had been reasonable.

Recommendations

We recommended that the board:

• issue a written apology to Mrs C for the failings identified in relation to the diagnosis of the cause of Mr A's pleural effusion and for the failure to communicate to the care home the family's request that Mr A was not to be given diuretics or morphine; and
• make the staff involved in Mr A's care and treatment aware of our decision.